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Use of restraints

A restraint is a device or medication used to restrict or control a person's movement or behaviour. Sometimes, because of the behaviours associated with Alzheimer's disease and related dementias, restraints are used on people with the disease. Although the intent may be to protect the safety of the person with the disease and others, the use of restraints can cause harm and lessen a person's independence and self-esteem. Understanding the reasons for some of the behavioural changes associated with Alzheimer's disease is a first step towards developing care strategies that provide alternatives to the use of restraints.

Alzheimer's disease symptoms and the resulting loss of abilities will cause changes in the way people react and respond to situations. These reactions may be the only way the person with the disease can communicate and may be caused by any of the following:

• The disease process
  As the disease affects different areas of the brain, certain abilities will be lost. Once lost, they can rarely be relearned. People may also experience depression, delusions (false beliefs about someone or something) or delirium (intense episodes of confusion) and respond with behaviours that those providing care find difficult to understand.


• Lost communication skills
  A person may no longer be able to express basic needs, such as the need for food, drink, sleep or the need to use the toilet.


• Physical discomfort
  There may be a physical problem. A person could be too cold, too hot, in pain or ill.


• Inability to interpret the environment
  A person may no longer recognize physical surroundings and may get lost, or not understand what to do in a particular setting, for example, use the toilet.


• Inability to understand or perform a task
  People may not understand what they are being asked to do. Or they could be over-stimulated, under-stimulated or feel rushed.

Types of restraints

There are three main types of restraints:

• Physical restraints that restrict or control movement or behaviour. They may be attached to a person's body or create physical barriers.
• Chemical restraints that are medications used to modify or restrict behaviour. For example, tranquilizers and sedatives.
• Environmental restraints that change or modify a person's surroundings to restrict or control movement. For example, a locked door.

The issues

For people with Alzheimer's disease:

Restriction of freedom:
Restraints can decrease a person's physical activity level and ability to function independently. For example, a chemical restraint may leave a person sedated and inactive. A physical restraint, such as a tray on a geriatric chair, may prevent a person from moving freely, which can lead to frustration. The excessive or inappropriate use of some caregiving strategies may result in a person's being restrained. These restrictions of freedom can also lead to a loss of confidence and self-esteem.

Risk of harm or injury:
Restraints can cause injuries. For example, where a bed rail is used, a person may try to climb over the rail during the night to get to the bathroom. This could result in a fall.

Loss of abilities:
The restrictions created by restraints may result in the loss of cognitive and physical abilities. For example, a person who is sedated for long periods may never regain abilities that existed before the sedation.

For family members and caregivers:

Risk of harm or injury:
Some behaviours expressed by a person with Alzheimer's disease may put that person and others at risk of injury. For example, people with Alzheimer's disease may go outdoors dressed inappropriately in sub-zero temperatures and put themselves at risk of injury. Also, a person who reacts aggressively to a situation may put someone close by at risk of harm.

Appropriate care strategies:
Family members may not be aware of appropriate care strategies for behaviours caused by the disease, or the risks associated with restraints, and may use restraints themselves or request that health-care professionals use them.

For health-care professionals:

Risk of harm or injury:
Some behaviours expressed by a person with Alzheimer's disease may put health-care professionals and other residents of a long-term care facility at risk of injury. For example, a person with Alzheimer's disease who responds aggressively to a situation may put other residents and staff at risk of harm.

Lack of understanding, training and human resources:
Some health-care professionals lack an understanding of the issues of Alzheimer's disease and behaviour and, consequently, fail to implement the preferred care strategies. Long-term care facilities may also lack appropriate educational, human and financial resources to provide quality care for people with the disease.

Preferred choice

No restraints

The preferred choice is to use no restraints. A physical, chemical or environmental restraint should not be used as a substitute for safe and well-designed environments or for the proper care and management of a person with Alzheimer's disease.

One of the most successful strategies for dealing with difficult behaviours, without using restraints, is to use the problem-solving approach.

1. Identify the problem: Take a step back and objectively pinpoint the problem.
2. Analyze the problem: Is the person trying to communicate something? What factors might be contributing to the person's reaction? What is happening and why? Could the person be reacting to something or someone in the environment?
3. List possible strategies: Think of all the ways to possibly solve the problem.
4. Choose a strategy: Weigh the pros and cons of each strategy. Select one.
5. Take action: Put the chosen strategy into effect.
6. Assess the results: Did the chosen strategy work? If not, why not? Should another strategy be tried?

Sometimes the first strategy is not successful. Or, it may work the first time, but not with subsequent attempts. Talking to other caregivers, a doctor or someone from the local Alzheimer Society may provide explanations about why the strategy may have been unsuccessful. They may have suggestions for other possible approaches.

When restraint-free strategies prove ineffective

• The preferred choice remains to use no restraints.
  If all other possible approaches have been exhausted and the use of a restraint is contemplated, the following factors should be considered:

• Has the problem been clearly defined?
• Has there been an assessment to determine why it is necessary to intervene?
• Have other strategies been tried?
• Has proper consideration been given to the reason for selecting the restraint?
• What are the risks and benefits for the person with Alzheimer's disease and others?

• Minimal restraint
  It may sometimes be necessary to use minimal restraint to cope with some of the behaviours for which restraint-free strategies cannot be found, and to ensure the safety of the person and others. If restraints are used, it is critical that the least restrictive restraints be chosen and that they be used appropriately. As well, short-term goals should be set, and the person should be monitored closely and re-assessed regularly.
• Inappropriate use of restraints

  An inappropriate use of restraints occurs if restraints are misused or used too often. For example, when the use of a restraint decreases the ability to participate in activities of daily living, creates stress and/or has a negative effect on quality of life.

The following chart gives examples of uses and risks associated with the three types of restraints.

In closing...

The care strategy of choice is to use no restraints. When minimal restraints are being considered, the positive and negative consequences for the person with the disease and others must be carefully measured and monitored. The physical and mental well-being of a person in a restrained condition should not be compromised.

Resources:

1. Dementia with Dignity. Eastway Communication, Crow's Nest, NSW, 2002. For ordering: www.mediaonevideo.com .
2. Everyone Wins! Quality Care Without Restraints [video and workbooks]. Independent Production Fund, New York, NY, 1995.
3. Understanding Difficult Behaviours: Some Practical Suggestions for Coping with Alzheimer's Disease and Related Illnesses. Anne Robinson, Beth Spencer and Laurie White, Geriatric Center of Michigan, Ypsilanti, Michigan, 1989.