The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) established a resident’s right to be free of physical or chemical restraints in nursing homes when used for the purpose of discipline or convenience and when not required to treat the resident’s medical symptoms. Uncooperativeness, restlessness, wandering, or unsociability are not sufficient reasons to justify the use of a restraint (Agens, 2010). This right to be free from physical or chemical restraints is reinforced by the Massachusetts Executive Office of Elder Affairs (Mass.gov, 2019a).
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 the most recent update of final regulations by the Centers for Medicare and Medicaid Services (CMS), effective 2019, for nursing homes participating in its programs this wording remains:
§ 483.12 Freedom from abuse, neglect, and exploitation.
… (a) The facility must — … (2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
There is concern about the strength of enforcement of these regulations, and these rights are not always observed. Those who care for and about elders with dementia need to remain vigilant, ask questions, and advocate for their patients and loved ones. Many families, for instance, do not realize they have the right to ask about and say no to inappropriate medications (CANHR, 2018, 2016, 2012; Seegert, 2018; Arlotta, 2015).
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 the body. 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. 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.
The use of physical restraints (including belts), can increase the risk of death or serious injury as well as increase the length of a hospital stay. 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 can also create an ethical dilemma by restricting a person’s autonomy and independence (Lai et al., 2011).
Tens of thousands of nursing home residents with dementia receive powerful antipsychotic drugs that are not intended or approved for their medical conditions. Rather, the drugs are often used to sedate and control them, a terrible substitute for the individualized care they need and deserve. The U.S. Food and Drug Administration (FDA) has issued its most dire warning—known as a black box warning—that antipsychotic drugs cause elders with dementia to die.
California Advocates for Nursing Home Reform, 2012
We do not usually think of a medication as having the potential to restrain a person’s free movement. However, in older adults with dementia there is a long history of antipsychotic and sedative use—chemical restraints—to subdue or otherwise alter a person’s behavior.
A chemical restraint is the intentional use of any medications to subdue, sedate, or restrain an individual. Chemical restraints have been used to restrict the freedom of movement of a patient—usually in acute, emergency, or psychiatric settings. Chemical restraints are often prescribed for what healthcare workers describe as dangerous, uncontrolled, aggressive, or violent behavior.
Anti-anxiety, antidepressant, and antipsychotic medications are often used to treat the behavioral and psychological symptoms associated with dementia. These medications affect mood, perception, consciousness, cognition, and behavior. They 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).
Several large clinical trials have demonstrated an increased risk of mortality with the use of atypical antipsychotics in people with 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 linked to a two- to three-fold higher risk of cerebrovascular events (Steinberg & Lyketsos, 2012).
In 2019 the American Geriatrics Society (AGS) Updated Beers criteria for safe medication use in older adults and recommended that if not treating for psychosis, use antipsychotics with caution. Drugs such as haloperidol (Haldol), risperidone (Risperdal), or quetiapine (Seroquel) are commonly used to treat behavioral problems in older adults with dementia. However, they can increase the risk of stroke and even death in those patients. They can also cause tremors and other side effects, and increase the risk of falls. In addition, dextromethorphan/quinidine should be avoided for the treatment of behavioral symptoms of dementia (Medscape, 2019).
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 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. 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.
For a nonpharmacologic toolkit for reducing antipsychotic use in older adults by promoting positive behavioral health, click here.