Restraint free care in older adults with dementia

Abstract

Abstract. During the past two decades, significant research and several government and health care quality groups have advised against the use of physical restraints in hospitals and nursing homes, yet older adults are continuing to die, become injured or experience the iatrogenic complications associated with this practice. Deaths are usually caused by asphyxiation, but also occur from strangulation, or cardiac arrest. Older adults with dementia are at high risk for restraint use because of impaired memory, language, judgment and visual perception. In moderate to severe dementia, the risk of falls is greater because of gait apraxia and unsteadiness. Agitation, disorientation, and pacing behaviors from delirium or dementia can precipitate staff to use restraints to prevent harm to the older adult or to others. Physical restraints should be eliminated as an intervention in older adults with dementia because they are also very likely to cause acute functional decline, incontinence, pressure ulcers and regressive behaviors in a short period of time. The purpose of this paper is to disseminate the dangers of this clinical practice and to summarize the latest research in restraint free care and restraint alternatives in the United States.

Use of Physical Restraints in a Rehabilitation Setting: Findings from a Point Prevalence Survey

“…Only a limited number of alternatives to restraints were identified with the team. The US Joint Commission on Accreditation of Healthcare Organizations advocated that restraint alternatives, such as wheelchair adaptations, wedge seats, assisted ambulation and individualized care programs, be considered prior to restraint initiation [37]. For those who need to use wheelchairs, other sources of restraint alternatives such as lap boards and seat belts can provide safe and adequate seating and mobility [38].…”

Vulnerable long-term psychiatric inpatients need screening for physicalhealth problems: An audit of regular hospital statistics and clinical files

“…Patients with dementia and delirium or confusion are at a particularly high risk of falling, with institutionalised patients having a 75% yearly prevalence of falls. 6,[19][20][21][22][23] Gait apraxia and unsteadiness often play a role in these falls. 6,19,[23][24][25][26][27] Moreover, these patients' increased risk of falling has much to do with side-effects of psychotropic medicationsespecially antipsychotic medications, but also antidepressants, mood stabilisers, and sedatives -or with ECT.…”

“…6,[19][20][21][22][23] Gait apraxia and unsteadiness often play a role in these falls. 6,19,[23][24][25][26][27] Moreover, these patients' increased risk of falling has much to do with side-effects of psychotropic medicationsespecially antipsychotic medications, but also antidepressants, mood stabilisers, and sedatives -or with ECT. 4,6,20,[23][24][25] Additional factors that increase the risk of falling include female gender, atherosclerotic disease, obesity, lower limb abnormalities, hearing or vision deficits, elevated temperature, anaemia, vitamin D deficiency and postprandial hypotension.…”

The ethics of coercive treatment of people with dementia

“…They showed an understanding of the person-centred approach described in the guidelines on dementia care. 31,32 They spoke not only of educational skills and adequate staffing as important factors in preventing coercive treatment, as previously described by others, 9,16,34 but also of developing new working routines with unlocked doors and new technology. There was an awareness of the importance of gerontological nurses being part of daily care to promote noncoercive nursing care.…”

“…Previous international studies have shown that joint working practices within a multi-professional team promote resident autonomy, high-quality nursing and medical care, as well as comply with preferences of residents with dementia. 9,16,34 Multi-professional teams could also encourage understanding of human rights and freedom, as such an approach would generate discussions among the whole team. 9,28,34 Despite their ability to describe alternative measures, the RNs still practice good and safe nursing with coercive treatment.…”