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.
Despite decades of concern about their safety, effectiveness and appropriateness, physical restraints remain widely used in nursing homes—particularly for residents with poor mobility, high dependency, or dementia. Death by asphyxiation or mechanical compression is the most horrific complication of physical restraint (O'Keeffe, 2017).
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, 2023).
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, 2020).
A physical restraint is any device, material, or equipment attached to or near a person’s body that prevents a person from moving freely and can neither be controlled nor easily removed by the person.
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).
There are compelling arguments for reducing, if not eliminating, the use of physical restraints in nursing homes, and in particular among people who are in their last days of life. Physical restraints have been shown to be neither safe nor effective. They do not reduce risk of falls or injury. They can have negative physical consequences such as decubitus ulcers, urinary and fecal incontinence, and higher walking dependence. They can also cause psychological issues such as anger, anxiety, and depression and have negative social consequences for residents and family members (Pivodic et al., 2020).
Restraint use increases the risk and persistence of delirium and can lead to death. Clinical trials and non-randomized experimental studies showed that physical restraints in nursing homes can almost completely be eliminated with reasonable levels of safety (Pivodic et al., 2020).
Decision-making related to restraint use is a complex process, influenced by various factors. Research from nursing homes indicates that not only patient characteristics such as cognitive decline and poor mobility but also nonpatient-related factors such as the attitude and knowledge of healthcare providers and legislation affect decision-making about restraint use. Factors influencing restraint use include insufficient supervision, decreases in wellbeing of informal caregivers, and dissatisfaction with family support. Legislation or regulations may limit the use of restraints in some settings (Scheepmans et al., 2020).
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 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
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.
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.
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 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 American Geriatric Society (AGS) Beers criteria for safe medication use in older adults list antipsychotics as potentially inappropriate medications (PIM) and 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.
In 1987, a law signed by President Ronald Reagan banned the use of drugs in nursing homes that served the interest of staff rather than the patient, except "to ensure the physical safety of the resident or other residents." In 2012, the Centers for Medicare & Medicaid Services (CMS) began requiring nursing homes to report antipsychotic drug use data, which then became part of each nursing home's "quality of resident care" score that contributes to a facility's CMS star rating. However, nursing homes were not required to report antipsychotic prescriptions for patients who had any of three conditions: schizophrenia, Tourette's syndrome, and Huntington's disease (Advisory Board, 2023).
Medicare data shows that since then, the share of nursing home residents diagnosed with schizophrenia has risen 70%. And today, one in nine nursing home residents have been diagnosed with the disease, despite the condition affecting just around one in 150 people in the general population (Advisory Board, 2023).
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.
Research into nursing homes suggests that a more favorable organizational context can lead to better person-centered care, a higher quality of care, lower rates of drug use, and less need to use restraints. Previous studies have found that nursing home facilities with more favorable organizational context, had lower rates of urinary tract infections and catheter use among older adults (Potrebny et al., 2022).
In addition, staff in favorable nursing home facilities generally reported greater job satisfaction, used best practice guidelines more often, and provided better treatment in relation to challenging behaviors related to dementia, combined with a more appropriate distribution of antipsychotic medication among older adults (Potrebny et al., 2022).
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 (www.nursinghometoolkit.com) (AGS, 2019).