Physical restraints in nursing homes: a review of the literature since the Nursing Home Reform Act of 1987

The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.     

The relationship between physical restraint removal and falls and injuries among nursing home residents

BACKGROUND: A major reason cited for continued restraint use in American nursing homes is the widely held belief that restraint reduction will lead to fall-related incidents and injuries. METHODS: This study represents an analysis of data collected in a clinical trial of interventions aimed at reducing the use of restraints in nursing homes. Two different designs were employed to test the relationship between restraint reduction and falls/injuries. First, multiple logistic regression was used to compare fall/injury rates in subjects who had restraints removed (n = 38) to those who continued to be restrained (n = 88); second, survival analysis was employed to test the relationship between physical restraint removal and falls/injuries at the institutional level by comparing fall/injury rates among three nursing homes (n = 633) with varying rates of restraint reduction. RESULTS: Based on the multiple logistic regression analysis, there was no indication of increased risk of falls or injuries with restraint removal. Moreover, restraint removal significantly decreased the chance of minor injuries due to falls (adjusted odds ratio: 0.3, 95% CI: 0.1, 0.9; p < .05). The survival analysis demonstrated that the nursing home that had the least restraint reduction (11%) had a 50% higher rate of falls (p < .01) and more than twice the rate of fall-related minor injuries (p < .001) when compared to the homes with 23% and 56% restraint reduction, respectively. CONCLUSIONS: Physical restraint removal does not lead to increases in falls or subsequent fall-related injury in older nursing home residents.     

Point mutation in a Becker muscular dystrophy patient

Occupational therapy intervention in the area of seating and positioning may play a vital role in improving the quality of life for nursing home residents. This case report indicates that appropriately positioning a client may increase comfort, decrease agitation, and decrease the administration of mood-altering drugs. Research would help to delineate the effects of appropriate seating systems, both to ensure reimbursement and to ensure that all who might benefit from positioning intervention receive the appropriate services. OBRA 1987 regulations are forcing nursing homes to assess residents for the least restrictive restraints. These assessments offer a golden opportunity for occupational therapists to become involved in determining the most appropriate seating systems and to conduct research on their benefits.     

Neuroleptic use and behavioral disturbance in nursing homes: a 1-year study

This article discusses a longitudinal study of change in disruptive behaviors among nursing home residents treated with neuroleptics compared with those not treated with neuroleptics. Observations were made of 201 participants on admission to and after 1 year in eight skilled nursing facilities. Nine disruptive behaviors were measured using the Psychogeriatric Dependency Rating Scale with nursing assistants. Neuroleptic use was documented from medication records. Odds ratios are reported for the association of behavior at baseline and use of neuroleptics on nine problem behaviors. For those who received neuroleptics during the year, there was greater change in both developing and resolving disruptive behaviors than for those not receiving neuroleptics. For both groups, restless or pacing behavior and belligerent behavior manifested by refusing instructions changed the most, both in developing and in apparently resolving. Our results show that change in disruptive behaviors occurs among nursing home residents regardless of neuroleptic use, but it occurs more frequently among those who receive neuroleptic medication. Knowledge of which disruptive behaviors are most likely to resolve or develop is important in training nursing home staff to cope with the behaviors as well as in planning interventions that may modify such behaviors.     

Tube feeding preferences among nursing home residents

OBJECTIVE: To determine the preferences of nursing home residents regarding the use of tube feedings and to characterize the clinical, functional, and psychosocial factors that are associated with preferences. DESIGN: In-person survey. SETTING: Forty-nine randomly selected nursing homes. PATIENTS/PARTICIPANTS: Three hundred seventy-nine randomly selected, decisionally capable, nursing home residents. MAIN RESULTS: Thirty-three percent of participants would prefer tube feedings if no longer able to eat because of permanent brain damage. Factors positively associated with preferences for tube feedings include male gender. African-American race, never having discussed treatment preferences with family members or health care providers, never having signed an advance directive, and believing that tube feeding preferences will be respected by the nursing home staff. Twenty-five percent of the participants changed from preferring tube feedings to not preferring tube feedings on learning that physical restraints are sometimes applied during the tube feeding process. CONCLUSIONS: Demographic and social factors are associated with preferences for tube feedings. The provision of information about the potential use of physical restraint altered a proportion of nursing home residents' treatment preferences.     

Physical restraints in geriatric care in Sweden: prevalence and patient characteristics

OBJECTIVE: Physical restraints are used frequently in geriatric care to promote the safety of frail older patients. This study investigated the prevalence of the use of physical restraints in geriatric care and the way in which patient characteristics are related to the use of physical restraints. DESIGN: A point prevalence study of patients cared for in various types of geriatric settings. SETTING: Eight nursing homes, 15 old people's homes, a somatic geriatric clinic, and a psychogeriatric clinic in a health care district in northern Sweden. PARTICIPANTS: A total of 1325 patients, mean age 82 years, 64% of whom were women. MEASUREMENTS: The Multi-Dimensional Dementia Assessment Scale (MDDAS) was used to measure motor function, vision, hearing, speech, ADLs, behavioral symptoms, psychiatric symptoms, use of psychoactive drugs, and the physical and psychological workload of the staff. In addition, questions concerning the use of physical restraints were added to the instrument. RESULTS: Twenty-four percent of the patients were physically restrained. The highest prevalence was found in nursing homes and psychogeriatric care. Physical restraints were found to relate most strongly to cognitive impairment, impaired ADLs, and speech and walking ability. Ninety-four percent of the restrained patients were cognitively impaired. Other variables relating to the use of physical restraints were psychiatric symptoms and behavioral disturbances. CONCLUSIONS: This study has shown that physical restraints are used frequently in geriatric care in Sweden and that cognitive and physical impairments relate very closely to the use of physical restraints.     

Regulation of aquaporin-2 gene transcription by GATA-3. off

Many nursing home residents are candidates for antipsychotic pharmacotherapy for dementia-related behavioral disturbances that include physical agitation and aggression, verbal outbursts, anxiety, and depression. These patients are often resistant to or intolerant of standard neuroleptics and are usually receiving multiple medications for concurrent psychiatric or medical conditions. New medications must be carefully considered because they may interact with concurrent medications or aggravate concurrent medical problems. Low doses of risperidone may be better tolerated in the elderly because the drug poses little risk of extrapyramidal side effects or blood disorders. One hundred and nine patients with dementia-related behavioral disturbances were studied in 9 nursing homes; most initially received 0.25 to 0.5 mg of risperidone twice daily. Their behavior was recorded for up to 6 months on questionnaires completed by a nursing staff member at each home. Risperidone was well tolerated overall and nursing staff viewed it as helpful in 38 of 100 patients, moderately helpful in 26, slightly helpful in 17, and not helpful in 19.     

Clinical assessment of extrapyramidal signs in nursing home patients given antipsychotic medication

BACKGROUND: We sought to quantify the relationship between antipsychotic drug use and clinical evidence of extrapyramidal dysfunction in a large population of elderly nursing home patients. METHODS: Subjects were 251 residents (mean age, 84.1 years; range, 65 to 105 years) who were taking psychoactive drugs in 12 long-term care facilities. Patient characteristics and all medication use (both scheduled and as needed) were measured during a 1-month observation period. We then performed neuropsychological and functional testing on residents who received any psychoactive medications during the study month. The presence of rigidity, bradykinesia, or masklike facies was assessed in each patient by a research assistant who was unaware of diagnoses and medication use. RESULTS: The parkinsonian signs studied were found in 127 (50.6%) of these residents. Using logistic regression modeling to adjust for potential confounding, we found this outcome to be increased more than threefold in patients who took low-potency neuroleptics (odds ratio [OR], 3.49 for > or = 50 mg/d of chlorpromazine-type drugs; 95% confidence interval [CI], 1.28 to 9.57) and more than sixfold for use of 1 mg/d or more of haloperidol (OR, 6.42; 95% CI, 2.16 to 19.04). Age, gender, and use of nonneuroleptic psychoactive drugs were not associated with an increase in parkinsonian signs. CONCLUSIONS: Clinical evidence of extrapyramidal dysfunction is three to six times more common in institutionalized elderly patients given antipsychotic medication than in comparable patients not using such drugs. Its risk is substantially increased even in patients given low-potency chlorpromazine-type drugs, as well as those taking haloperidol. The effect is not explained by age or mental status and is not seen with other psychoactive medications. The expected frequency of parkinsonian symptoms can help to inform the balancing of risks vs therapeutic effect when the use of all drugs in this class is considered.     

Hospital nurses' views about physical restraint use with older patients

1. A survey of knowledge, practice and attitudes about physical restraints was completed by nursing staff (RN, LPN, CNA) from four hospitals. 2. Nurses from both geriatric and geropsychiatric units reported significantly more educational activities about restraint use than did nurses on medical units. 3. RNs had the highest knowledge scores (56%), but lacked specific information about the dangers associated with restraint use. 4. While education about restraints is important, staff need role models who can help them problem solve and examine alternatives to restraints.     

Disruptive behavior of elderly residents and the use of nursing methods

This study is the first part of a larger research project concerned with disruptive behaviour and the use of physical restraints on elderly nursing home residents. This paper is focused on the types and prevalence of disruptive behaviour among elderly residents, nurses' experiences and the types of nursing interventions employed. Data was collected from nurses of varying qualifications (n = 173) in seven Swiss nursing homes by using a questionnaire. The most frequent behavioural problems reported by nurses were mobility, incontinence, getting dressed, verbal communication, passivity, withdrawal and continual requests. Nurses found physical aggression, continual shouting and verbal abuse the most difficult to manage with. The results also indicated that experiences varied between nurses. In particular, nursing staff always considered disruptive behaviour more disruptive against other residents rather then against themselves. The most frequently used interventions against disruptive behaviour were considering residents' wants and needs, getting close, adjustment to residents' background and organisation of activities. Physical and chemical restraints were also used.     

Neoplasm of endolymphatic sac origin: clinical, radiological and pathological features

PURPOSE: Examine antiepileptic drug (AED) use in nursing homes by age, gender, and use of comedication that can interact with AEDs. METHODS: Two point-prevalence evaluations of AED use from computerized medical records of nursing home residents throughout the United States (set 1, 43,757; set 2, 41,386) 65 years and older serviced by PHARMERICA. RESULTS: 10.5% of residents received an AED. Of the age group 65-84 years, 15 % received an AED compared with 6.1% of those 85 years or older (p < 0.001). Gender differences were present; 13.4% of the male residents and 9.4% of the female residents were treated with an AED (p < 0.001). The most frequently prescribed AEDs were phenytoin, carbamazepine, clonazepam, or phenobarbital. The average number of routine medications taken by AED recipients was 5.6, greater than the average of 4.6 for other residents. CONCLUSIONS: AEDs are extensively prescribed for elderly nursing home residents. Men and persons aged 65-85 years were more likely to receive AEDs than were women or those older than 85 years. AED recipients receive more routine medications than do other residents, including co-medications that alter hepatic metabolism and clinical response. The reasons for age and gender differences are unclear and require further study.     

Physical restraint use in critical care: legal issues

Landmark federal legislation and several other social and clinical forces have induced nursing homes to reduce their use of physical or mechanical restraints on their residents during the past decade. Attention is being paid to the overuse of restraining devices and methods in acute care hospitals, including critical care units, and the need to develop strategies for their reduction or elimination. One of the most serious barriers to accomplishing this objective is anxiety on the part of health professionals and administrators about potential legal liability for patient injury. This article discusses the potential legal implications of physical restraint reduction in hospitals, with special emphasis on the critical care context. It places risks in realistic perspective, ultimately arguing that developing suitable alternatives to restraint use in most cases best serves the legal--as well as the clinical, ethical, and financial--interests of all concerned parties.     

The link between knowledge and remembering in Alzheimer''s disease

This article presents results from a retrospective study of psychological assessments of elderly persons with chronic mental illness residing in nursing homes. All residents (N = 570) received this assessment as part of federally mandated screening for mentally ill persons residing in long-term care. The process, the Preadmission Screening and Resident Review, was mandated by the Omnibus Budget Reconciliation Act (OBRA 87). These assessments were the first stage in a process to determine if the nursing home was the most appropriate placement for each resident. If nursing home care was deemed appropriate, then a psychological treatment program was to be established within the nursing home setting. The sample ranged in age from 50 to 104 (mean of 70). The majority had a diagnosis of schizophrenia and a history of psychiatric hospitalization occurring early in their life. The assessments did not include any quantifiable data on activities of daily living, cognitive functioning, or level of psychiatric impairment. Therefore, the researchers coded the narrative data so that it could be interpreted. The majority functioned within the none-to-mild range of cognitive impairment, and very few were completely dependent in the need for physical care. The most recorded symptom was social withdrawal. Neuroleptic medications were administered to 64% of elderly persons with chronic mental illness. Importantly, there was no relationship between demographic or clinical information and treatment recommendations. Implications of these findings for psychiatric nurses are discussed.     

Research-based practice: reducing restraints in an acute care setting--phase I

The purpose of this research utilization project was to select and implement a research-based Restraint Education Program for reducing the use of restraints in an acute care setting by changing the perception of the restraint coordinators about restraints in the direction of decreased importance. The Iowa Model, Research Based Practice to Promote Quality Care (Titler et al., 1994) was selected to guide the change process. A multidisciplinary team reviewed the restraint policy and procedure, new restraint products and alternative restraint methods. After a review of the literature on restraint education programs, the committee concluded that education was the key component in decreasing the use of physical restraints. The research-based Restraint Education Program developed by Drs. Strumpf and Evans was selected as the educational program. Education sessions were developed and a pilot study was conducted with the restraint coordinators. The Perceptions of Restraint Use Questionnaire (PRUQ) (Strumpf & Evans, 1988) was administered before and after the education sessions. The results of the t-test showed a decrease in the post-test mean scores on 7 of the 17 items indicating a less important perception by the staff about the use of restraints. Four items had an increase in mean scores on the post-test indicating the restraint coordinators increased their perception of the importance of physical restraints with these items. The restraint education program was presented to the nursing staff throughout the institution. Risk management and quality assurance will monitor patients restrained and evaluate the nursing staff with the PRUQ in 3 months.     

Sclerosing encapsulating peritonitis--a review

OBJECTIVE: To determine the pattern of use of psychotropic drugs in Sydney nursing homes. DESIGN: Survey of data from medical records of residents and interviews with residents and staff. SETTING: Central Sydney Health Area, June to December 1993. PARTICIPANTS: All residents of 46 of the 47 nursing homes in the western sector of the health area. MAIN OUTCOME MEASURES: Psychotropic drugs used regularly or as required. Degree of cognitive impairment and depression rated on interview with residents, using Mini-Mental State Examination and Geriatric Depression Scale. Behavioural disturbances reported by staff. RESULTS: Most residents (58.9%) were taking one or more psychotropic drugs regularly and another 7% were prescribed these drugs as required. Neuroleptics were taken regularly by 27.4% and as required by a further 1.4% (at least one dose in the previous four weeks), but doses were equivalent to more than 100 mg/day of chlorpromazine for only 8.8%. Neuroleptics were more likely to be given to residents with greater cognitive impairment and more disturbed behaviour. Other psychotropic drugs in regular use were: benzodiazepines (32.3%); hypnotics (26.6%); antidepressants (15.6%); and anxiolytics (8.6%). At least half of antidepressant doses were subtherapeutic. Of 874 residents who responded to a depression questionnaire, 30% scored as significantly depressed; one-third of these were taking antidepressants. CONCLUSIONS: The percentage of residents in Central Sydney nursing homes who were taking neuroleptics, hypnotics or anxiolytics is among the highest reported from geriatric institutions around the world. Prescribing practices in Australian nursing homes need to be reviewed.     

Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

OBJECTIVE: As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening. DESIGN: Cross-sectional study. SETTING: The 54 Medicare-certified King County nursing homes (total beds = 7013). PARTICIPANTS: All patients referred for psychiatric evaluation under PASARR (n = 510). MEASUREMENTS: A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators. RESULTS: Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs. CONCLUSIONS: The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.     

Resident characteristics and organizational factors influencing the quality of drug use in Swedish nursing homes

Appropriateness of drug use is an important indicator of the quality of care in nursing homes. In this study, we analyzed the influence of resident characteristics and selected organizational factors on the appropriateness of psychotropic drug use in 33 Swedish nursing homes. Specific criteria based on published guidelines and recommendations were developed to measure appropriateness. Residents diagnosed with a psychiatric disorder and younger residents had more deviations from the criteria; however, resident mix did not explain variations in appropriateness of drug use at the facility level. Facilities with better nurse staffing and drug intervention teams had fewer deviations from the criteria, but only 15-20% of the variation in drug prescribing was explained by these predictors.     

Recombinant allergens for diagnosis of allergic bronchopulmonary aspergillosis

PURPOSE: The investigation aimed at assessing the prevalence of depression among residents in a nursing home. METHODS: In a rural area of Germany a representative sample was examined by means of the "Brief Assessment Interview" (BAI). RESULTS: 17% had a depressive disorder without dementia, 9% had a mild dementia syndrome and a depressive disorder; a total of 47% suffered from symptoms of dementia without depression. Most of the patients were treated by general practitioners or internists. 11% of the patients with depression were treated with antidepressants, 19% with neuroleptics, 17% with minor tranquillizers, and 17% with hypnotics. Only 20% of the depressive patients had ever been examined by a psychiatrist, 4% underwent an actual psychiatric therapy. CONCLUSION: Elderly patients with depressive disorders living in nursing homes need a more specific psychiatric treatment.     

An evaluation of a family visit education program

OBJECTIVES: This study was designed to examine the impact of the Family Visit Education Program (FVEP) on family members, nursing staff, and nursing home residents with dementia. DESIGN: The study employed a 2 x 3 single-blind, randomized control group design with two study conditions, FVEP or usual care (UC), and three times of measurement, baseline, 3-months, and 6-months. SETTING: The study was conducted in five skilled-care nursing homes that ranged in size from 120 to 300 beds. PARTICIPANTS: Sixty-six residents with dementia and their primary visitor were randomly assigned to FVEP (n = 32) or UC (n = 34). MEASUREMENTS: Residents were assessed for (1) psychosocial functioning, (2) depression, (3) agitated behavior, and (4) degree of positive social interaction. Nursing staff were assessed for changes in the time and methods used to manage problem behaviors. Visitors were assessed for (1) dementia management skills, (2) extent of perceived caregiving hassles, and (3) visit satisfaction. RESULTS: FVEP was effective for reducing residents' problem behaviors and for decreasing their symptoms of depression and irritability. It was also effective for improving the way family members and other visitors communicated with residents, but, with the exception of reducing the use of mechanical restraints, it was not effective in changing nurses' management of residents' behavior problems. CONCLUSIONS: It is possible to educate family members to communicate and interact more effectively with nursing home residents with dementia. This has beneficial effects on residents but not on nursing staff's management of problem behaviors.