BEHAVIOUR SUPPORT PLANS AN ESSENTIAL STEP TOWARDS BETTER DEMENTIA CARE

Assoc Prof Steve Macfarlane

Organisations tasked with dementia care face big challenges as they move to adapt to recommendations from the Royal Commission into Aged Care Quality and Safety.

The Royal Commission revealed a range of serious shortcomings in aged care, with the sectors’ historical response to dementia care of particular concern.

Among its most damning findings, the Royal Commission found many patients classed as difficult to manage were routinely subjected to the overuse of “restrictive practices” in the form of medication or physical restraint.

These findings especially resonated this week – Dementia Action Week – which aims to fight discrimination against those living with dementia.

The Royal Commission noted “the overuse of restrictive practices in aged care is a major quality and safety issue. Restrictive practices impact the liberty and dignity of people receiving aged care.”

As a result, restrictive practices can now only be used as a last resort and in the least restrictive form, if at all.

And, most importantly, a behaviour support plan must now be in place for every client who exhibits behaviours of concern or changed behaviours, or who has restrictive practices considered, applied or used as part of their care.

Associate Professor Steve Macfarlane, Head of Clinical Services, Dementia Support Australia, in partnership with Hammond Care, says the changes were long overdue.

“The Royal Commission revealed the very poor standard of care of people with behaviour secondary to dementia, in particular the overuse of antipsychotics,” Professor Steven Macfarlane says.

“Behaviour support plans should always have been there as best practice, but they are now being mandated as a result of findings from the Royal Commission.”

These plans must include best-practice strategies, be responsive to patient needs, reduce or end the need for restrictive practices, provide individualised support, address underlying causes of concern, provide safeguards, and optimise patient health and wellbeing.

Professor Macfarlane says a behaviour plan is an essential step in client assessment and treatment, as it is impossible to manage behavior without understanding it first.

He uses the medical analogy of a patient presenting at the GP with a cough. “You don’t just give them a cough suppressant, you try to determine what is causing it,” he says.

“It’s the same with behavior. There can be multiple different causes, so to take the first step you need to assess the resident to see what is likely to be causing the problem.

“The key to understanding that is knowing your residents well, having taken a history on admission of their likes and dislikes, their personalities and routines, and their occupation and relationships with other people.

“That knowledge forms the basis of any behaviour support plan.”

Professor Macfarlane says there are other components to a client’s assessment.

“If they have started to display a behaviour, we may ask the question, is there an underlying medical cause?

“Are they delirious? Are they depressed? Are they in pain? It is pretty meaningless to launch into a management plan in the absence of those details.”

In the worst-case scenario, providers must now satisfy a number of conditions before using any restrictive practice, document the alternatives and why they have not been successful, and have a clinical governance framework in place to minimise their use.

They must also ensure informed consent has been obtained, and affected patients must be monitored for signs of distress or harm, side effects and adverse events, changes in wellbeing, as well as independent functions or ability to undertake activities of daily living.

But Professor Macfarlane says restraints should always be a last resort, used only if all other options have been exhausted.

And he says simply prescribing antipsychotics for a behavior, regardless of the cause, is senseless and heavy-handed.

“Non-pharmacological strategies are the gold standard now,” he says. “The Act now requires that all reasonable alternatives must be trialled before one of those restrictive practices is used.

“This could include providing meaningful activities, addressing pain, addressing boredom, addressing loneliness.

“The outcomes of these interventions are much more powerful, and completely safe when compared to antipsychotics.”

Professor Macfarlane says better use of behaviour support plans will require improved staff training and skills.

He says employers will have to make the necessary training provisions for those already employed in the sector, while training must begin beforehand for those planning to work in the sector.

“Currently you can get a job as a carer on the floor by doing an online course that has an optional component in dementia,” he says. “People are entering employment with very little knowledge of what dementia is, let alone about behavior problems.

“It’s a big ask to expect a workforce who are inadequately prepared to do these assessments about contributing factors.”

New provisions enforceable from this month aim to ensure providers have updated all their policies, procedures and staff training.

“This first step will ensure providers have necessary policies and procedures in place, and a plan to train their workforce,” Professor Macfarlane says.

“It’s a challenge – but an appropriate challenge – for the industry, because dementia care across the board has been done very badly for many years.

“It’s one of many steps that will lead to an improved standard of care in the future.”