Mechanical restraint use among residents of skilled nursing home facilities: prevalence, patterns, and predictors

Article Abstract:

The role of nursing homes as both a care facility and a home to frail, elderly patients causes a conflict between ensuring patient safety and allowing freedom of movement. The controversy over the use of mechanical restraints has resulted in federal regulations designed to provide guidelines for when they should be used and to decrease their use overall. The restraints prevent falls and other accidents that can sometimes be catastrophic, and decrease the probability of being sued. On the other hand, preservation of autonomy and mobility justifies some risk. Physical restraints can cause strangulation, nerve damage, increased agitation, bed sores, incontinence, and other adverse reactions. Other countries, notably Britain and Sweden, use restraints far less frequently, with no greater proportion of injuries than tend to occur in than the United States. This study of 12 skilled nursing facilities (SNFs), with a total of 1,756 patients over a one-year period, attempted to supply data on the use of restraints (which varies between 25 and 85 percent in other nursing home studies). Two thirds of SNF residents were restrained at some time during the year. Variability was related to resident characteristics rather than payment source, staff-to-resident ratio, or other SNF characteristic. Most likely to be restrained were older, disoriented, less physically able residents who participated more in social activities, characteristics associated in another study with a greater likelihood of accidents. Intermittent use of restraints may increase patients' difficulties by reducing marginal strength and stability, and restraint of agitated patients only increases their agitation. The focus should shift to alternatives such as fall-risk assessment, supervised walking, and balance and gait training. Examination for underlying causes can lead to specific interventions. The problem is that almost half of these patients have more than one cause of the problem behavior. (Consumer Summary produced by Reliance Medical Information, Inc.)

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Managing behavior problems in nursing homes

Article Abstract:

Two articles in the January 23, 1991 issue of the Journal of the American Medical Association, one on the use of neuroleptic (antipsychotic) drugs by Garrard and her colleagues, the other on the use of mechanical restraints by Tinetti and her colleagues, raise disquieting issues of the treatment of nursing home patients. Nursing home residents are prescribed more drugs than can be explained by good medical practice, and there is reason to believe that the neuroleptics are being used as chemical restraints. These drugs have serious side effects, especially in the disabled and elderly, and when prescribed inappropriately, can worsen the problem, leading to an increase in dosage, and a vicious circle. Mechanical restraints are used in the same way, to incapacitate rather than to rehabilitate residents, and are usually applied to restrain active residents, rather than to treat medical conditions. In European countries, mechanical restraints are seldom used, contrary to practice in the United States, with no corresponding increase in injuries. Psychiatric institutions now use restraints only in emergencies. A few nursing home at the forefront of care of the elderly have made far-reaching changes. The Health Care Financing Administration (HCFA) regulations are an attempt to change such practices in all nursing homes. Mind-altering drugs and mechanical restraints are clinical interventions, and physicians should not forget that clinical interventions should be based on an understanding of the problem and a working diagnosis, as well as a consideration of appropriate therapeutic alternatives. Few physicians, including psychiatrists, are well trained in the care of the elderly, and the literature is not readily available to them. Interdisciplinary planning, consultation, and continuing education are needed. (Consumer Summary produced by Reliance Medical Information, Inc.)

Usage, editorial

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Evaluation of neuroleptic drug use by nursing home elderly under proposed Medicare and Medicaid regulations

Article Abstract:

There has been considerable concern about drug prescribing practices in nursing homes. Neuroleptics, which are antipsychotic drugs that produce passivity, anxiety and indifference to the surroundings, are most likely to be overused, exposing the patients to possible harm from side effects. Among the side effects of this class of drugs are tardive dyskinesia (uncontrollable tremors) and confusion, which may lead to falls and other accidents. Federal legislation regulated the use of these drugs in nursing homes certified by Medicare and Medicaid, in the Omnibus Budget Reconciliation Act, and guidelines were developed by the Health Care Financing Administration (HCFA). Neuroleptic drug use in nursing homes has been examined in several studies, but none have used the HCFA guidelines to judge the appropriateness of drug use over time. In this study, almost 996 of 4,756 nursing home patients (21 percent) were taking neuroleptic drugs on admission. Approximately half of the residents were not eligible to take neuroleptics, according to HCFA guidelines; either they were taking the drug for a mental disorder not included in the guidelines, or else the drugs had been prescribed for advanced age. The implication is that the drugs are being used as a restraint mechanism. Those taking the drugs were also more likely to have been admitted from a hospital. Almost every nursing home had at least one patient who was not eligible to take neuroleptics, according to the guidelines. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Dosage and administration, Medicaid, Medicare

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