Pulling out tubes
The use of physical and chemical restraints in hospitals and nursing homes has long been considered a dangerous practice with significant health consequences, yet older adults continue to experience injury and death as result of this practice.1,2 Approximately one third of patients in intensive care units is under physical or chemical restraint.3 A physical restraint is defined as any device which limits a person’s freedom to move voluntarily when applied to the body and may include hand mitts, soft ties, restraining vests, body belts, wheelchair bars, and bilateral bedrails.2,3 These restraints are commonly used to prevent falls, injury, and removal of intravenous catheters and tubes by patients.1,2,3 A chemical restraint is defined as any medication used to manage challenging behaviors, such as agitation, aggression, or verbal abuse.3 Elderly patients who suffer from disorientation, delirium, and agitation are at high risk of physical and chemical restraint by staff to prevent harm to themselves and others.1,2 When restraints are used, patients are likely to experience acute decline in function, falls, incontinence, dehydration, skin breakdown, pressure ulcers, altered nutrition, psychological distress, and disorganized behavior.1,2 In tragic cases, death may result from asphyxiation, strangulation, entrapment, or cardiac arrest.1,2,3
Older adults with dementia are at high risk for restraint use because of impaired memory, language, judgment and visual perception.1,2 These patients are less likely to understand and remember the necessity of invasive treatment interventions such as intravenous lines, urinary catheters, feeding tubes, and wound dressing, which may lead to forceful removal.1 Patients with dementia who have limited mobility, gait apraxia, and unsteadiness are also at high risk of falls secondary to restraint use.1 Older adults exhibiting symptoms of delirium such as agitation, anxiety, pacing, and psychosis are also more likely to be sedated as means of chemical restraint.1 Paradoxically, use of restraints may cause or worsen symptoms of delirium in older adults.3 Patients under restraint are also more likely to suffer falls. Falls are a significant problem for frail older adults and especially those with dementia. The most physically dependent and immobile older adults are most likely to be restrained, and subsequently, to suffer falls and other negative consequences of restraint.1,2,3
Interprofessional Assessment and Collaborative Interventions
It is important that the interdisciplinary team conduct a thorough assessment of each patient to identify underlying causes of agitation that may lead to use of restraints. Motor and sensory function, include gait, balance, range of motion, and use of assistive devices, will be evaluated. Ability to perform activities of daily living (ADLs) and instrumental activities of daily living (iADLs) will be established as baseline and reevaluated periodically for changes that may indicate onset or worsening of dementia and other chronic illness. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommends use of restraint alternatives, such as wheelchair adaptations, wedge seats, assisted ambulation, and individualized, regular voiding schedules in all settings.1 Physical and occupational therapists can aid in instituting a regular walking program and activity interventions to prevent functional decline, falls, and restraint use.1
Patients should also be evaluated for presence of acute or chronic pain. Nurses and providers will assess for verbal and nonverbal expressions of pain, including refusal to get out of bed and inability to complete ADLs. Patients with invasive treatment interventions such as oxygen and nasogastric tubing and urinary catheters in place should be assessed for discomfort. Alternative interventions such as wrapping or covering the tube or dressing with clothing or gauze can help distract the patient. Administration of analgesics and other pain relieving measures may also be appropriate.1
It is also important that the team assess patients’ psychosocial and behavioral needs. Agitated, anxious, and aggressive behaviors often accompany changes in environment and routine and can be overwhelming for a patient with dementia. Sound and lighting may be over-stimulating for these individuals and should be adjusted to avoid agitated behavior, such as attempting to elope from bed during the night.1 Nurses may find that providing care activities at a reasonable pace with reassuring communication is helpful in keeping these patients calm. Self-care should be encouraged for patients while recognizing that frail older adults with dementia often require more time with bathing, dressing, toileting and walking activities.1 Nurses, primary and acute care providers, and pharmacists should review all patients’ medications for potential adverse effects and interactions that may underlie development of delirium and use of restraints.1
Organizations and agencies should invest in educational programs for staff highlighting the need to reduce and eliminate use of restraints in hospital and nursing home settings. Staff perceptions that patients with delirium lack judgment needed to participate in treatment decisions often creates an environment of paternalism that leads to use of restraints. Institutions are encouraged to implement standardized clinical assessment protocols to determine the meaning of patient’s behavior, diagnose the cause, and to develop alternative restraint-free responses.1,2 In circumstances where physical and chemical restraints are used as a last resort, it is necessary that staff understand the dangers associated with restraints, understand correct application of devices, and ensure that adequate staffing is available to safely manage the restrained person and provide respectful person-centered care.2,3
Interprofessional contacts for this topic:
Acute care providers
Primary care providers
Extended care facility personnel
Link to the following evidence-based protocols:
1Cotter, V.T. (2005). Restraint free care in older adults with dementia. The Keio Journal of Medicine, 54(2), 80-84.
2Sullivan-Marx, E.M. (1994). Delirium and physical restraint in the hospitalized elderly. The Journal of Nursing Scholarship, 26(4), 295-300.
3Tolson, D., & Morley, J. E. (2012). Physical restraints: Abusive and harmful. Journal of the American Medical Directors Association, 13(4), 311-313.