Since the Royal Commission, I am getting requests to prescribe sedatives instead of antipsychotics for some of the more severe symptoms associated with dementia, because the post-royal commission paperwork load is too much for many residential aged care facilities to manage.

I don't think this was the intended outcome of the commission and I'm pretty sure it's not what families of those oversedated on these agents want. I am now also required to write that my patients are psychotic to circumvent the paper work which again, was probably not intended.

I don't want my clinical practice to generate levels of paperwork that change my clinical practice, or a GPs, or an aged care facility. The majority of GPs working in aged care are very very good at what they do, they are just not remunerated properly and time-poor.

The majority of GPs have no interest in sedating anyone to the eyeballs and neither do most nursing homes. Oversedation happens due to a lack of training and/or understanding in dementia, not a lack of paperwork. That's the rant part.

To understand when to use these agents in dementia, it's better to understand what they DON'T work for. They don't work for wandering. Most people who are wandering doso because they used to walk a lot or they don't feel safe. You cannot medicate your way out of wandering.

They don't work for calling out. People call out because they need something. They may not be able to communicate what that is. If you forget where you are every 2 seconds, you will call out every 2 seconds to check where you are. This cannot be medicated.

However, approximately 20% of patients with dementia will experience symptoms that may require medication that manages those symptoms. Sometimes, to everyones horror, its aggression that puts the person or their carers at risk. Sometimes you can't find the underlying reason.

Sometimes people will need assistance with highly intimate personal care such as toileting or showering. Sometimes they have such extreme anxiety and paranoia that they are left terrified by things they cannot explain.

Brodaty et al MJA 2003 visualised these symptoms very well, Tier 4 and above is where you start considering medications:

And if you are going to use an antipsychotic, consider your goal. Your goal is not to sedate. It is not to stop wandering or calling out. It is not to make a shift easier.
Dementia is a terminal disease and in terminal diseases our goal should always be to relieve suffering.

Relieving suffering does not equal sedating. It means allowing a person to be able to go about their day and enjoy a stable quality of life for as long as they can, without distress.

So when you get that request to 'please give them something', consider what it is that they need. The wanderer isn't suffering if they're allowed to wander. The caller-outer isn't suffering when someone sits with them. Lashing out is. Terrifying paranoia is.

Prescribe music. Prescribe people. Prescribe books and art and photos of families and journals. Prescribe someone saying good night and tucking them in. Heat packs. Aromatherapy. Tiger balm. Fresh flowers. Shared memories. Familiar things.

And for that real distress driven entirely by the disease that doesn't respond to all of the above that has nothing to do with making your or anyone elses day easier, ring their loved one first. Discuss medication and what its role is, and what it can and can't do.

People are generally grateful and accepting when they know you've tried everything you can first, and very grateful that you're taking the time to communicate them honestly about the challenges involved. Paperwork doesn't change much at all. Thankyou for reading.