What is Chemical Restraint and is it Legal?
Human Rights Watch documented several cases in which family members described how relatives with dementia who were taken off medications used to restrain them regained much of their vitality, once again talking and interacting, and staying awake during the day.’
What is Chemical Restraint?
Chemical restraint is the administering of medicine to restrict the freedom or sedate a person in your care. The drugs used are not related to the medical treatment of the individual.
Global research has shown healthcare professionals are treating residents (including those with disabilities) with psychotropic medicines (these influence the central nervous system to affect perception, mood, consciousness, cognition and behaviour) instead of managing their behaviour or attending to their physical symptoms (Egan 2019).
Reports reveal the practice of chemical restraint is very common within Australian aged care facilities.
A recent study into antipsychotic and benzodiazepine prescribing in residential aged care facilities found that of over 12,000 residents across 150 homes, 22% were taking antipsychotics every day. Over one in ten were charted for these drugs on an ‘as required’ basis (Breen et al. 2018).
Findings indicate that chemical restraint is particularly common for handling aged care residents who have dementia.
A study conducted in 2013 found through analysis of PBS (Pharmaceutical Benefits Scheme) prescription data that a high level of questionable prescribing of antipsychotics in older people was occurring. There was (and still is) concern that antipsychotics and similar medicines are being prescribed to residents with dementia as a first-line means of behaviour control (National Prescribing Service 2013 quoted by Peisah and Skladzien 2014).
The View From the Human Rights Watch
A Human Rights Watch report released in October, ‘Fading Away’: How Aged Care Facilities Chemically Restrain Older People with Dementia looked into the use of antipsychotics, benzodiazepines and sedative-hypnotic drugs (known as tranquilisers, sleeping pills or sedatives, and opioid analgesics) as chemical restraints in 35 aged care facilities across Queensland, New South Wales and Victoria.
Through interviews with family members, doctors, nurses, and advocates, it uncovered numerous cases of secretive chemical restraint. The author, Bethany Brown, called on the government to ban chemical restraint and to make training compulsory for staff in how to handle the behaviour of residents with dementia.
In many of the case studies featured in the report, family members claimed to have noticed significant and worrying differences in their relatives.
These changes included:
- Deterioration in their condition, such as becoming lethargic and losing the ability to speak.
- Many claimed their relatives slept for longer periods, and could not be awakened easily.
- They reported weight loss as a result of the resident not being able to remain awake long enough to eat.
The HRW report calls for a shift towards person-centred care. Studies from the US have found that people with dementia treated with these interventions showed signs of improved quality of life, decreased agitation, improved sleep patterns, and improved self-esteem (HRW 2019).
The HRW report claims that those who were taken off chemical restraint medications regained vitality, talked and interacted more, and stayed awake during the day. Unfortunately, others continued to experience the physical and cognitive complications of chemical restraints, such as the loss of muscle strength and the inability to swallow (HRW 2019).
What is the Risk of Antipsychotics?
Clinical trials in the US have found that antipsychotic drugs increased the risk of death in older people who had dementia. This includes benzodiazepine, which is associated with an increased risk of falls, pneumonia, and death in older people (Chang 2019).
It was ascertained that often staff did not seek or secure informed consent prior to giving these medications. Many relatives said they only learned of these medications upon receiving pharmacy bills that listed them (HRW 2019).Why is the Practice of Chemical Restraint Commonplace?
The report blames understaffing and inadequate training in dementia support for the prominence of chemical restraint in aged care. It claims that these factors make it very difficult to take an individualised, comprehensive approach to caring for people with dementia (HRW 2019).
The issue of chemical restraint is timely as the older population of Australia continues to increase, the report calls for an increase in staffing and regulatory change and enforcement around chemical restraint.The key recommendations of the report are as follows:
To enact legislation to prohibit the use of chemical restraint as a means of controlling the behaviour of older people (specifically, with dementia) for the convenience of facility staff, as well as:
- Mandatory training for all staff in dementia and alternative methods to de-escalate unwanted behaviour and to support their needs.
- Minimum staffing to ensure support is adequate.
- Appropriate enforcement mechanisms to protect the rights of older people.
Breen (2019) notes that it’s important to acknowledge that some residents with behavioural symptoms of dementia might require a low dose of antipsychotic if they are severely distressed or at risk of causing or incurring harm. Approximately 20% of people with dementia displaying aggressive behaviour will show improvements when prescribed these.
The Government’s Stance on Chemical Restraint
Legal frameworks around chemical restraint are recent, it was not until July 2019 that regulation around chemical restraint was introduced.
While the regulation aims to minimise chemical restraint, it does not prohibit chemical restraint, enforce the right to informed consent or offer a complaint mechanism if it is suspected that chemical restraint has been used (HRW 2019).
The Australian government argues that using restraint in aged care is only to be used as a last resort. They state that residential aged care providers have specific responsibilities relating to the use of physical and chemical restraints (Department of Health 2020).
These responsibilities are outlined in the Quality of Care Principles.
The Quality of Care Amendment Principles 2019 came into effect on 29 November 2019. This legislation:
- Establishes restraint must always be used as a last resort.
- Refers to state and territory legislation for prescribers’ responsibilities regarding informed consent.
- Requires a 12-month review of the restraint regulation operations to ensure they are minimising the use of inappropriate restraint.
(Department of Health 2020)
Chemical Restraint on the World Stage
The terminology ‘chemical restraint’ itself carries a stigma. In healthcare, drugs are not commonly referred to as ‘chemicals’. It is not often said ‘chemically relieving a person with asthma,’ but you may hear the phrase ‘chemically restraining a person with schizophrenia’.
By calling psychiatric medications ‘chemicals’ it differentiates them from other drugs, or implies that agitation deserves punishment or subjugation as opposed to healing (Zeller 2017).
Internationally, the World Health Organization has launched a ‘Quality Rights Initiative’ aimed at improving care (primarily for mental health facilities). It is in the process of developing training modules, including one on strategies to rule out the use of seclusion and all forms of restraint, including chemical restraint (McSherry 2017).
Under international human rights law, governments are obligated to respect the dignity of persons with disabilities, including older people, by recognising them as being on an equal basis with others. This includes respecting their right to live independently without being made to live in an institution, and to have all their human rights protected if they decide to be in institutions such as aged care facilities (HRW 2019).Additional Resources
- Human Rights Watch, ‘Fading Away’, https://www.hrw.org/report/2019/10/15/fading-away/how-aged-care-facilities-australia-chemically-restrain-older-people
- Restraint Use in Healthcare, https://www.ausmed.com.au/cpd/courses/restraint
Multiple Choice Questions Q1. In a study looking at over 12,000 residents across 150 homes, what percentage of residents were taking antipsychotics every day?
- Breen, J 2019a, ‘Tweaking Prescribing Rules Won’t Fix Chemical Restraint in Aged Care', The Conversation, viewed 30 January 2020, https://theconversation.com/tweaking-prescribing-rules-wont-fix-chemical-restrain t-in-aged-care-126347
- Breen, J 2019b, ‘Chemical Restraint Has No Place in Aged Care, but Poorly Designed Reforms Can Easily Go Wrong’, The Conversation, viewed 30 January 2020, https://theconversation.com/chemical-restraint-has-no-place-in-aged-care-but-poorly-designed-reforms-can-easily-go- wrong-112218
- Breen, JW, Gee, P, Ling, T, Brown, DT, Franks, KH, Bindoff, I, Bindoff, A and Peterson, GM 2018, ‘RedUSe: Reducing Antipsychotic and Benzodiazepine Prescribing in Residential Aged Care Facilities’, Med J Aust, 208 (9), pp.398-403, https://www.mja.com.au/journal/2018/208/9/reduse-reducing-antipsychotic-and-benzodiazepine-prescribing-residential-aged
- Chang, C 2019, ‘The Disturbing Use of Drugs to Control Behaviour in Australian Aged Care Facilities’, News.com.au, viewed 30 January 2020, https://www.news.com.au/finance/business/the-disturbing-use-of-drugs-to-control-b ehaviour-in-australian-aged-care-facilities/news-story/2dbdf5ac02c81feb2acc 40eb6b4fddf8
- Department of Health 2020, ‘Minimising Restraints in Aged Care’, Department of Health, viewed 30 January 2020, https://www.health.gov.au/health-topics/aged-care/providing-aged-care-services/working-in-age d-care/minimising-restraints-in-aged-care
- Egan, N 2019, ‘Report Calls For End To Chemical Restraint of Residents’, Australian Ageing Agenda, viewed 30 January 2020, https://www.agedcarecrisis.com/care-issues/restraints/chemical-restraints
- McSherry, B 2017, ‘Chemical Restraint: Behind Locked Doors’, Pursuit, viewed 30 January 2020, https://pursuit.unimelb.edu.au/articles/chemical-restraint-behind-locked-doors
- Peisah, C and Skladzien, E 2014, ‘The Use of Restraints and Psychotropic Medications In People With Dementia’, Dementia.org, viewed 30 January 2020, https://www.dementia.org.au/files/Publication_38_A4_print_version_Web.pdf
- Zeller, S 2017, ‘The End of Chemical Restraints: Expert Opinion’, Psychiatry Advisor, viewed 30 January 2020, https://www.psychiatryadvisor.com/home/practice-management/the-end-of-chemical-restraints-expert-opinion/
(Answers: c, a, a)
Ausmed Editorial Team
Ausmed’s Editorial team is committed to providing high-quality and thoroughly researched content to our readers, free of any commercial bias or conflict of interest. All articles are developed in consultation with healthcare professionals and peer reviewed where necessary, undergoing a yearly review to ensure all healthcare information is kept up to date. See Educator Profile