At the 10th Annual Alzheimer Symposium on January 31, 1997, Judy Tiivel, acute care nurse practitioner, Regional Geriatric Program, The Toronto Hospital, made some interesting commnets on the use of restraints.

Her comments included:

• the definition of a restraint: the use of physical, mechanical or chemical means to prevent harm occuring to a patient
• between six and 50 per cent of people in institutions are restrained
• in North America we restrain people eight times more than they do in Great Britain
• at times the use of a restraint is necessary but routine evaluation must follow
• restraints should only be used after all other interventions have been tried and have failed

Why We Use Restraints

1. because of staff shortages: concern for staff and patient safety
2. to keep people from falling (most falls occur while climbing out of bed to go to the bathroom); many other falls are due to slipping and tripping

Types of Restraints

1. physical restraints: hand mitt, bed restraint, arm restraint, vest restraint
2. mechanical restraints: wheelchair tables, wheelchair footrests
3. chemical/pharmachological restraints: drugs

What We Can Do to Avoid Using Restraints

0. lower beds to make it easier and safer to get out (if appropriate)
1. use night lites
2. use half side rails
3. use sensor alarms ie. attach a bell to patient so staff can hear if patient moves
4. use wedge pillows to maintain position in bed
5. place a piece of non-skid foam on the floor by the bed so if a fall occurs injury can be minimized
6. if necessary place the mattress on the floor

When you are evaluating a housing alternative for someone with dementia, ask them to state their restraint policy.

Watch for any illness (flu, pneumonia, infection), drug reactions, dehydration, pain, too much stimuli (too hot, too cold, too much light, noise) that could cause agitation. If a person cannot communicate because of dementia, they will act out. Try to get to the root of the problem before employing restraints.

I was amazed to learn that in a hospital study floor staff were asked not to only document every fall or incident, but were also asked to document why it happened. As a result, the researchers noticed that during the study the level of incidents decreased. The probable reason: staff were spending more time with patients, communicating and caring.

Rather sad but critical observation -- we have all the restraints in the world, just not enough people (staff) in institutions.

My dad spends most of his time in a wheelchair and does try to get up or do things unassisted; invariably he ends up on the floor, fortunately with little or no injury as he seems to slide down to the floor. We put a tray on his chair when he gets very agitated but I know that when I or a staff member spend time with him, and talk quietly and patiently to him, that very often he quietens down. He wants attention, like every other human being.

We have eliminated restraints in our 60-bed facility completely. It took a year of slow work with the help of an incredibly effective Quaker-based non-profit organization called Untie the Elderly. They have great consulting service and excellent video and written materials for the families, the staff and the administration.

Untie the Elderly
c/o Kendal Corporation
P.O. Box 100
Kennett Square, PA 19348
phone: 610/388-5580
website: www.ute.kendal.org

Our most effective strategies in reducing harmful wandering and falls:

1. A good mobility, range of motion and strength program for these residents (CNAs and Activities do it).

2. Knowing what the resident's life work has been, and finding activities that help them feel that they are still in some way doing that work, so that they are happier and more settled. Example: A man with Alzheimers who was an administrator in his work now sits at our Asst. DON's desk at night with a list of phone numbers that we know answer with some kind of message. He sits importantly at the desk and scribbles down what he hears on the messages. An accountant has an adding machine. A world traveler has a travel bag of travel magazines. Know your residents and give them a sense of purpose. After that, any agitation has a cause (infection, constipation, medications, family or staff member dynamics, etc.) and it's source can be found with careful investigation. Turn your staff into sleuths and give them rewards for finding the solution to each of these very individual puzzles. Make them heroes.

3. Bed alarms for the most forgetful, and low beds for some. (By the way, to reduce back injuries, some facilities are having their direct service staff go through Feldenkrais movement awareness training -- easy, painless body mechanics training that works). We've got one man who doesn't need staff assistance and sleeps on a mattress on the floor. With good arguments, states usually make exceptions to the hospital bed rules.

4. Administrators willing to be there every day and many nights with sleeves rolled up, getting through the hard times until the restraints are gone.

I talk to staff a lot about how restraints break people's spirits -- both the spirit of the resident and the spirit of the staff. They all know what I mean. It doesn't need to happen -- we don't need to be walking around with broken hearts.

-- Bev Cowdrick, Administrator