Dangers of Using Physical Restraints with Dementia

Concerns and Alternatives

Physical Restraints Can Increase Injury and Depression
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Because dementia can trigger some challenging behaviors such as aggression and catastrophic reactions, restraints have been used at times in the past to help prevent injuries to that person or others around them.

Fortunately, as a society and medical community, we've become more aware of the anxieties and agitation that restraints produce, as well as the increased risk of injuries with their use. In facilities, restraint use now is extremely limited.

What Is a Restraint?

A restraint is anything that hinders movement or restricts freedom.

Years ago, restraint use was much more common and included extremely restrictive restraints such as straight jackets and vests. While these restraints aren't used today in nursing home, it's important to recognize that other equipment can act as a restraint even it the goal in its use is to keep someone safe.

Examples of Restraints

  • Lap Buddies

    A lap buddy is a cushioned devise that fits in a wheelchair and assists with reminding a person not to get up by himself. Lap buddies can also be used to help with positioning if a person tends to lean forward in his wheelchair and is in danger of falling out of the chair.

  • Seat Belts

    Seat belts have been used in wheelchairs to protect someone from falling out or from getting up without assistance. Seat belts that the person cannot remove are considered a restraint and can pose a danger to the person if she tries to get out of the chair- either of falling forward with the wheelchair still attached or by pushing and falling backwards.

    An alternative is a seat belt that comes loose easily but sounds an alarm when it's removed to alert someone for assistance

    • Recliner Chairs

      While a recliner chair can be used for comfort and positioning, it also can be a restraint for some people if they can't get out of it independently.

    • Side Rails

      Side rails can be a very dangerous restraint. Typically used to prevent someone from rolling or falling out of his bed, side rails can also be used to keep someone from getting out of the bed, thus making them a restraint.

      The dangers of side rails are well-documented. In short, people can become entrapped in them or go over top of them, causing a greater injury or even death. In nursing homes, full side rails have all but been eliminated due to these concerns but in the community, side rails are still used at times to try to prevent someone from wandering or getting up independently out of bed.

    • Tucking in Sheets Tightly

      If the sheets in a bed are tucked too tightly so that the person can't get out of bed or move freely, this serves as a restraint.

    • Positioning at a Table

      Pushing someone in a wheelchair up to a table and locking the chair in position can also be used as a restraint since it prevents the person from freely moving. A locked wheelchair can be quite dangerous as a person may push backwards and tip the wheelchair (and themselves) over.

    • Seat Trays

      Placing a locking tray in front of someone, even if its purpose is for use as a writing tray, is considered a restraint if they can't remove it and it inhibits the person's ability to get up.

    Why Have Restraints Been Used?

    • Protect from Self

      The most common use for a restraint in people who have dementia is to protect them from injuring themselves. This can be related to a tendency to forget they're not able to walk independently, poor positioning in wheelchairs, or agitation such that they are removing breathing tubes or intravenous needles from their arms.

    • Protect Others

      Occasionally, restraints have been used to protect others around that person if she is extremely agitated and is likely to hurt others around her.

    Restraints as a Last Resort

    In order for a nursing home to use a restraint, the staff must have tried and been unsuccessful in using less restrictive alternatives first, and these attempts must be clearly documented. (Less restrictive measures include attempts to more safely and comfortably position the person in a chair, providing increased supervision, offering meaningful activities or attempting to improve functioning through physical or occupational therapy.)

    Facilities must also have a time-limited order from a physician in order to use any type of a restraint, and the person, his guardian or his power of attorney for healthcare must have been educated on the risks vs. the benefits of using a restraint and have given permission to do so.

    Dangers of Restraints

    Let's put ourselves in the place of the person with dementia. Perhaps she needs to use the bathroom or stretch her legs, or she's feeling hungry or bored. When she tries to move around, she's unable to and consequently, can't tend to that need.

    Restraints affect a person's mental health. People who have been restrained report feelings of depression, fear, anger, humiliation, anxiety, and helplessness. Not surprisingly, a person might also experience a significant negative reaction to a restraint such as screaming, fighting and extreme agitation which can be traumatic for that person and her caregiver.

    According to the March 2006 issue of the Journal of Medical Ethics, the negative consequences of restraints include:

    • bruises
    • decubitus ulcers
    • respiratory complications
    • urinary incontinence and constipation
    • poor nutrition
    • increased dependence in activities of daily living
    • impaired muscle strength and balance
    • decreased cardiovascular endurance
    • increased agitation
    • increased risk for mortality caused by strangulation or as a consequence of serious injuries—for example, fracture, head trauma

    In addition to those physical consequences, restraints are frequently ineffective and don't prevent falls. Rather, research has shown that injuries are escalated because of the force the person needed to use to escape from the restraint.

    Alternatives to Restraints

    • Education

      One of the best ways to reduce restraint use is to provide adequate training to staff and family caregivers on understanding behaviors as communication and using other interventions.

    • Consistent Caregivers

      Caregivers who know your loved one can anticipate and help meet his needs more effectively than someone who doesn't know his routine.

    • Alarms

      Bed alarms, chair alarms and door alarms can provide freedom for the person with dementia while still alerting you to her need for assistance.

    • Meaningful Activities

      Using a variety of activities to engage the person can sometimes prevent some behaviors such as restlessness, combativeness with care and wandering.

    Compassionate Care is the Guiding Rule

    As caregivers and family members, the task of caring for others is ours because we care about them. This involves not only having good intentions but also maintaining current knowledge of the risks and benefits of how we provide care, including our philosophy and use of restraints for our patients and loved ones.

    Sources:

    Department of Health & Human Service. Centers for Medicare & Medicaid Services. November 7, 2008. Freedom from Unnecessary Physical Restraints: Two Decades of National Progress in Nursing Home Care. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter09-11.pdf

    Journal of Medical Ethics. 2006 March; 32(3): 148–152. Use of physical restraint in nursing homes: clinical‐ethical considerations. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564468/

    Texas Department of Human Services. Reducing the Use of Restraints in Texas Nursing Homes. January 2003. 

    US Food and Drug Administration. A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts. Accessed August 27, 2013. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/HospitalBeds/ucm123676.htm

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