| |
Restraints
Background
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.
- Identify
the problem: Take a step back and objectively
pinpoint the problem.
- 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?
- List
possible strategies: Think of all the ways to
possibly solve the problem.
- Choose
a strategy: Weigh the pros and cons of each strategy.
Select one.
- Take
action: Put the chosen strategy into effect.
- 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.
Type
of restraint |
Minimal
use |
Inappropriate
use |
Potential
risks |
Physical |
Use
of a lap belt to help a person sit up and participate
in an activity. |
Use
of a table tray to prevent a person from walking
around. |
Increased
falls.
Increased
frustration and restlessness.
|
Chemical |
Use
of medication to stop disruptive behaviour and
allow a person to participate fully in daily
life.
The
medication plan has short-term goals, and the person
is monitored closely and re-assessed regularly
to ensure that the medication continues to allow
participation in daily activities.
|
Use
of medication to stop disruptive behaviour, without
proper assessment of side-effects. |
Increased
confusion.
Increased
disorientation.
Increased
potential for falls.
|
|
A
protected garden with free access to the inside
of a building. |
A
locked bedroom door. |
Increased
frustration and restlessness. |
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:
From
the Alzheimer Society of Canada:
- The
Alzheimer Journey Module 4. Understanding Alzheimer Disease: The Link Between Brain and Behaviour
Other:
- Dementia
with Dignity. Eastway Communication, Crow's Nest,
NSW, 2002. For ordering: www.mediaonevideo.com.
- Everyone
Wins! Quality Care Without Restraints [video
and workbooks]. Independent Production Fund, New
York, NY, 1995.
- 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.
|
