Imposing physical restraints is not good practice for protecting residents who are prone to falling or unsafe wandering.
Jane Tilley and Peter Reed
Falls, Wandering, and Physical Restraints
Because unsafe behaviors such as wandering, aggressive behaviors, and falls are so common in people with dementia, it may seem like a good idea to restrain them when you think they are in danger. But many studies have shown that restraints can actually increase the risk of falls and contribute to other negative physical and psychological outcomes such as bruises, musculoskeletal injuries, skin tears, physical deconditioning, pressure ulcers, anger, depression, and anxiety.
The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) established a resident’s right to be free of the use 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 also 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:
In most states the use of physical and chemical restraints on nursing home patients is illegal.
A physical restraint is “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient that the individual cannot remove easily and which restricts freedom of movement or normal access to one’s body” (Canadian Patient Safety Institute, 2007).
The use of physical restraints can be reduced or even eliminated using environmental, psychosocial, and physical alternatives. Since 2007, the Department of Health and Human Services (DHHS) reports that use of physical restraints is down to about 5% overall in the United States (Agens, 2010). A key concern for any healthcare facility is finding ways to address patient safety—reducing falls, wandering, and agitated behaviors without the use of restraints.
Falls can be addressed environmentally using the following techniques:
Wandering and agitated behaviors can be addressed environmentally by:
A chemical restraint is the use of any medications to subdue, sedate, or restrain an individual. Chemical restraints are intended to restrict the freedom of movement of a patient—usually in acute, emergency, or psychiatric settings. Chemical restraint may be prescribed for dangerous, uncontrolled, aggressive, or violent behavior, and should be used for the shortest time possible.
Chemical restraints have been used more prevalently than physical restraints—their use has been as high as 34% in long-term care facilities prior to recent regulations (Agens, 2010). As with physical restraints, there is evidence that the use of chemical restraints has also declined significantly in the last 5 years. One case-control study of more than 71,000 nursing home patients in four states showed that patients in Alzheimer special care units were no less likely to be physically restrained than those in traditional units. However, they were more likely to receive psychotropic medication (Agens, 2010).
While a physical restraint is visible, chemical restraints used to subdue a patient (often in the form of antipsychotic medications) are invisible, and abuse of chemical restraints can be difficult to detect. As with physical restraint, chemical restraint is associated with an increase in confusion, falls, pressure ulcers, and length of stay (Agens, 2010). Antipsychotics should be used only in select cases, be carefully documented, and only with informed consent.
Test your knowledge. . .
Mr. Trenton sits in a chair near the front door as he has done every day since he moved to Lakeside Nursing and Rehabilitation. Lately he has been walking out the door and roaming the neighborhood.
One environmental adaptation you could make is:
Pharmacotherapy has only a modest effect on the behavioral and cognitive symptoms of dementia, and many medications have potentially serious side effects. The most commonly used drugs for the treatment of BPSD are the antipsychotics.
Medications used to treat the cognitive effects of dementia have only a modest effect. The most commonly prescribed drugs in this category are anti-cholinesterase inhibitors and NMDA receptor antagonists.
Typical antipsychotics have been used since the 1950s for the treatment of psychosis in dementia, but they can cause irreversible physical symptoms such as Parkinsonism and tardive dyskinesia (extrapyramidal symptoms). These agents have also been systematically used for the treatment of other behavioral and psychological symptoms of dementia (besides psychosis) despite a substantial lack of scientific evidence supporting their use (Liperoti et al., 2008).
Atypical antipsychotics were approved exclusively for the treatment of schizophrenia by Food and Drug Administration (FDA) in the 1990s. Soon after, these medications became the new standard of care for BPSD due to their reported advantages over conventional agents, particularly with respect to extrapyramidal symptoms. In the late 1990s, atypical agents accounted for more than 80% of antipsychotic prescriptions used in dementia patients (Liperoti et al., 2008).
Over the last decade, the off-label use of atypical antipsychotics has been promoted by clinical practice guidelines although there are a limited number of clinical trials suggesting their efficacy in dementia. In 2008 the FDA issued a “drug alert” notifying prescribers that both typical and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia-related psychosis (FDA, 2009).
Because of safety considerations associated with antipsychotic medications, non-pharmacologic approaches are generally recognized as the first-line strategy for the treatment of BPSD. Antipsychotic medications are recommended only for the short-term treatment (up to 3 months) and among those patients who manifest severe symptoms that may cause extreme distress and harm to patients or others. A prescriber may still choose to prescribe antipsychotic medications for BPSD and they may indeed 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.
Certain medications can be prescribed for mild to moderate ADRD to control cognitive symptoms. Two classifications of medications are approved for this purpose: anticholinesterase inhibitors and NMDA (memantine) receptor antagonists. These medications have a very slight effect on a person’s ability to perform daily activities and sometimes dampen behavioral and psychological symptoms (although this is an off-label use).
Anticholinesterase inhibitors slow the breakdown of acetylcholine, allowing it to stay in the brain a little longer. Anticholinesterase inhibitors include:
Memantine (NMDA, Namenda) is approved for use in moderate to severe dementia. Memantine is a receptor antagonist that works by decreasing abnormal activity in the brain. It can help people with AD think more clearly and perform daily activities more easily, but it is not a cure and does not stop the progression of the disease. It may help patients maintain certain daily functions a little longer than they would without the medication.