Psychotropic Medications in Dementia and Determining Chemical Restraint
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FACILITY RESOURCE
Psychotropic Medications in Dementia
and Determining Chemical Restraint
DEFINITION AND LEGISLATION Difficulties in determining if a
medication is chemical restraint
Prescribers are asked to identify chemical
restraints based on the reason for prescribing It can be difficult to establish if there is a
or continuing and according to the definition of diagnosed mental disorder or physical illness/
chemical restraint in the Quality of Care Principles condition. Chemical restraint may also apply
2014 (current version available at https://www. outside the setting of dementia such as with a
legislation.gov.au/Details/F2020C00096): diagnosis of Developmental Disability.
Chemical restraint is a practice or intervention There are some ‘grey’ areas where it may be
that is, or that involves, the use of medication or
helpful for a psychiatrist/ geriatrician, sometimes
a chemical substance for the primary purpose of together with a behaviour management clinician
influencing a care recipient’s behaviour, but does
(e.g. through Dementia Services Australia or in
not include the use of medication prescribed for:the disability sector where there are specialist
behaviour practitioners who assist with required
(a) the treatment of, or to enable treatment of, Behaviour Support Plans), to collaborate with the
the care recipient for: GP to assess the reason for use of a psychotropic
(i) a diagnosed mental disorder; or medication and determine its continued benefit
(ii) a physical illness; or as well as whether the use is a chemical restraint.
(iii) a physical condition; or
Individual circumstances may vary and where
(b) end of life care for the care recipient there are multiple and complex conditions
involved, specialist advice can also help minimise
dose and length of treatment.
If the reason for use is to
manage a behaviour,
the medication is likely
to be considered
chemical restraint.
1
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Psychotropic management is similar
whether or not the medication is All psychotropic medications used appropriately,
chemical restraint including those that are chemical restraint, should
contribute to achieving the best possible outcomes
The appropriate management of ALL psychotropic for the resident.
agents, whether or not they are chemical restraints,
Documentation – monitoring and efficacy
requires clear understanding and documentation of
the following: Facility staff should document details of monitoring
carried out in relation to the efficacy or not of
• the diagnosis or reason (indication) for use a psychotropic agent and the occurrence of any
• regular review of whether use remains required adverse effects – this is relevant for all psychotropics
or if the dose could be reduced and forms part of the required documentation in the
• the basis for continuation updated Quality of Care Principles 2014 from 1 July
• the appropriate consent as per state/territory 2021 for chemical restraints.
legislation.
Best Practice Guidance for Psychotropics in
In some cases, prescribers and facility staff are keen Behaviour Management
to avoid identifying a medication as a chemical
restraint. This may lead to longer than necessary According to Therapeutic Guidelines - Psychotropic
treatment and inappropriate use. (March 2021):
Note that where a medication is not flagged as a Behavioural and psychological symptoms of dementia
chemical restraint, there should still be evidence are often temporary and can usually be prevented
for the use, review and continuation which reflects and treated with nonpharmacological management.
its role in the appropriate treatment of a diagnosed Communication abilities often decline as dementia
mental illness, physical condition or physical illness. progresses, and changed or challenging behaviour is
often caused by unmet needs unlikely to be helped
Chemical restraint is not determined by ‘on label’ by drugs (eg need to toilet, distress from pain or
or ‘off label’ use of a medication. For example loneliness, frustration). If behaviour is adequately
the use of all antipsychotics for behaviours in assessed and its cause is promptly addressed, drugs
dementia is deemed chemical restraint, despite that are unnecessary for most patients with dementia
risperidone has a PBS-listing in BPSD with psychosis who experience symptoms of agitation, aggression
and aggression, and others such as olanzapine, or psychosis.
aripiprazole and quetiapine are also recommended
in guidance information in specific circumstances of Australia’s Clinical Practice Guidelines and Principles
aggression and psychotic symptoms. of Care for People with Dementia (2016) is based
on the UK’s NICE guideline 2006 although the NICE
While chemical restraint is best avoided where guideline has since been updated in June 2018,
possible, it does have a role in reducing distress and provides similar recommendations to those in
and the risk of harm for some residents, and use Therapeutic Guidelines – Psychotropic (March 2021).
is allowed under the circumstances specified in
updated Restrictive Practices legislation (Quality of
Care Principles 2014). 2
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user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the
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From the Clinical Practice Guidelines and Principles
of Care for People with Dementia: • Be aware that for people with dementia with
Lewy bodies or Parkinson’s disease dementia,
• At the time of diagnosis of dementia, and at antipsychotics can worsen the motor features of
regular intervals subsequently, assessment the condition, and in some cases cause severe
should be made for medical comorbidities and key antipsychotic sensitivity reactions.
psychiatric features associated with dementia,
including depression and psychosis, to ensure • Do not offer melatonin to manage insomnia in
optimal management of coexisting conditions. people living with Alzheimer’s disease.
• People with dementia who experience agitation • For people living with dementia who have
should be offered a trial of selective serotonin sleep problems, consider a personalised
reuptake inhibitor (SSRI) antidepressants (the multicomponent sleep management approach
strongest evidence for effectiveness exists for that includes sleep hygiene education, exposure
citalopram) if non-pharmacological treatments to daylight, exercise and personalised activities.
are inappropriate or have failed. Review with
evaluation of efficacy and consideration of de- Some of the relevant guidance information from
prescribing should occur after two months. The Therapeutic Guidelines – Psychotropic is included
need for adherence, time to onset of action and in the table below which contains examples and
risk of withdrawal effects and possible side effects
information about drug types and situations that
should be explained at the start of treatment are or are not considered chemical restraint. Note
that only psychotropic drug types that may be most
• If a person with dementia is suspected to be commonly used as chemical restraints are included.
in pain due to their distress or behaviour, as
indicated by responses on an observational pain
assessment tool, analgesic medication should
NOTE
be trialled using a stepped approach. The trial
should be for a defined time period, particularly
The information in the tables on
if opioids are used.
the following pages are not definitive
and should be used as a guide only – the
prescriber in each case should confirm
Some further recommendations from the NICE
reasons for continuing all psychotropics
guideline, Dementia: assessment, management and
which may be considered potential chemical
support for people living with dementia and their
restraints. Prescribers are suggested to
carers:
refer to available treatment guidance for
psychotropic diagnoses/indications
• Be aware that some commonly prescribed
to ensure appropriate use, and
medicines are associated with increased
document reasons for treatment
anticholinergic burden, and therefore cognitive
decisions at each review.
impairment.
• Do not stop acetylcholinesterase (AChE) inhibitors
in people with Alzheimer’s disease because of
disease severity alone. 3
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user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the
loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.
Examples of Common Psychotropic Medications and some uses which may be Chemical Restraint
Examples of DRUG TYPE Chemical Comments
and Diagnosis / Symptoms Restraint
(reason for prescribing)
ANTIPSYCHOTICS: Yes Target behaviours should be specified and evidenced in behaviour monitoring
Dementia records.
Behaviours
BPSD Use is only recommended after (and with continued) non-pharmacological
Developmental disability interventions which are inadequate alone.
Aggression
Agitation Therapeutic Guidelines – Psychotropic (March 2021):
Psychotic symptoms (e.g.
hallucinations, delusions) Antipsychotics are the drug class of choice for agitation, aggression or
Anxiety/depression psychotic symptoms of Alzheimer disease and mixed Alzheimer disease and
(symptoms rather than vascular dementia because they have the strongest evidence (although small)
diagnosed disorders) of benefit. This modest efficacy must be balanced with a range of adverse
effects, including further cognitive decline and an increased risk of death and
cerebrovascular events. If the patient is at high risk of stroke (eg has poorly
controlled vascular disease, atrial fibrillation or a history of stroke), avoid
using an antipsychotic; undertake a benefit–harm analysis and if possible, seek
expert advice.
Patients who have dementia with Lewy bodies can experience severe sensitivity
reactions and worsening of motor symptoms in response to antipsychotics.
The drugs of choice for agitation, aggression or psychosis in these patients are
rivastigmine or donepezil. There is insufficient evidence to guide antipsychotic
therapy in dementia with Lewy bodies—use antipsychotic therapy with
caution. If antipsychotic therapy is used, low-dose quetiapine is preferred
because it may be less likely to cause the aforementioned adverse effects.
Note that risperidone is PBS-listed for use in BPSD in Alzheimer’s disease
where there are “psychotic symptoms and aggression” and where there is
failure to respond to non-pharmacological management (+ other restrictions
specified).
ANTIPSYCHOTICS No People with mental health illness requiring antipsychotics have usually been
Schizophrenia under the care of a psychiatrist and local mental health teams in the past and
Bipolar disorder historical confirmation of the diagnosis and treatments utilised is suggested to
Psychotic depression be sought to assist with ongoing management and review.
End-of-life care (e.g.
midazolam for agitation or Note however that the setting of mixed mental health diagnosis and
haloperidol for nausea). behavioural issues may include chemical restraint if a stable dose of
antipsychotic used to treat a diagnosed disorder is increased so as to also
manage behavioural issues.
e.g. schizophrenia well controlled with olanzapine but dosage increased
or PRN added to treat behaviours associated with developmental delay or
progressing dementia.
4
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user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the
loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.
Examples of DRUG TYPE Chemical Comments
and Diagnosis / Symptoms Restraint
(reason for prescribing)
ANTIDEPRESSANTS Yes Citalopram/escitalopram have some evidence of benefit in agitated/
Dementia aggressive behaviours in dementia (chemical restraint).
Behaviours
BPSD Therapeutic Guidelines – Psychotropic (March 2021):
Developmental disability
Aggression If an antipsychotic cannot be used or has been ineffective, a selective
Agitation serotonin reuptake inhibitor (SSRI) antidepressant may be considered for
agitation or aggression (not psychosis) of dementia.… Of all the SSRIs,
citalopram has the strongest evidence for agitation and aggression of
dementia—if it is used, monitor for adverse effects and review response to
treatment at 2 to 3 months and consider stopping if effectiveness is limited.
ANTIDEPRESSANTS No Therapeutic Guidelines – Psychotropic (March 2021):
Major depression
Generalised anxiety disor- Treat a patient with dementia who has major depression by optimising
der (GAD) nonpharmacological interventions.
Post traumatic distress There is a lack of evidence to support the use of antidepressants for major
disorder (PTSD) depression in dementia—a Cochrane review found they had limited or no
Obsessive-compulsive efficacy. Antidepressants are associated with adverse effects (eg dry mouth,
disorder (OCD) dizziness, hyponatraemia) and increase the risk of falls and fractures in older
Panic disorder people…...
Neuropathic pain (e.g. du- Nevertheless, consider starting an antidepressant for major depression in
loxetine, amitriptyline) dementia if the patient has:
• mild to moderate major depression that does not respond to
nonpharmacological therapies within 4 to 6 weeks
• moderate major depression and has previously responded well to an
antidepressant
• severe major depression.
BENZODIAZEPINES Yes Therapeutic Guidelines – Psychotropic (March 2021):
Dementia
Behaviours Avoid using benzodiazepines to treat agitation, aggression and psychosis of
BPSD dementia—there is limited evidence of benefit and they are associated with
Developmental disability serious adverse effects including cognitive decline, urinary incontinence, falls,
Aggression hip fractures and dependence. Benzodiazepine use has also been associated
Agitation with increased all-cause mortality. If an antipsychotic or an antidepressant
Psychosis cannot be used, a benzodiazepine with a (comparatively) short half-life
Nocturnal wandering or and no active metabolites (eg oxazepam) may be considered for agitation,
disruptiveness aggression or psychosis of dementia for a maximum of 2 weeks—closely
monitor the patient for adverse effects.
People with dementia often have marked sleep fragmentation—they may
doze during the day and experience sundowning (agitation and wandering)
in the early evening or at night. Sleep problems can be behavioural and
psychological symptoms of dementia..
5
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user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the
loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.
Examples of DRUG TYPE Chemical Comments
and Diagnosis / Symptoms Restraint
BENZODIAZEPINES No Therapeutic Guidelines – Psychotropic (March 2021:
Generalised anxiety disor-
der (GAD) Benzodiazepines are effective in reducing symptoms of generalised anxiety
Post traumatic distress disorder. However, they should not be used as first-line pharmacotherapy
disorder (PTSD) because of potential harms… If a benzodiazepine is used for an older person,
Obsessive-compulsive lower doses may be needed…. Benzodiazepine use is usually restricted to
disorder (OCD) acute crises and short-term initial therapy. In treatment resistance, they
Panic attacks may be considered for maintenance therapy, ideally in consultation with a
Panic disorder psychiatrist.
Insomnia
Avoid using drugs to treat insomnia in people with dementia—there is
insufficient evidence to support their use.
And for older people with insomnia:
Avoid long-term hypnotic use—it is associated with daytime sedation,
cognitive impairment, accidents, falls and hip fractures.
Note that where used in the management of mixed diagnoses such as a
history of GAD and current progressing dementia with behavioural issues,
the use may be chemical restraint if commenced or dosage increased to treat
escalating behaviours.
Supporting documentation of the details of the symptoms prompting
commencement or dosage increase is important, and the effect in the
management of these should be reflected in the monitoring carried out
and documented (e.g. whether effective or not and whether there are any
adverse effects observed).
ANTICONVULSANTS Yes Therapeutic Guidelines – Psychotropic (March 2021:
Dementia
Behaviours Do not use sodium valproate to treat agitation, aggression or psychosis of
BPSD dementia. Limited evidence suggests it does not improve these symptoms
Psychosis and is associated with a higher rate of adverse effects, some of which are
Aggression serious—a Cochrane review concluded that further research on sodium
Agitation valproate for agitation, aggression or psychosis of dementia may not be
Mood stabilisation justified.
ANTICONVULSANTS No Minimise doses due to the potential for adverse effects such as ataxia,
Epilepsy confusion, weight gain.
Neuropathic pain
Bipolar disorder
REFERENCES:
(1) Quality of Care Principles 2014. https://www.legislation.gov.au/Details/F2020C00096
(2) Therapeutic Guidelines – Psychotropic in eTG complete. https://tgldcdp.tg.org.au/etgAccess
(3) Guideline Adaptation Committee. Clinical Practice Guidelines and Principles of Care for People with Dementia. Sydney. Guideline Adaptation
Committee; 2016. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf
(4) Dementia: assessment, management and support for people living with dementia and their carers. NICE guideline [NG97] Published: 20 June 2018.
https://www.nice.org.uk/guidance/ng97/chapter/Recommendations#pharmacological-interventions-for-dementia 6
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user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the
loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.
Case Scenarios – Chemical Restraint or not?
The following scenarios are from Meditrax pharmacists conducting Residential Medication
Management Reviews (RMMRs) and Psychotropic Medications Analysis (PMA) Audits.
1. (RMMR): “Mrs ‘Resident’ has significant dementia and
previously received frequent PRN clonazepam. This was
changed to lorazepam charted for PRN use in the afternoon due
to anxiety and calling out. The drug has now been administered
at 2pm on a regular basis although care charts do report that
she still calls out intermittently. When asked, she does not
know the reason for this behaviour. It may be prudent to
review whether the regular use of lorazepam in the afternoon
is contributing to sedation and possibly whether the dose could
be slowly reduced. Increased sedation could increase the risk of
aspiration.”
Is the use of lorazepam in this scenario chemical restraint?
Lorazepam is used to manage calling out behaviour,
YES however facility documentation indicated it was
not a chemical restraint as the resident also had a
diagnosis of anxiety.
2. (RMMR): A resident prescribed quetiapine 25mg qid prn (no indication in charted order) was
administered it without documentation of the reason or outcome, and the diagnosis or reason for
prescribing was unclear despite thorough search of medical notes and other documents. The resident
had recently been assessed by Dementia Support Australia for non-pharmacological management of
behavioural issues.
Is this chemical restraint?
It could be an appropriate chemical restraint if there was evidence that use was a last
YES resort (after use of other strategies), however this was clearly not the case according to the
documentation available.
3. (PMA): A resident with developmental delay, osteoarthritis, chronic pain, and hypertension is quite
restless at night banging on other residents’ doors and is prescribed mirtazapine 15mg nocte.
Is this chemical restraint?
YES Mirtazapine is likely prescribed to treat the agitated behaviour occurring at night.
7
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user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the
loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.Case Scenarios – Chemical Restraint or not?
4. (PMA & RMMR): A resident was prescribed fluvoxamine
150mg daily and olanzapine 2.5mg nocte, for “treatment-
resistant persistant depressive disorder, GAD, and obsessive
and dependent personality traits” as per psychogeriatrician
diagnoses, together with lorazepam 1mg daily prn “for severe
agitation only” as per charted instruction and with diagnoses
of “severe anxiety” per CMA and “GAD” per psychogeriatrician
review. RMMR noted that the resident did not have dementia
but was worried about developing it as she was often forgetful,
noting this can be a symptom present due to depression/
anxiety and potentially exacerbated by the anticholinergic effects of olanzapine. RMMR also noted she
“only requests the PRN lorazepam when she feels very anxious”.
Are any, some or all of the psychotropics in this scenario chemical restraint?
However the charted indication of ‘agitation’ for lorazepam should perhaps more accurately
NO state ‘for severe anxiety’ instead, which is the intended and actual use of lorazepam. The
resident has treatment-resistant depression and severe anxiety with generalised anxiety
disorder diagnosed and the psychotropics she is prescribed are appropriate to treat her
diagnosed mental illnesses. Olanzapine in this scenario was confirmed in RMMR to be
“adjunct therapy for her treatment-resistant depression and anxiety disorder”.
5. (RMMR): A resident was prescribed PRN Endone ‘for agitation’ as per the charted order, and it
had been given occasionally with documentation that the resident was agitated as the reason for
administration.
Is this chemical restraint?
The use of the medication is for agitation which may have a number of potential causes, and
YES although it may be a presentation of pain in some residents, there was not a relevant pain
assessment or other documentation indicating that pain was the cause of the agitation.
6. (RMMR): A resident with paranoid schizophrenia is prescribed two antipsychotics; flupentixol injec-
tion and olanzapine wafer, and phenytoin capsules with medical progress notes documenting in January
2021 the phenytoin was for agitation and anxiety, while an older progress note from 2018 stated for
seizure.
Are any, some or all of these medications chemical restraint?
- If phenytoin is confirmed for seizures. The January progress note documentation may be an
NO error, however it would be important to confirm there was a diagnosis of epilepsy or seziures
as use of phenytoin for agitation/anxiety would be inappropriate and a chemical restraint in
this setting. 8
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user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the
loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.Case Scenarios – Chemical Restraint or not?
7. (PMA): A resident was prescribed regular duloxetine for depression/anxiety and PRN diazepam for
anxiety, and his diagnosis list and CMA also indicated he required long term treatment. Facility care plan
documented both as chemical restraints. The resident was not cognitively impaired or lacking capacity
and was noted to request PRN diazepam when he was feeling unable to cope with his anxiety symptoms.
Is the duloxetine or PRN diazepam a chemical restraint?
The resident has diagnosed depressive and anxiety disorders requiring continued treatment,
NO and was aware of the availability of PRN diazepam for when his symptoms were exacerbated.
Facility staff work with him to ensure he has non-pharmacological support as part of his
management plan.
8. (RMMR): A resident has a diagnosis of schizophrenia noted on the facility Psychotropic Register for
treatment with risperidone 0.5 mg twice daily.
Is this chemical restraint?
Schizophrenia is a diagnosed mental illness…..BUT POTENTIALLY YES in this case. The
NO resident’s diagnosis of schizophrenia could not be confirmed in other documentation such as
medical progress notes, Health Summary from the previous GP or other historical information.
Nursing progress notes indicated the resident was experiencing hallucinations occasionally
and there was a diagnosis of advancing dementia. The Care Manager and GP arranged for
psychogeriatrician assessment to determine appropriate ongoing management and whether
there was potentially late-onset schizophrenia.
9. (PMA): A resident with Alzheimer’s dementia was charted
oxazepam for anxiety/agitation, and carbamazepine had
also been commenced but a diagnosis not included on
the facility Psychotropic Register. The Care Manager had
thought the oxazepam was not a chemical restraint due
to there being anxiety included in the charted indication
for use, but was not clear why carbamazepine had been
started. The following entry was located in recent medical
progress notes: “Agitated at times and will not allow carer
to assist him, increase oxazepam to 15 mg bd and add
Tegretol 100 mg bd as mood stabiliser”.
Is one or more of the psychotropics in this scenario chemical restraint?
YES Both oxazepam and carbamazepine are being used in the management of agitation.
9
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