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About 220,000 older Australians are living in Residential Aged Care Homes (RACH) and over 50% of these are ‘people living with dementia’ (PLWD) with varying degrees of severity, with about 40% having mild symptoms and <1% extreme. At the recent Dementia in Residential Aged Care Forum, a diverse group of experts from about ten disciplines presented evidence-based data that expanded the knowledge of all who attended.
RACH staff including clinical administrators, nurses and carers have the principal role in observing early changes such as apathy, agitation, anxiety, depression, irritability, delusions, disinhibition, hallucinations and wandering that may prompt initial assessment and diagnosis. They also witness the changes known as ‘behaviours and psychological symptoms of dementia’ (BPSD), and are the first to note deterioration in memory, thinking, mood and usual behaviours that reflect the altered communication that occurs in this syndrome. The underlying organic cerebral changes can occur in different regions of the brain and thus the different types of dementia e.g. Alzheimer’s, frontotemporal and Lewy Body will feature different syndromes. Dementia is now the most common cause of death in Australian females and the #2 cause in males[1].
With the large cohort of patients with dementia, RACH staff are now well-placed to recognise and manage BPSDs as a result of programs that are available from Dementia Support Australia (DSA) 1800 699 799 and Dementia Training Australia (DTA) 1300 229 092. Both organisations provide many resources including DTA’s Changed Behaviour Toolkit with online courses and workshops available, as well as programs to Respond Safely to a Critical Situation, using the AID model to “Assess risk and Assign a leader / Investigate / Do something”. DSA has also developed a Delerium Screen Tool allowing staff to identify potential causes which may relate to bowel, pain, medicines and infection. A recurrent message was that the aberrant behaviours that cause concern to family friends and staff are generally best managed by RACH staff, and that medical interventions provide few successful treatment options. We were reminded that use of the common medicines used to treat behaviour disorders such as anti-psychotics, antidepressants, anxiolytics and mood stabilisers provide limited therapeutic benefit and a lot of potential adverse effects that can result in poor outcomes. Simply checking – for glasses, hearing aids, pain relief, fluid intake, nutrition, bowel management, sleep hygiene, exercise programs and elimination of irritating noise or light may solve a behaviour disturbance.
Behaviour support plans are critical for the management of PLWD. The plan needs to be cohesive and fit for purpose and needs to address Restrictive Practices (RPs). This important aspect of care was rooted in Legislation and identifies
chemical, mechanical, environmental, physical and seclusion modalities as potentially restricting the rights and freedoms of consumers. Enaction of an RP mandates informed consent, assessment, monitoring, review, documentation, behaviour support and alternative strategies where possible. Biopsychosocial assessment of pain, loneliness, delirium, mood disorder, over/ under stimulation and carer style should be utilised for all BPSD.
There were important messages from our ambulance paramedic colleagues revealing a very integrated team with a central ‘clinical hub’ with liaison to the Emergency Department (ED), mental health and social work experts. They have medications available but must involve the police if any physical restraint is required. Ambulance transfer to hospital may be a harrowing experience and thus RACH staff should exhaust all alternatives before transferring to ED. When BPSDs involve potential criminal conduct, RACH staff are required to call police and everyone needs to be cognisant of circumstances, especially when ‘Elder Abuse’ occurs where the vulnerable may become victims.
Looking after older citizens in RACHs is a vocation and RACH staff are all heroes – thank you for your service.
Dr Laurence Kelly
Chevron After Hours
[1] Dementia Australia (2023) Dementia Prevalence Data 2024-2054, commissioned research undertaken by the Australian Institute of Health and Welfare instead of Australian Institute of Health and Welfare (2022) Dementia in Australia, AIHW, Australian Government, accessed 20 January 2023
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