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Restraint Free Care in Older Adults with Dementia Valerie T. Cotter, MSN, FAANP University of Pennsylvania School of Nursing Alzheimer’s Disease Center

Grateful thanks to: Yoshiko Leibowitz, RN, MAN Director of International Affairs Faculty of Health Sciences Aomori University of Health and Welfare

University of Pennsylvania School of Nursing

University of Pennsylvania School of Nursing Neville Strumpf Director, Hartford Center for Geriatric Nursing Excellence    Norma Lang    Director, Office of    International Programs

Why Discuss Restraint Free Care in Older Adults with Dementia in 2004?

Patient Safety is Paramount From 1995-2004, 112 patient death or injury in restraints From 1995-2001, 237 deaths, 73 injuries from side rail entrapment 53% occurred in nursing homes 20% occurred in hospitals 35 deaths involved air pressure mattresses JCAHO Sentinel Event Statistics, 2004; 2002

Life Expectancy at Age 65 in Japan and the U.S. : 1970, 1980, 1998

Aging-Dementia Imperative: U.S. Perspective Number of Americans affected by Alzheimer’s disease projected to increase from 4.5 to 14 million by 2050 U.S. nursing home population expected to grow from 1.7 million in 2000 to over 3.3 million in 2030 Dementia is a primary diagnosis in 80% of residents in nursing homes

Aging-Dementia Imperative: Japan Perspective Alzheimer’s Association Japan, 2004

Rationale for Restraint Use Management of behaviors common in dementia Prevention of falls Prevention of treatment interference

Restraints and Dementia Impaired memory, judgment, visual perception Gait apraxia, unsteadiness Behaviors in moderate-severe stage such as elopement, agitation

Restraints and Falls Visual impairment Elevated bed height Medications that lower blood pressure, affect gait or mental status History of falls Decline in function, mobility

Fall Risk Assessment and Injury Prevention Fall risk increases with age and is much higher in older adults living in the nursing home than in the community More than 50 % of nursing home residents fall annually and over 40 % experience repeated falls Approximately 11% of falls result in serious injury, such as hip fractures, often leading to hospitalization and physical deterioration

Restraints and Treatment Interference Intravenous lines, urinary catheter, nasal tube, feeding tube, endotracheal tube Used during hospital admission for acute medical problem

Reducing Restraints: Relevant Law and Regulations Nursing Home Reform Act 1987 provides that residents have the right to be free from restraints Federal Food & Drug Administration (FDA) alerts on restraints 1992, side rails 1995 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards emphasize restraint alternatives Legal standard of care is against restraint use

JCAHO Sentinel Event Warning 2002 Are there gaps in your bed safety practices?

Negative Consequences Associated with Restraints Physical Iatrogenic outcomes: Increased risk for falling, pressure ulcers, incontinence, bone demineralization, muscle deconditioning Serious injuries: Hip fracture, head trauma Psychological, Behavioral Combativeness, aggression Increased disorientation Regression, dependency, functional decline

Nursing Home-Hospital Concerns about Standards of Care for Restraint Use Safety Fears of patient harm Cost/constrained resources Conflicting standards Shortened length of stay in hospitals, greater acuity and severity of illness Systemic tensions from nursing shortages and organizational change

Restraints 2004

15 Year Program of Research Strumpf & Evans, University of Pennsylvania School of Nursing Cross-cultural studies of US/European hospitals/nursing homes Restraint reduction in nursing homes Restraint reduction in hospitals Advancement of individualized restraint free care for older adults across all settings

Key Findings from Program of Research Physical restraint has harmful consequences Interdisciplinary dialogue is scant American nurses see few alternatives and experience system stresses Regulation alone does not change embedded practices

Voices of Restrained Patients “I felt like a dog and cried all night. It hurt me to have to be tied up…The hospital is worse than a jail.” “If there was a fire, I’d be caught.  When someone is tied and chained in a fire, how will you save the person?  How would I get out?” Strumpf & Evans, 1988

Voices of Hospital Nurses “I’d rather use a restraint than have her fall.” “Sometimes it bothers me when the patient can’t understand the need for restraint.  I wonder if it’s really for his own good.” “It drives me crazy to restrain so many patients.  I feel like a jailer rather than a nurse.” “I feel guilty at times because you take away the patient’s freedom and that bothers me.” Strumpf & Evans, 1988

Reducing Restraints in Nursing Homes:  Advanced Practice Nurse Intervention Restraint education and unit-based nursing consultation showed reduction in restraint prevalence without increases in staff, psychoactive drugs or serious fall-related injuries 3 months post-intervention, decline 20% (7% restraint education only; 7% control only) 6 months post-intervention decline 18% (4% restraint education only; 6% control only) Evans et al, 1997

Individualized Interventions

Restraint Removal: Falls and Injuries Among Nursing Home Residents Restraint removal does not lead to increases in falls or subsequent fall-related injury Capezuti et al, 1998

Side Rails and Bed-Related Fall Outcomes in Nursing Home Bilateral side rails do not significantly reduce the likelihood of falls, recurrent falls or serious injuries 319 subjects with consistent nighttime side rail use Cognitively impaired patients and those with behavioral symptoms were more likely to be restrained with side rails Capezuti et al, 2002

Effect of Bilateral Side Rails on Fall/Recurrent Fall Risk Controlling for Function, Cognition, Behavior

Effect of Advanced Practice Nurse Intervention in Hospitalized Nursing Home Residents Restraint reduction protocol utilized in hospitalized nursing home residents not restrained before admission Staff education Initial assessment within 12-36 hours of admission Development of individualized care plan Ongoing reassessment, monitoring Enhanced communication Strumpf, 1997

Key Findings Advanced practice nurse intervention was effective in reducing daily restraint use and any restraint use Adjusted odds ratio 7.3 (confidence interval 1.9) More effective in high risk patients Strumpf, 1997

Practice Implications: Individualized Care Assess sensory and functional impairments gait, balance, sensation, motor strength, range of motion, function, and use of assistive devices Address fear of falling Assess environmental factors wet floors, unstable furniture, dim lighting, loose clothing or shoes, overuse of wheelchairs, poorly adapted bathroom

Practice Implications: Individualized Dementia Care Assess stage of dementia, functional abilities Assess mood, behavior Incorporate past interests into day-to-day activities Encourage socialization

Nighttime Environmental Assessment A side rail can increase the height of the fall by two feet, thus increasing the risk of an injurious fall Climbing out of bed with the rails raised also leads to entrapment injuries and death Bed height is essential for safe transfers A bed height of approximately 100% to 120 % of the lower leg (distance from the lateral malleolus to the lateral tibial plateau) facilitates standing

The Get Up and Go Go Test Observe the person’s ability to do the following: sit and stand from a chair turn around (360 degrees) while standing walk or wheel to the bathroom or toilet get onto and use the toilet including clothing management, etc. get off the toilet and get into wheelchair, if used walk or wheel from the toilet/bathroom to the bed get into and out of bed Donius, M. (1995). Fall prevention and management. In J. Rader & E.M. Tornquist (Eds.) Individualized dementia care: Creative, compassionate approaches (pp. 145-167). NY: Springer.

Practice Implications: Organizational Interventions Commitment from administrative-clinical staff Revision of mission, vision, philosophy of care Educate staff through educational programs, advanced practice nurse consultation

Conclusion: Research Supports Restraint Free Care Restraints increase number of falls and serious injury Restraints have little or no safety value, and are actually hazardous Side rails don’t prevent falls and injury and can result in serious injury, death Individualized, comprehensive interventions reduce incidence of falls and need for restraints

Conclusion: Changing Practice Staff education, consultation, modeling Advanced practice nurse leadership Remove devices from facilities Apply gerontological care standards and guidelines Educate families Develop protocols for fall risk and post-fall assessment, and management program Develop protocols for behavioral symptoms of dementia, and management program