The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) established a resident’s right to be free of restraints in nursing homes when used for the purpose of discipline or convenience and when not required to treat the resident’s medical symptoms. Related regulations specify that uncooperativeness, restlessness, wandering, or unsociability are not sufficient reasons to justify the use of antipsychotic medications (Agens, 2010).
Use of restraints should be:
- Reserved for documented indications;
- Time limited; and
- Frequently re-evaluated for their indications, effectiveness, and side effects in each patient. (Agens, 2010)
In most states the use of physical and chemical restraints on nursing home patients is illegal. Many have a Nursing Home Bill of Rights intended to protect residents’ physical and mental well-being. The bill of rights generally state that a nursing home resident has the right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints authorized in writing by a physician for a specified and limited period of time or as are necessitated by an emergency. Statutes often stipulate that, in case of an emergency, a restraint may be applied only by a licensed nurse who must document the circumstances requiring the use of restraint, and, in the case of a chemical restraint, a physician must be consulted immediately. Restraints cannot be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety.
A physical restraint is any device, material, or equipment attached to or near a person’s body that can neither be controlled nor easily removed by the person, and that deliberately prevents or is deliberately intended to prevent a person’s free body movement to a position of choice or a person’s normal access to his body (Lai et al., 2011). Restraint also includes using (or threatening) force to make a person do something that they are resisting, and restricting their movements, whether or not they resist (Nuffield Council on Bioethics, 2009). The prevalence of physical restraint varies from 5% to 56% as reported in existing literature (Lai et al., 2011).
Physical restraints include vests, straps, wrist ties, splints, mitts, belts, recliners, geri-chairs, and bedside rails, among others. Several studies have demonstrated that carefully orchestrated restraint-reduction programming can greatly reduce the use of physical restraining devices (Lai et al., 2011).
The use of physical restraints (including belts), increases the risk of death or serious injury and can increase the length of a hospital stay. The use of restraints may also indicate a failure to address the real needs of residents and patients (Gulpers et al., 2010).
Both prolonged and short periods of physical restraint use are associated with pressure sores, loss of muscle strength and endurance, joint contractures, incontinence, demoralization, humiliation, feelings of low self-worth, depression, aggression, and impaired social functioning (Gulpers et al., 2010).
The use of physical restraints creates an ethical dilemma by impinging on a person’s autonomy. Their use is associated increased instances of falling, the development of hospital-associated infections, and cognitive decline. Restraints also increase dependency in activities of daily living and walking (Lai et al., 2011).
A chemical restraint is the intentional use of any medications to subdue, sedate, or restrain an individual. Traditionally they have been used to restrict the freedom of movement of a patient—usually in acute, emergency, or psychiatric settings. Chemical restraints are typically prescribed for dangerous, uncontrolled, aggressive, or violent behavior and should always be used for the shortest time possible.
In older adults with dementia, psychotropic agents such as anti-anxiety, antidepressant, and antipsychotic medications are commonly used to treat the behavioral and psychological symptoms associated with dementia. These medications, which affect mood, perception, consciousness, cognition, and behavior can become a chemical restraint if used improperly and may be overused a means of behavioral control in older adults with dementia (Peisah & Skladzien, 2014).
Attention to the misuse of antipsychotic drugs, particularly the newer atypical antipsychotic drugs, was brought to public attention by Lucette Lagnado, writing in the Wall Street Journal in December 2007. She reported that atypical antipsychotic drugs are used off-label in nursing facilities as a substitute for adequate staffing and to quiet residents. She described several reasons for the off-label use of antipsychotic drugs in nursing homes, including the 1987 Nursing Home Reform Law’s limits on the use of physical restraints, off-label marketing of antipsychotic drugs by drug companies, and insufficient staffing in nursing facilities. Lagnado reported that the Medicaid program spent more on antipsychotic drugs than on any other class of drugs (Edelman & Lerner, 2013).
Atypical antipsychotics were approved by Food and Drug Administration (FDA) in the 1990s exclusively for the treatment of schizophrenia. Soon after, these medications became the new standard of care for behavioral and psychological symptoms of dementia due to their reported advantages over conventional agents, particularly with respect to extrapyramidal symptoms such as dyskinesias (Liperoti et al., 2008).
In the elder population, the largest number of prescriptions for atypical antipsychotics is written for the neuropsychiatric symptoms of dementia, which include delusions, depression, and agitation. Neuropsychiatric symptoms affect up to 97% of people with dementia over the course of their illness. No atypical antipsychotic is FDA-approved for the treatment of any neuropsychiatric symptoms in dementia (Steinberg & Lyketsos, 2012).
Several large clinical trials have consistently demonstrated an increased risk of mortality with the use of atypical antipsychotics in dementia. All atypical antipsychotics now carry a black box warning from the FDA about this risk, and a similar warning applies to conventional antipsychotics. Atypical antipsychotics are also linked to a two- to three-fold higher risk of cerebrovascular events (Steinberg & Lyketsos, 2012).
The 2012 American Geriatric Society (AGS) Beers consensus criteria for safe medication use in elders recommend avoiding antipsychotics for treatment of neuropsychiatric symptoms of dementia due to the increased mortality and cerebrovascular events risk “unless nonpharmacologic options have failed and patient is threat to self or others” (Steinberg & Lyketsos, 2012).
A prescriber may choose to prescribe antipsychotic medications for behavioral and psychological symptoms associated with dementia and they may be effective in some cases. The prescriber must, however, disclose to the patient or family that the medication is being used off-label* and obtain permission to use it for behavioral symptoms.
*Off-label use is the practice of prescribing pharmaceuticals for an unapproved indication, age group, dose, or form of administration.
Alternatives to Restraints
Many attempts have been made to reduce restraint use in clinical practice. Most interventions have used educational approaches, aiming to improve nursing staff knowledge and confidence to avoid physical restraints and to use alternative measures that target the resident’s underlying problems (Gulpers et al., 2010).
In a small Dutch study involving 30 residents, education, institutional changes, and alternative interventions resulted in a significant reduction in the use of belt restraints. Belts were replaced with resident-centered interventions such as movement and balance training, lower beds, hip protectors, extra supervision, and monitoring devices (video camera, sensor mat, and infrared alarm systems) (Gulpers et al., 2010).
Other strategies have been used as an alternative to physical restraints. Reducing clutter, keeping hallways free of equipment and obstacles, and liberal use of rails, grab bars, and transfer poles in rooms, bathrooms, hallways, and common areas is recommended. A friendly, uncluttered, home-like environment provides a safe and effective alternative to physical restraints. Other suggestions related to the environment:
- Redesign the location of nursing stations so they are part of a home-like design.
- Provide pressure-relief wheelchair and chair cushions to improve comfort.
- Lower wheelchairs to allow self-propelling with feet.
- Provide comfortable, easy-to-access alternative seating.
- Install carpeting to reduce injury from falls.
Psychosocial policies and activities can also assist in reducing or eliminating the use of restraints. Establishing a routine, including a toileting schedule, will improve comfort and reduce anxiety. Regular exercise and comfortable places to rest and nap are important. Other psychosocial suggestions:
- Assess and treat hunger, thirst, and discomfort.
- Change medications or taper medications with adverse effects.
- Treat all underlying causes, including pain.
- Assess hearing and vision.
- Establish a nap schedule.
- Relieve impaction.