The use of physical and chemical restraints is widespread in all settings despite evidence their use leads to functional and cognitive decline. Restraint use also contributes to loss of control, stigma, loneliness, loss of dignity, and boredom.
The amount of restraint use in nursing homes varies, with some studies noting rates as high as 60% for certain types of restraint. It is not uncommon for a resident to be given both a chemical restraint (often atypical antipsychotics) and a physical restraint although chemical restraints are used most often. Not surprisingly, residents given both types of restraints have the worst outcomes (Foebel et al., 2016).
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 (GovTrack, 2020).
Use of restraints should be:
- Reserved for documented indications
- Time limited
- Frequently re-evaluated for their indications, effectiveness, and side effects in each patient
Florida Nursing Home Bill of Rights
In most states the use of physical and chemical restraints on nursing home patients is illegal. In Florida, the Nursing Home Bill of Rights states 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. In case of an emergency, restraint may be applied only by a qualified licensed nurse who shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety (Florida Statutes, 2019).
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).
Physical restraints include vests, straps, wrist ties, splints, mitts, belts, recliners, geri-chairs, and bedside rails, among others. Restraint can also include 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, latest available).
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).
Unfortunately, the use of physical restraints is a common practice, not only in nursing facilities but in the homecare setting as well. A study in Flanders, Belgium found nurses reported that some of their clients—cognitively impaired older persons, some of whom sometimes lived alone—were restrained or locked up without continuous follow-up. Interviews indicated that the patient’s family played a dominant role in the decision to use restraints. Reasons for using restraints included “providing relief to the family” and “keeping the patient at home as long as possible to avoid admission to a nursing home.” The nurses stated that general practitioners often had no clear role in deciding whether to use restraints (Scheepmans et al., 2014).
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 are commonly used to restrict a person’s freedom of movement 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 commonly 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).
Antipsychotics carry a U.S. Food and Drug Administration (FDA) black-box warning in dementia; they must be used with extreme caution, ongoing monitoring, and only when strict conditions are met. Short-term and long-term antipsychotic use is associated with substantial risk of cognitive decline, morbidity, and mortality. The use of antipsychotics is reserved as a last resort for severe refractory behavioral disturbances without an identifiable and treatable cause or when a serious risk of immediate harm or safety exists that cannot be otherwise ameliorated (Atri, 2019).
The 2015 American Geriatric Society (AGS) Updated Beers criteria for safe medication use in older adults recommend avoiding antipsychotics for treatment of behavioral symptoms or delirium in people with dementia due to the increased risk of cerebrovascular events and greater risk of cognitive decline and mortality. Further, antipsychotics should be avoided unless non-pharmacologic options have failed or are not possible and the older adult is threatening substantial harm to self or others (AGS, 2019).
Nevertheless, a prescriber may choose to prescribe antipsychotic medications for behavioral 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, with some notable successes. Most interventions use education and training aimed at addressing and resolving behavioral triggers.
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. Changes intended to create a more dementia-friendly environment include:
- Redesigning nursing stations so they are part of a home-like design.
- Providing comfortable, easy-to-access alternative seating.
- Lowering wheelchairs to allow self-propelling with feet.
- Providing pressure-relief wheelchair and chair cushions to support comfort and reduce skin breakdown.
- Installing carpeting or rubber mats in key areas 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, improves comfort and reduces anxiety. Regular exercise and comfortable places to rest and nap are important. Other dementia-friendly psychosocial changes include:
- Assessing and treating hunger, thirst, cold, and discomfort.
- Changing medications or tapering medications with adverse effects.
- Treating all underlying causes, including pain.
- Assessing hearing and vision.
- Establishing a nap schedule.
- Relieving fecal impactions.
A nonpharmacological toolkit for reducing antipsychotic use in older adults by promoting positive behavioral health can be accessed online (AGS, 2019).