Dementia Series: Dr Laurence Kelly

“Everyone has the right to safe compassionate care. We preserve the right and ensure that people who use aged care are treated with dignity and respect” was the premise of the Royal Commission into Aged Care Quality and Safety. The recent Dementia in Residential Aged Care Forum brought together a group of speakers who gave different perspectives on the subject. It was humbling as a GP to see how many are involved in caring for our patients with dementia.

How things have changed over the years – dementia can affect any person, and about 50% of residents in Residential Aged Care Homes (RACH) may have this diagnosis – Alzheimer’s being most common, as well as vascular, mixed, Fronto-Temporal, Lewy Body and many other causes. Patients present with numerous symptoms of variable severity, allowing grading into different diagnostic categories – from mild, moderate, severe and extreme. Numerous changes are collectively termed ‘behaviours and psychological symptoms of dementia’ (BPSD) and ‘people living with dementia’ (PLWD) have a syndrome related to altered communication with limited effective treatment options. About 40% have mild dementia with little BPSD and <1% are extreme.

A recurrent theme at the workshop, related to the limited role of medications in managing symptoms and some discussion about the major classes of medications commonly used to treat symptoms. Antipsychotics, antidepressants, anxiolytics and mood stabilisers were all discussed with a limited evidence base for their use and multiple adverse effects that include increased stroke risk, sedation, falls, fracture risk, dependence, dry eyes, constipation, cognitive impairment and weight gain. Symptom severity could warrant the use of medications if other management strategies were unsuccessful, but close monitoring for side effects and deprescribing when possible was essential. If used at all, antipsychotic treatment is recommended at the lowest possible dose for a maximum of 12 weeks.

Restrictive Practices (RP) including chemical, mechanical, environmental, physical and seclusion relate to any practice or intervention that has the effect of restricting the rights or freedom of movement of consumers. Decision-making with respect to RPs involves GPs, RNs, or Clinical Managers and family and all 5 categories require informed consent, assessment, monitoring, evaluation, documentation and review as well as behaviour support and exploring potential alternative strategies. GPs will have experience with the chemical restraint requirements when using prescribing software like BESTMED.

Dementia Services Australia (DSA) provides 24-hour phone support at 1800 699 799 and a comprehensive website www.dementia.com.au which emphasises a biopsychosocial approach to all aspects of care, and thus provides an invaluable resource emphasising non-pharmacological solutions in addition to behavioural assessment screening tools. Dementia Training Australia (DTA) is another dedicated resource for BPSD.

There were 8,410 calls for Ambulance transfers from RACHs to Gold Coast hospital EDs last year. The experience of travelling in an ambulance is unpleasant for dementia patients. They lay on narrow beds and are often claustrophobic and fearful and may spend hours ‘ramping’ – waiting to be handed over to the Emergency Department (ED) staff. The ambulance paramedics are well trained with a ‘Clinical Hub’ allowing access to ED Mental Health and Social Workers. Interestingly, only 0.2% need chemical sedation; paramedics use Droperidol IM 5-10 and ketamine, with olanzapine to be available in the future.

Queensland Police officers reminded us of the potential criminal exploitation of the vulnerable dementia cohort and explained the situations where police should be called to investigate allegations of neglect, inappropriate care or ‘Elder Abuse’. Areas of concern include both physical and financial abuse by a person in a position of trust, where the actions are concealed or only discovered by chance.

DSA provided a Delerium Screen Tool and DTA 1300 229092  DTA.com.au advised a Changed Behaviour Toolkit, and a protocol to Respond Safely to a Critical Situation, using the AID model to “Assess risk and Assign a leader / Investigate / Do something”. Other Services noted were the Acute Care Team 1300 642 255 and GP Psychiatry Support Line 1800 161 718. The Forum demonstrated that dementia care should be a major area of interest for all GPs. Doctors are well supported by very well-trained allied health professionals. In the past, every GP had RACH patients and all GPs should be encouraged to participate in this sector – both in and after hours. 

Dr Laurence Kelly

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