Restraints in Dementia Care

A Nurse's Guide to Minimizing Their Use

Atul Sunny Luthra, Yarima Gonzalez, Heather Millman

• Publisher: Brush Education
• Year: 2019
• ISBN:
  9781550598025
• Topic: Medizin
• Subtopic: Gesundheitswesen, Verwaltung & Pflege

Your best tool to optimize patient care by minimizing restraint use

Frontline nurses face fraught decisions every day about whether and how to use restraints in dementia care. They need to consider many complicated issues: legislation governing the use of restraints, the policies of health-care facilities, the expectations of families, and—most importantly—the well-being, dignity, and safety of patients and care providers.

Frontline nurses need the right support to navigate decisions about restraint use.

Dr. Atul Sunny Luthra and his colleagues have developed an algorithm to provide that support. Their work comes from focus-group consultations with frontline staff, a review of current literature on restraint use, and a clear summary of key legislation. The algorithm's systematic approach ensures restraints are a last-resort measure, and puts the right steps in place when restraints are necessary.

This short guide includes:

• A review of nurses' perspectives on restraint use.
• Alternatives to restraints in patient management and assessment of clinical indicators for restraint use.
• Procedures to ensure informed consent when restraints are necessary.
• A reference on appropriate and inappropriate restraint use in everyday clinical situations.

1 Five Clinical Scenarios Perspectives on Restraint use from Frontline Staff at Homewood Health Centre

The use of restraints in dementia care remains a controversial issue, regardless of the reasons for using restraints. Over the last two decades, initiatives to minimize restraint use have focused on multistep approaches, including educational programs for frontline staff, expanded roles for interdisciplinary teams (IDTs), and legislation. Educational programs have included print and digital brochures, interactive websites, and workshops and symposiums. IDTs have expanded to include occupational and recreational therapists with expertise in creating and implementing alternative care plans to the use of restraints. Finally, provincial governments have enacted legislation to regulate the use of restraints in dementia care.

The knowledge gained from legislation, combined with evidence-informed clinical research, has resulted in the generation of best-practice guidelines that govern the clinical use of restraints for all regulated health-care professionals. These best-practice guidelines often inform policy-and-procedure documents in regulated health-care institutions. Policy-and-procedure documents govern the use of restraints by regulated health-care staff in the care of persons with dementia, and ensure rigorous adherence to best practices. These documents are meant to provide regulated health-care staff with parameters to operate within, once the clinical decision to apply restraints has been made. They include specific clinical indicators for the use of restraints in the care of persons with dementia within legislated health-care facilities, but they do not guide staff in considering risks posed by specific clinical indicators in the context of specific clinical situations. Hence, these documents do not generally guide health-care staff on the appropriateness of using restraints in specific clinical situations.

The five clinical scenarios presented in this chapter, which involve “agitated” behaviours, make this point clear.

“Agitation” covers a wide range of issues in persons with dementia who exhibit behavioural symptoms. It is one of the most all-encompassing terms in the dementia literature. It is often used interchangeably with terms describing physical aggression, verbal aggression, disinhibited behaviours, disruptive behaviours, and many other behaviours.

The literature is slowly moving away from the term agitation and toward terms such as behavioural expressions and responsive behaviours—terms that acknowledge and capture the behavioural and psychological symptoms of dementia (BPSD) that most persons with dementia experience. Behavioural expressions tends to be a broader term, often used by the medical community for a group of clinical manifestations of dementia (Dementia Initiative, 2013). Responsive behaviours—a term coined by the Murray Alzheimer Research and Education Program (MAREP)—identifies behaviours within BPSD that are ways to communicate when traditional ways have become impaired (Dupuis, Wiersma, & Loiselle, 2012). These more specific terms recognize that persons with dementia are still able to experience thoughts and feelings, and they counter the risk of pathologizing every behaviour observed in dementia patients.

However, these evidence-based, more precise terms have yet to gain currency in the policy-and-procedure documents of legislated health-care institutions in Canada. When describing acceptable clinical indicators for the use of restraints, “agitation” remains a commonly cited reason. The following five clinical scenarios highlight some of the challenges faced by nursing staff in the use of restraints as a way of managing the clinical indication of agitation.

Clinical Scenario 1

Patients in the moderately advanced stages of dementia often exhibit impaired facial recognition, and they may misidentify individuals on a dementia unit as people familiar to them. For example, a male resident may identify a female resident as his wife. He may spend increasing amounts of time in her vicinity, hold her hand, enter her room, and insist on sitting with her during meals. If the female resident has a spouse, the male resident’s behaviour creates a difficult dynamic for staff to manage. The male resident may become intrusive or upset when, during visits, the female resident’s family or spouse wants some private time. The male resident may become “agitated” and aggressive. Nursing staff may use restraints as a way to manage this clinical situation and, in most policy-and-procedure documents, this would be an acceptable clinical indication for doing so.

Clinical Scenario 2

Persons with advanced dementia commonly exhibit repetitive behaviours of increasing intensity. For example, a resident may repeatedly visit the unit nursing station with requests to go to the bank to withdraw money so they can pay their utility bills. This fixation is incessant and unrelenting, and, lacking permission to leave the unit, the resident becomes increasingly angry, upset, and unsettled. The resident may start to intrude into the nursing station, insisting on calling their spouse or children to arrange a trip to the bank. The resident may also “exit seek”—for example, by trying to open the main entrance of the unit. This state of “agitation” can present quite a challenge to nursing staff. A way to manage this behaviour would be to use restraints, and this situation, again, would be an acceptable clinical indication for doing so.

Clinical Scenario 3

Persons with advanced dementia frequently exhibit “rummaging” behaviour, where they enter other residents’ rooms, open their drawers, take out their belongings, and carry the belongings to other places on the unit or to someone else’s room. They often rummage through their own drawers, packing and unpacking their own belongings, or collecting all their belongings on their bed. This propensity to collect and rummage may involve any objects anywhere on the unit, which end up in the resident’s room, or anyone else’s room, or other places. This behavioural expression can go on for hours and presents a challenge for nursing staff, who must repeatedly find and restore the rummaged objects. This state of “agitation” can be managed through the use of restraints, and, yet again, it would be an acceptable clinical indication for doing so.

Clinical Scenario 4

Persons with dementia often reenact their former work lives or organizational routines. Individuals with a health-care background might move other residents around, make efforts to feed them, or attempt to pull them out of bed. They may shift bags of soiled linen, or change linen on different beds at different times of the day. Individuals with a background in a trade (e.g., carpentry, plumbing, electrical work) may move furniture to create spaces where they pace around. They may get angry when other residents intrude into the spaces, or show pronounced impatience when nursing staff attempt to redirect the behaviour. Any of these behavioural expressions of work life easily fit the label of “agitation.” Staff can manage them through use of restraints, and policy-and-procedure documents would accept these behaviours as clinical indications for doing so.

Clinical Scenario 5

Persons with dementia are commonly emotional and weepy, repeatedly asking to go home to see their mom and dad, and even expressing concern over being late to get home. Residents may direct their requests to nursing staff or any other interdisciplinary team member, and the behaviour may progress to involve other residents on the unit. This behavioural expression can go on for hours as a part of “sundowning” phenomena. It is often labelled as “agitation” and may be managed by nursing staff through the use of restraints, a decision within the clinical guidelines of most policy-and-procedure documents.

A Closer Analysis of the Clinical Scenarios

The clinical scenarios show that using restraints to manage “agitation” does not violate the policy-and-procedure documents of legislated health-care institutions. However, the pivotal question is this: Are restraints the most appropriate intervention for behavioural symptoms in persons with dementia? On the surface, each of the behavioural expressions in the clinical scenarios can be classified as “agitation,” but a closer analysis reveals a very different purpose and meaning for these expressions in these individuals.

Recent literature on behavioural expressions in persons with dementia identifies behavioural expressions as “modes of communication” for individuals who have lost their language functions. Hence, a way to approach the management of these behaviours is to understand their purpose and meaning: What is the person with dementia trying to communicate to us? A better understanding of the purpose and meaning of these individual behavioural expressions (their quality) allows identification of their specific associated risks. Each quality of behavioural expression may have unique associated risks. Each of the risks identified can then have a unique behavioural intervention to keep patients safe, and none of the interventions need to involve the use of restraints. Examining each clinical scenario further illustrates this point.

In the first clinical scenario, the person with dementia identifies a female resident as his wife. As a result, he may feel completely justified in following her around, in becoming upset and angry when staff members separate him from her, and, ultimately, in approaching her sexually. Hence, risks in this clinical situation include aggression from the person with dementia toward the female resident’s husband and family, and toward staff during attempted separations; and sexual interaction with the female resident. A care plan based on environmental interventions is a way to mitigate these risks. Environmental interventions can be structural or functional. Structural interventions could include moving the two residents to opposite ends of the unit or to different units altogether. Functional changes could include a behavioural care plan that arranges different shifts in the dining room for the two residents, different groups for therapeutic milieu activities, and different excursions outside the unit. A behavioural care plan can mitigate all the identified risks without the use of restraints.

In the second clinical scenario, the meaning of the behavioural expression may connect to a need to show good citizenship as part of belonging to a civil and orderly society. In an orderly society, people follow the rule of law, pay their bills, and live by good example. Risks in this situation include escalation to aggression directed toward staff or other residents (for example, as the individual pushes their way to a phone), and exit seeking and impaired “wayfinding” (the ability to navigate physical spaces without getting lost). A behavioural care plan that validates and supports the resident in upholding their values can mitigate these risks. It can include seeking assistance from the unit’s therapeutic recreationist to simulate bankbooks, phone calls, and other ways to satisfy the resident’s goals and need to belong. These interventions assist in deescalating the resident’s behavioural expression, thereby mitigating its risks without the use of restraints.

In the third clinical scenario, the meaning of the behavioural expression seems connected to insecurity about times of scarcity or deprivation. The individual may simply want to ensure “enough” for family if a war breaks out (in an actual case of this behaviour, the resident had lived through war in her younger years). The risks of this behavioural expression include trip-type falls and aggression toward the individual from other residents. A behavioural care plan can include the individual in laundry management: bringing linen from the laundry to a safe room, assisting to fold the linen in piles, and assisting staff to transfer the piles in a safe way to the resident’s room and other residents’ rooms. This behavioural plan can mitigate both the risk of trip-type falls from scattered linen and the risk of aggression from others. Neither of the risks needs management through the use of restraints.

In the fourth clinical scenario, the meaning of the behavioural expression may connect to a need for validation and acceptance through work (in actual cases of these behaviours, the residents defined their identity through work). The risks of the behaviour depend on the type of work the person with dementia reenacts in the context of the unit. If the person reenacts health-care work, the risks could involve attempting to feed other residents, who may have a nonfunctional swallow, thereby increasing the risk of food aspiration for these residents; or attempting to transfer residents from their beds, thereby creating a risk of falls and injury for the residents and themselves. If the person reenacts work in a trade, the risks may involve confrontation with, and subsequent aggression toward, other residents who are “in the way”; or proximity to electrical outlets, or attempts to en...