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 (GovTrack, 2020):

• Reserved for documented indications.
• Time limited.
• Frequently re-evaluated for their indications, effectiveness, and side effects in each patient.

Although OBRA is intended for nursing homes, these regulations should be followed in all other settings, including in the home.

3.1 Physical Restraints

A physical restraint is defined by the Centers for Medicare and Medicaid Services (CMS) as “any manual method, physical or mechanical device, material, or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.” Physical restraints can include belts, mittens, vests, bedrails, geriatric chairs, and other devices (Staggs et al., 2016).

Use of physical restraints has come under intense scrutiny because they can cause agitation, confusion, deconditioning, pressure ulcers, strangulation, adverse psychological effects, and even death. They affect a person’s sense of well-being, causing feelings of low self-worth, depression, humiliation, and anger.

Because of these potentially serious consequences, physical restraint use is part of public reporting for nursing homes through the CMS Nursing Home Compare website (Staggs et al., 2016). Several studies have demonstrated that carefully orchestrated restraint-reduction programming can greatly reduce the use of physical restraining devices.

Restraints are not limited only to physical devices. Restraint can include using (or threatening) force or restricting a person’s movements—even if they do not resist (Nuffield Council on Bioethics, 2009 latest available). Forced isolation (such as locking a person in their bedroom) is also a type of restraint.

Regular interaction with caregivers in an adult daycare setting provides the opportunity to educate family members about the use of restraints in the home. Current evidence indicates that restraints are regularly used in home care, that they are mainly applied to vulnerable older persons, and that informal caregivers—who have less knowledge of the negative consequences of restraint use—play an important role in the application of restraints, by granting permission for the use of restraints and deciding to use restraints (Scheepmans et al., 2020).

Nurses and other healthcare providers play a pivotal role in the use of restraints. Recent studies suggest most healthcare providers have insufficient knowledge of the concept of restraints, the frequency of their use in clinical practice, and the negative impact on the client (Scheepmans et al., 2020).

3.2 Chemical Restraints

Antipsychotics and psychotropic medications are often used intentionally to chemically 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 should be prescribed for the shortest time possible for dangerous, uncontrolled, aggressive, or violent behaviors.

A 2022 report from the Office of the Inspector General (OIS) found that psychotropic drugs were prescribed to about 80% of nursing home residents between 2011 and 2019. Higher use of psychotropic drugs, including antipsychotics, anticonvulsants, mood stabilizers, and central nervous system agents was associated with nursing homes that have certain characteristics. Those with lower ratios of registered nurse staff to residents used more psychotropic drugs. Nursing homes with a higher percentage of low-income residents were also associated with higher use of these drugs (OIS, 2022).

In older adults with dementia, psychotropic agents such as anti-anxiety, antidepressant, and antipsychotic medications are often 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 or when used as a means of behavioral control in older adults with dementia (Peisah &  Skladzien, 2014).

Clinical trials have consistently demonstrated an increased risk of mortality with the use of atypical antipsychotics in older adults 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.

In 2023, the American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults modified and clarified the criteria for delirium, dementia, and Parkinson disease, including adding opioids to the list of drugs that can exacerbate delirium. The update stresses the need to avoid antipsychotics and other medications for behavioral problems of dementia and delirium because their use is frequently associated with harm (AGS, 2023).

Behavioral interventions are the preferred management strategy for treatment of challenging behaviors associated with dementia. The use of antipsychotics and other potentially inappropriate medications should be a last resort. The decision to use or not use a chemical restraint should always be made in collaboration with the patient and their care partner (AGS, 2023).

For a person with dementia (Reus et al., 2016):

• Nonemergency antipsychotic medication should only be used for the treatment of agitation or psychosis when symptoms are severe, dangerous, and/or cause significant distress to the patient.
• Nonpharmacological interventions should be assessed prior to non-emergency use of an antipsychotic medication to treat agitation or psychosis.
• Potential risks and benefits should be assessed by the clinician and discussed with the patient as well as with family or others involved with the patient.

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 and family that the medication is being used off-label* meaning a drug has not been approved by the FDA for treatment of behavioral symptoms of dementia. The prescriber must obtain permission from the patient or family member to use it for behavioral symptoms of dementia.

*Off-label: the practice of prescribing pharmaceuticals for an unapproved indication, age group, dose, or form of administration.

3.3 Alternatives to Restraints

The preferred choice is to use no restraints. Physical, chemical, or environmental restraints should not be used as a substitute for safe and well-designed environments or for the care and management of a person with dementia. One of the most successful strategies for dealing with difficult behaviors without using restraints is to use a problem-solving approach (Alzheimer Society, 2023), which will be discussed in the next section

Certain policies and activities can reduce or eliminate 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 suggestions:

• Assess and treat hunger, thirst, and discomfort.
• Change or taper medications with adverse effects.
• Treat all underlying causes, including pain.
• Assess hearing and vision.
• Establish a nap schedule.
• Relieve impaction.

A friendly, uncluttered, home-like environment provides a safe and effective alternative to physical restraints. Keep hallways free of equipment and obstacles, make liberal use of rails, grab bars, and transfer poles in rooms, bathrooms, hallways, and common areas. Additional suggestions:

• 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, where practical, to reduce injury from falls.