Sample Literature Review On Use Of Restraint In Dementia Patients
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Most often affecting the elderly, dementia causes complete inability to perform routine daily activities due to impairment of memory, thinking and social abilities. Caring for dementia patients can be very challenging given their actions, reactions and activities have the potential to inflict pain, injury, or harm to themselves or to those around them. The use of restraints as a means to control dementia patient actions is a routine practice in healthcare. The restraints include seat belts, collars, chains, bed rails, lap barriers, wrist restraints, ties to bed, strait jackets, padded cells, and electronic devices. Clinical and healthcare research suggests that these restraints are not an answer to the most difficult job of care giving to dementia patients. The restraints sometimes increase the risk of physical harm and produce negative psychological after effects. The present paper is as appraisal of the scientific literature around the issue of use of restraints in dementia patients.
Keywords: dementia, restraints, elderly, healthcare,
Use of Restraints in Dementia Patients
The term dementia does not refer to a particular disease. Dementia pertains to problems or impairment associated with brain functions of memory and judgment. Most often encountered in elderly, the dementia symptoms can affect memory, thinking and social abilities to the extent of complete inability to perform routine daily activities. Caring for dementia patients can be very challenging, particularly if the actions, reactions, and activities of patients have the potential to inflict pain, injury, or harm to themselves or to those around them. In this context, the use of restraints as a means to control dementia patient actions, have come into practice in healthcare.
The use of restraints in dementia patients is a practice that has been used for a long while in the nursing profession. However, this practice is surrounded by ethical and legal implications, which have led to a review of the practice by both the legal teams and the nursing profession. Although the nursing profession employs this measure as the last resort, it still has the same implications on dementia patients. Among the many other uses, use of restraint is employed primarily in an effort to reduce injuries to the patients. However, studies have indicated that there are other alternatives to this measure which are more effective and they reduce the chances of injuries to the patients. According to Tinetti, et al (2008), use of restraint in dementia patients has been reported to do more harm than good to the patients, as it has been observed to cause pressure ulcers and patient psychological agitation. The present paper will review and analyze the state of current scientific literature around the issue of use of restraints in dementia patients.
Dementia is a syndrome that affects memory, thinking, behavior, and the ability to perform daily activities. This syndrome mainly affects the elderly people, who account for almost 70- 80% of the dementia population, although it can also affect younger ones. This is one of the major causes of disability and dependency among elderly generation (Schussler, Dassen & Lohomann, 2014). Challenges posed by dementia lead to various impacts like physiological, psychological, economic and social impact on the caregivers and the families. People suffering from Dementia are usually conscious but there is cognitive impairment and may proceed in deterioration of social behavior, emotional control or motivation. Dementia may be of different forms of which the most common is Alzheimer’s disease. This disability and dependency may lead to various risks and hazards of injury to the patient. Therefore, these patients need some interventions in the form of physical and chemical restraints to safe guard their lives (Meyer, Köpke, Haastert, & Mühlhauser, 2009).
Many forms of restraints are used to prevent the patients from various physical and environmental risks in everyday life. These restraints may include various things like seat belts, collars, chains; bed rails, lap barriers, wrist restraints, ties to bed, strait jackets, padded cells or enteral tubes, and other electronic devices that help in locating and preventing risks. Some extreme cases may require chemical restraints in the form of drugs. Despite the negative feeling prevalent among the health care providers and nurses attending to geriatric patients, the necessity of restraints in geriatric care can’t be overlooked (Meyer, Köpke, Haastert, & Mühlhauser, 2009).
Falls and unsafe wandering are the most common consequences of dementia that leads to use of physical restraints. In modern views the use of these restraints are undesirable and abusive. They are associated with poor staffing, exhausted and frustrated caregivers who are trying some level of control over these restless, demented self-determined and often aggressive people. Studies identify that people with cognitive impairment are at more risks of being subjected to restraints in nursing home, hospitals and other health care settings. Clinicians and various researchers (Di Giulio, Toscani, Villani, Brunelli, Gentile & Spadin, 2008) have found that these restraints are not an answer to the most difficult job of caring and keeping safe these patients with dementia. These restraints sometimes increase the risk of physical harm and negative psychological after effects.
This requires the use of other strategies to combat their negative feelings. Some health care professionals do have ethical considerations in using restraints. They believe in autonomy and respect for the person concerned. The necessary interventions must improve physical health, cognition, activity and overall well-being. This also ensures in treating behavioral and other psychological ailments, giving information and supporting long-term care (Testad, Ballard, Brønnick & Aarsland, 2010).
Older dementia patients are at a higher risk of suffering from other conditions when placed in restraints than other patients. There are several negative physical or psychological outcomes in the use of restraints. However, many nurses believe that restraints are necessary to manage behavioral symptoms, to avoid falls or the interruption of life sustaining therapies (Evans & Cotter, 2008).
Use of restraints leads to fear, frustration and a loss of dignity, increasing agitation, loss of independence and go against human rights. Therefore, restraints are just not an answer to deal with these patients. The only restraint that used to solve these problems is the occasional use of chairs with lap top tables and closely monitored. These tables are useful for some activities and in having food. Cautious use of medications may help in reducing agitation and use of physical restraints. These medications must not be overdosed to create drowsiness and sleep among dementia patients.
According to the Government of UK, the dementia strategies ensure in improving formal care services. To improve the services of NHS and care services received by dementia patients, Prime Minister’s Challenge on dementia was launched in 2012. The Care Quality Commissions up dated care in 2013 shows that adult social care is not enough for caring adequately for dementia patients and is frequently referring their problems to hospitals. More than half of these dementia patients in care homes are going to hospitals with avoidable circumstances such as dehydration, decubitus ulcers or pressure sores (Sampson, Candy & Jones, 2009). Almost one third of hospital admissions of the dementia patients do not have proper records of past medical history. According to the Alzheimer’s Society of the Program of Support Stay Safe, people living at home are getting insufficient support highlighting various negative repercussions of the dementia symptoms and general health. According to Equity and Human rights Commission there are various incidences where human rights are breached in home care as a result of how it is carried out (Gastmans & Milisen, 2008). Most of the care-givers are dissatisfied with the quality of care provided in hospitals. These relates to lack of understanding dementia by the nurses, not helping these patients in eating and drinking, lacking in patient centered care, insufficient social interactions, and lacking in dignity and respect ( Landau, Werner, Auslander, Shoval & Heinik, 2008). The 2010 enquiry identifies several cases where the staffs treat patients with dementia with no dignity or respect. Most of the hospitals fail to meet the basic standards in dementia care. This led to Francis Enquiry of 2013 that the organizations are more efficient in providing information about services than the causes responsible for poor quality services. These leads to application of four basic principles:
Providing training for the staff who have right to use specialist support
Maintaining of human rights along with dignity and respect
Proper coordination among various professionals, and services between health care, social care and housing
Non-use of restraints or using alternative measures requires reevaluation of the care practices. A complete evaluation of the physical condition, keeping the halls free of obstacles, installing rails, grabs and poles nest to chair, bedrooms, bathrooms and adapting wheel chairs to improve position, support and relieve, and providing pressure relief cushions in wheel chair are some of the necessary measures ( Brodaty & Burns, 2012). Other necessary measures include lowering of wheel chairs in self-drive of feet, installing carpets to reduce injury, alternative comfortable seating and in using pads in undergarments to reduce injuries from falls. Creating an amiable and soothing environment, home like to reduce agitated behaviors are helpful. Using soothing lights and colors along with aromatherapy and music therapy helps in decreasing agitations. Other measures (Xie, Brayne & Matthew, 2008) are reducing noise and external stimuli, avoiding mirrors and glasses, arranging for wandering paths and keeping the exit doors blocked and alarmed, providing gentle and cool reassurance along with assessment of hunger thirst and discomfort.
Recently, most nursing associations like American Nursing Association emphasize on much support in participation of registered nurses in curbing use of restraint and seclusion in dementia patients. Previously, it was perceived that the successful use of restraints or seclusion is helpful in reducing patients’ injury or harm to others like, nursing staff, patients or visitors. However, the use of restraints causes more problem than relief. These assumptions are contrary to the primary goals and moral traditions of nursing profession (Berzlanovich, Schöpfer, & Keil, 2012). Nursing profession should uphold the sovereignty and self-respect of each patient or resident. Nurses are now struggling to balance their responsibilities in protecting patients’ rights of freedom with their responsibility to protect them from injury. They also face pressure from family or peer in using restraints. Some of the outcomes that arise from immobilization or restraint include difficulty to maintain balance, strength or gait because of loss of bone or muscle mass. Older adults after release from restraints are at higher risks of falls and injuries due to immobilization for long period. The ability to perform their daily activities after discharge is much reduced than patients without restraints. These relate to poor outcomes of using restraints and increases awareness of the adverse effects of these restraints (Steinert, et al., 2010). All health care settings must promote and protect patients’ rights maintaining dignity and autonomy. However, reduced use of restraint in dementia patients is usually associated with better outcomes like reduced agitation.
The IOM in USA recommends several approaches in delivery of care and in preparing direct care by health care workers. This ensures in expansion of team-based workers so that efficient health care workers deliver care efficiently. The direct care workers in long-term care have various difficulties like long hours, poor payments, little benefits, and are susceptible to injuries and depression (Bowers, Van Der Merwe, Patterso., Stewart, 2011). The stresses experienced by the nurses and the personal care givers are important not only for the workers themselves but also for the well-being of residents, families and the patients they serve. There are some new measures so that the provision of care in dementia under direct care providers in long-term care facilities enhances. This relates in advanced role of direct care workers with appropriate training, supervision and support so that home care workers can play an enhanced role in caring for dementia and older adults (Tinetti, et al., 2008). This ensures in person centered care in dementia, which requires long-term care. Individuals with severe dementia need special care units where the workers face a number of challenges including residents, families understaffing or inexpert co-workers and unmet expectations. Majority of the long-term care units do not have facilities of special care units.
In conclusion, the use of restraint in dementia patients is a practice that is slowly being phased out in care homes for the elderly. This is because of the implications that accompany the practice. Patients suffering from dementia are prone to increased agitation due to the restriction, and are also prone to development of injuries like pressure ulcers. Due to these complications, researchers have carried out studies to determine other interventions that can help in elimination of use of restraint in dementia patients. Some of those alternatives include proper environmental design for care homes, nursing training, and more personalized care for the dementia patients.
Berzlanovich, A. M., Schöpfer, J., and Keil, W. (2012). Deaths Due to Physical Restraint. Dtsch Arztebl Int., 109(3), 27-32.
Bowers, L., Van Der Merwe, M., Patterson, B. and Stewart, D. (2011). Manual restraint and shows of force: The City-128 study. International Journal of Mental Health Nursing, 12(4), 245-252.
Brodaty, H. and Burns, K. (2012). Non-pharmacological Management of Apathy in Dementia: A Systematic Review. American Journal of Psychiatry, 20(7), 549-564.
Di Giulio, P., Toscani, F., Villani, D., Brunelli, C., Gentile, S., and Spadin, P. (2008). Critical Care in Dementia. Journal of Palliative Medicine, 11(7), 1023-1028.
Evans, L. K. and Cotter, V. T. (2008). Avoiding Restraints in Patients with Dementia: Understanding, prevention, and management are the keys. American Journal of Nursing, 108(3), 40-49.
Feil, D. G., MacLean, C., and Sultzer, D. (2008). Quality Indicators for the Care of Dementia in Vulnerable Elders. Journal of the American Geriatrics Society, 55(2), 293–301.
Gastmans, C. and Milisen, K. (2008). Use of physical restraint in nursing homes: clinical‐ethical considerations. Journal of Medical Ethics, 32(3), 148-152.
Landau, R., Werner, S., Auslander, G. K., Shoval, N. and Heinik, J. (2008). Attitudes of Family and Professional Care-Givers towards the Use of GPS for Tracking Patients with Dementia: An Exploratory Study. British Journal of Social Work, 39(2), 399-407.
Meyer, G., Köpke, S., Haastert, B. and Mühlhauser, I. (2009). Restraints use among nursing home residents. Journal of Clinical Nursing, 18(7), 981-990.
Sampson, E. L., Candy, B. and Jones, L. (2009). Enteral tube feeding for older people with advanced dementia. Cochrane Dementia and Cognitive Improvement Group, 4(8), 893-910.
Schussler, S., Dassen, T. and Lohomann, C. (2014). Care dependency and nursing care problems in nursing home residents with and without dementia. Aging Clinical and Experimental Research Springer International Publishing, 27(14), 987-993.
Steinert, T., Lepping, P. and Bernhardsgrütter, R. (2010). Incidence of seclusion and restraint in psychiatric hospitals: A literature review and survey of international trends. Social Psychiatric Epidemiology, 45(7), 889-897.
Testad, I., Ballard, C., Bronnick, K. and Aarsland, D. (2010). The effect of staff training on agitation and use of restraint in nursing home residents with dementia. The Journal of Clinical Psychiatry, 71(1), 80-86.
Tinetti, M., Baker, D. and King, M. (2008). Effect of dissemination of evidence in reducing injuries from falls. New England Journal of Medicine, 359(25), 252-261.
Xie, J., Brayne, C. and Matthew, F. E. (2008). Medical Research Council Cognitive Function and Ageing Study Collaborators. British Medical Journal, 36(3), 258-262.
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