The Use of Mechanical and Chemical Restraints in Nursing Homes

Abstract

The use of mechanical and chemical restraints in nursing homes is a common practice, fraught with potential abuse. The patient's freedom of movement and right to an adequate medical and psychiatric evaluation are of the utmost importance. Restraints should be used only as a last resort and should not be a substitute for inadequate staffing or incomplete medical appraisal. Guidelines are offered that maximize the patients' freedom, maintain medical responsibility, and assure safety. Alternatives to the use of restraints are discussed.

Physical Restraint Use and Falls in Nursing Home Residents

“…The safety of confused ambulatory nursing home residents often concerns staff because residents may have poor judgment or wander from the unit 27, 28 . Confusion remains the most consistent significant predictor for restraint use 23, 27, 28, 38, 40–44 . In our sample, the nonconfused ambulatory residents were virtually never restrained, whereas 37% of the confused ambulatory residents were restrained.…”

Individualized Care Alternatives Used in the Process of Removing Physical Restraints in the Nursing Home

“…Psychosocial alternatives, such as reality orientation, have been cited frequently as positive alternatives to the use of physical restraints 25 . They were, however, seldom used in the residents in this study.…”

Physical and Pharmacologic Restraint of Nursing Home Patients With Dementia

“…Factors associated with physical restraint use include a patient's dementing illness, diminished activities of daily living, increased illness sever¬ ity, and race. 8 percentage of residents whose care is supported by Medicaid, facility size, and staff-to-patient ratio) have been as¬ sociated with use of psychotropic agents.14,19 Severe cognitive impairment (dementia) is the most consistent pre¬ dictor for the use of both physical and pharmacologie restraints. 8,10,12"14,19'21 This extensive reliance on physical and pharmacologie restraints in nursing homes' management of those patients who have a dementing illness has drawn recent criticism.10*11*14*22-24 Both categories of restraint use have significant adverse effects, including excess physical dis¬ ability,1" more frequent falls,13,25 physio¬ logic consequences of immobility,10,21 and new or aggravated behavioral symptoms.…”

“…Restraints are often used invol¬ untarily, many times over the patient's explicit and continued objec¬ tions. 8,20,22,26,27 One innovation in the management of a dementing illness has been the devel¬ opment of segregated units in which the environment, staffing, and treatment address the unique needs of cognitively impaired individuals.3 Such specialized dementia units, often called "special care units," have proliferated in recent years.2,28 The typical dementia unit occu¬ pies a wing or separate section of an existing facility and has self-contained dining and recreation areas, design fea¬ tures that orient and direct patients, staff with special training, admission and discharge criteria, and nursing care and activity programs designed specifi¬ cally for the residents of a dementia unit.2,6,29 Many dementia units explicitly identify the minimization of the use of physical and pharmacologie restraints as a goal. 3,30 This report discusses the use of physi¬ cal and pharmacologie restraints in the management of dementia among a rep¬ resentative sample of 307 residents in specialized units and 318 residents who received traditional nursing home care in five states.…”

“…A recent report by Doane et al,16 which found neuroleptic use to be reduced among dementia units in Washington State, supports this hypothesis.Absence of the use of physical or pharmacologie restraint is not synony¬ mous with quality care, however.918,36 Both should be regarded as treatment options.37,38 Given the known adverse ef¬ fects of both types of restraint, minimiz-ing their use seems a reasonable goal.As noted by Evans and Strumpf,10 there may be more rationale for restraint use in acute care, where the goal of im¬ provement more readily justifies a de¬ gree of coercion. Long-term care goals revolve around quality of life and main¬ tenance of function, however, and nei¬ ther of these is generally promoted by the use of restraints.10 A wide variety of environmental, social, and program¬ matic alternatives to the use of re¬ straints exist 3,8,10,21,39,40. More attention to these techniques may explain the reduc¬ tion in physical restraint use observed among dementia unit patients.…”