Residential aged care psychiatry — behavioural crisis and prescribing (MEQ)

(i) Assessment. Behavioural change in RAC is multifactorial. Structure: safety (aggression, falls, absconding); collateral from staff and family for time course and baseline; medical screen for delirium, infection, pain, constipation, retention, dehydration, hypoxia; medication review (oxybutynin anticholinergic burden; temazepam sedative/deliriogenic); define target behaviours with ABC charting and NPI-style domains; risk and capacity/proxy map. High psychiatric morbidity in LTC means do not dismiss symptoms, but do not label every crisis as primary psychosis.[1][2]

(ii) Non-drug care. First-line is person-centred care, meaningful activity, sensory aids, consistent approach to personal care, and staff training. Fossey cluster RCT: enhanced psychosocial care reduced antipsychotic use in severe dementia nursing homes without significantly worsening behaviour. WHELD/person-centred packages improve quality of life and agitation metrics and can reduce antipsychotic use. Husebo: protocolised pain treatment reduces behavioural disturbance in nursing-home dementia — treat pain before escalating psychotropics. Stop or minimise oxybutynin and temazepam if safer alternatives exist.[4][5][6]

(iii) Antipsychotics. Benefits are modest and symptom-targeted for severe distress or danger only. Harms: Schneider meta-analysis — increased death with atypical antipsychotics in dementia RCTs; observational mortality and serious-event data (Gill/Huybrechts/Rochon class of evidence). If continued briefly for clear risk: lowest dose (e.g. risperidone 0.25–0.5 mg range), ECG/falls monitoring, documented target, consent/proxy, review/stop date. DART-AD: continuing neuroleptics is not clearly advantageous for many; long-term follow-up raised mortality concerns with continued treatment — plan deprescribing when stable.[3][7][8]

(iv) Restraint, capacity, disposition. Near-daily PRN without documented indication risks chemical restraint framing — document therapeutic purpose or stop. Capacity is decision-specific for psychotropic consent and transfer; engage proxy under local law. Disposition: optimise in place with old-age liaison/DBMAS-style support; hospital only if medical instability or risk exceeds facility capacity. Reassurance to staff that evidence-based non-drug care can reduce drug reliance is part of systems leadership.[2][4]