Project Summary
Clayton Church Homes in partnership with the University of South Australia, Southern Cross Care (SA, NT & Vic) and Geriatric Care Australia has been awarded an ARIIA grant for their project ‘A clinical pathway for best practice in dementia care: A cluster randomised controlled trial’.
Changed behaviours of dementia, including aggression, agitation, depression, and wandering, can be extremely stressful for the individual, carers and staff and are a contributing factor for people admitted to residential aged care facilities. Dementia is present at similar rates per person across all areas of Australia, yet healthcare delivery in rural and remote areas of Australia present unique challenges that metropolitan areas do not face.
A clinical pathway developed in collaboration with the staff and management at an aged care facility that support health and social care staff in the identification, monitoring, and support of changed behaviours, based on current best practice guidelines, and designed for implementation in Australian Rural Aged Care Facilities (RACFs) will be used.
This research will involve regional aged care providers and aims to assess the effectiveness and implementation of a clinical pathway to reduce the use of psychotropic medications and adverse events specific to changed behaviours and increase interprofessional collaboration within aged care facilities.
Project Outcomes
Background and Aims
Dementia Australia reports that there are an estimated 433,300 Australians living with dementia, with approximately 1.7 million people involved in their care (Dementia Australia, 2025). One important area of focus for dementia care is appropriate and safe management of behavioural and psychological symptoms of dementia (BPSD).
There are two main types of interventions for managing BPSD:
- non-pharmacological practices which include behavioural and environmental changes, and
- restrictive practices which can include physical, mechanical, environmental, seclusion or chemical restraint.
In the context of restrictive practices, chemical restraint refers to the use of medication for the purpose of influencing a person’s behaviour. The use of psychotropic medication to influence a person’s behaviour in people living with BPSD is chemical restraint (Australian Government, 2020). It is generally agreed that behavioural approaches should be the first-line intervention to address changed behaviours (Guideline Adaptation Committee, 2016; Harrison et al., 2020; Legere et al., 2018; Tible et al., 2017). Evidence suggests that the use of psychotropic drugs as a restrictive practice should be avoided where possible and used only if there is a risk of self-harm or harm to others (NICE, 2018), due to the increased risk of serious adverse events linked to these medications (Guideline Adaptation Committee, 2016). When pharmacological treatment is appropriate it should always be used in conjunction with consistent non-pharmacological strategies (Guideline Adaptation Committee, 2016; Guideline Development Group, 2023; Tible et al., 2017). The Australian Commission on Safety and Quality in Health Care highlighted the overuse of antipsychotic medications in aged care in the Australian Atlas of Healthcare Variation in 2015 and a repeat analysis in 2018 found little change in the overall use of antipsychotic medications in aged care (The Australian Commission on Safety and Quality in Health Care, 2022).
This evidence-practice gap creates opportunities for applied research to support residential aged care facilities (RACF) to test new interventions that aim to foster an environment of an “optimal default” care response by staff. That is, interventions that foster conditions that support the preferred, best practice care outcome, as the default response by staff. This project is phase three of a research project that aims to explore the implementation and effectiveness of a six-month clinical pathway for best-practice management of behavioural and psychological symptoms of dementia (BPSD). Phase three is split into two parts – the first investigating the impact of the clinical pathway on metropolitan RACFs, and the second, and discussed in this report, is the impact of the clinical pathway on regional RACFs.
The aim of the study was to assess the implementability and effectiveness of the DCP in different aged care homes across regional Adelaide. The study was guided by the following questions to assess the implementability and effectiveness:
Implementation research questions
- Does the clinical pathway improve clinician confidence to provide care to people with BPSD?
- What are the barriers to and facilitators of successful implementation of the clinical pathway across multiple residential aged care facilities?
- How and where does the pathway need to be adapted to suit the context in which care is being delivered?
Effectiveness research questions
- Does the clinical pathway improve clinical outcomes for people with BPSD living in RACFs?
- Does the pathway improve quality of life for people with BPSD living in RACFs?
What We Did
The intervention consists of an education program for nurses, clinical care teams, and personal care workers on the use of a newly developed clinical pathway – a dementia care pathway (DCP) – for the evidence-based care of people living with dementia who are experiencing BPSD.
The core of the information included in the clinical pathway was based on recommendations from the Clinical Practice Guidelines and Principles of Care for People with Dementia, (Guideline Adaptation Committee, 2016) an Australian clinical practice guideline. This clinical practice guideline was adapted to Australian healthcare settings in 2016, from a UK clinical practice guideline on dementia care. The UK clinical practice guideline was updated in 2018, (NICE, 2018) and this version was used to check the currency of the Australian clinical practice guideline recommendations. This content was supplemented by more recent evidence from national and international health service operational guides, (National Health Service, 2011; Victorian Department of Health and Human Services, 2019) a clinical practice guideline developed for Dementia Behaviour Management Advisory Service providers, (Burns et al., 2012) a systematic review that provided updated data on the effectiveness of multisensory stimulation (Silva et al., 2018) and a Canadian clinical practice guideline on deprescribing antipsychotics for BPSD (Bjerre et al., 2018).
The DCP aimed to address staff knowledge and confidence, and site processes and protocols for early intervention, management or prevention of potential BPSD incidents, with no or minimal use of restrictive practices such as physical, mechanical, environmental, or chemical restraint. The DCP was designed for RACF staff to identify, monitor, and support persons living with dementia, who are experiencing BPSD, with specific consideration to reducing the requirement for the use of psychotropics or other restrictive practices within this process.
The DCP meets all eight of the current Aged Care Quality Standards (Aged Care Quality and Safety Commission, 2018), covering a large number of the requirements within each of the standards. The DCP also provides a framework of documentation that addresses the evidence required to demonstrate compliance with the use of restrictive practices if required.
Outcomes
Survey
There was a trend for slight improvements in the confidence in a staff members own ability to care for someone with changed behaviours, and the knowledge of pharmacological, and non-pharmacological treatments to manage changed behaviours, however these differences were not statistically significant. There was a trend for the mean scores for the clearness of all documentation to improve, however, the differences between timepoints were not significant. There was a trend for the sense of competence for all aspects to be higher at timepoint 2, however, the differences between timepoints was not significant. There was a trend for the overall mean dementia knowledge to decrease, however, the difference between timepoints was not significant.
All respondents believed a flowchart/checklist would help their confidence in their decisions, believed the checklist would improve the consistency of caring for people with BPSD, believed it would encourage standardisation of record keeping, and believed it would make them feel supported in their decision making.
Less than half of all direct care respondents (i.e., nurses, care workers, n = 3, 43%) had completed professional development courses that were specific to the management of BPSD, BPSD of dementia, or dementia specific care, and fewer non-care staff (i.e., grounds staff, cleaning staff, n = 5, 28%) had completed any course that was specific to caring for or interacting with people living with dementia.
Interviews and focus groups
Staff from both sites discussed how the DCP could impact both resident and staff outcomes. The DCP supported sites in decision making around caring for residents. The DCP supported the sites decision to transfer a resident to hospital for further assessment on an appropriate care facility. The manager believed that being able to demonstrate to the paramedics the behaviour support plan for that resident, and the use of the DCP, made them more confident in their decision making. Additionally, a different manager provided an example where the DCP helped to emphasise and encourage a resident’s family in decision making and care planning. This collaborative approach, with support from the use of the DCP supported the site to find appropriate solutions to support the resident. One manager discussed that the use of the DCP could help nurses, particularly new nurses, to feel confident in their decision making, citing they have identified skill gaps in dementia care. A different care manager identified that the use of the DCP can support staff in managing their workflows, which can have a positive impact on their workload.
Management staff from both sites commented on components of implementation which are important for implementing the DCP into this site. One care worker member discussed the importance of having at least one consistent care worker who is trained in the DCP on during all shifts. Having at least one consistent care worker can support other staff to meet the individualised resident’s needs. This is important, as consistent staff, sharing strategies and workflows will be more time efficient and better able to support individualised care. Management staff across both sites discussed having the right resources at the site were critical for successful implementation. The resources discussed were specifically around having skilled staff with a passion and knowledge in dementia care in positions to support the implementation and ongoing use of the DCP. Care managers identified that many staff, while aware of dementia, may not have in-depth knowledge of caring and supporting people with dementia. As such, providing these staff with the training to have the knowledge of how to care for residents is crucial.
Themes regarding the impact of working in a rural or regional area on supporting residents with dementia were discussed. Accessing external support services in regional areas was considered more difficult. It was highlighted that while accessing aged care GPs or geriatricians are difficult across the sector, these can be even more limited in regional settings.
Both managers discussed what aspect of the DCP they thought would be crucial to maintain going forward. The manager from site one identified the traffic light system was beneficial in identifying key triggers and communicating the residents individual needs during handovers. This was beneficial as staff will likely not have the time to read through a resident’s three-four-page long behaviour support plan. The manager from site two identified that the ABC (Antecedent, Behaviour, Consequence) tool was beneficial in supporting staff to identify triggers and strategies to support changed behaviours and provide written evidence of discussion of non-pharmacological strategies.
Observations by the research team
Consistency of care and clinical staff, and engagement of a site champion were identified as facilitators to successful implementation. Engagement of site champions were important for the wider adherence to the DCP at a site level. Site champions, whose role sits within the organisation, but outside of providing direct care for residents have more capacity to support the implementation of the DCP than site managers, or champions who continue to provide care as part of their role. Site champions who are engaged with the purpose of the DCP and have capacity are more appropriately suited to support the implementation of the DCP including ensuring staff have appropriate training and the resources required to provide individualised care, and engaging residents and their families in the decision-making process. Additionally, sites need to have adequate resources, specifically enough staff to support the implementation.
Implementation analysis aligned to the theoretical framework
The implementation was analysed according to the evaluation framework for implementation outcomes. The acceptability and appropriateness of the DCP was successful across both sites, while the adoption, cost/resources, feasibility, fidelity, penetration, and sustainability had neutral success.
Impact on Aged Care and Workforce
Overall, the results suggest that the pathway was a useful tool for supporting staff to protocolise care, better identify care needs, provide guidance and more effectively nuance care to each resident depending on their dementia support needs at the time and trajectory. The pathway was not a panacea for BPSD nor removal of psychotropic medication, but it was described to be a useful aid in the identification of strategies to reduce over-reliance on non-behavioural interventions, as well as providing staff with confidence in their clinical care. In one example, case notes suggested that the pathway helped sites to realise that the resident’s care needs were beyond their capacity to support, and they required specialist dementia care. This is potentially a beneficial outcome for all concerned.
There was evidence of clear reasoning behind the prescribing/deprescribing of antipsychotic medications, and identification of behaviours of unmet needs. There was evidence of more individualised strategies being implemented for residents throughout the study. There was a trend for a small increase in the self-rated confidence in providing care to people with BPSD. The DCP supported clinician confidence.
Resources Developed
A flowchart to support staff to identify residents’ level of BPSD risk and guide actions to be undertaken to address and reduce risk was created. See below:
Future plans
Peer-reviewed articles are being drafted for publication in academic journals. No further plans.
Key contact for further information