For more information, check out our brochure on Dementia and responsive behaviours.
Use of restraints
A restraint is anything that restricts or controls a person's movement or behaviour. There are three main types of restraints:
- Physical restraints restrict or control movement or behaviour. They may be attached to a person's body or create physical barriers.
- Chemical restraints are medications used to modify or restrict behaviour, for example, tranquilizers and sedatives.
- Environmental restraints change or modify a person's surroundings to restrict or control movement, for example, a locked door.
Restraints are sometimes useful. For example, the temporary use of a lap belt can support a person to sit up and participate in a group activity. The short-term use of a medication can decrease disturbing hallucinations. A protected garden can allow for safe wandering.
Using restraints to manage behaviour in the belief that less harm will be done if the person is restrained is inappropriate and debilitating. It can cause the person to lose skills and abilities that are unlikely to return. Loss of independence and low self-esteem can also occur. Relying on restraints discourages caregivers from trying to find the cause of the person's distress that led to using the restraint.
It’s best to use no restraints. However, using restraints for a limited time, with close monitoring can be helpful. Use the following guidelines:
- Try to avoid or manage the behaviour that led to considering restraint use.
- Ask your facility or agency about their protocol on the use of physical, chemical and environmental restraints.
- Try to make the use of restraints, when they are necessary, a useful tool that preserves the person's dignity.
Why restraints are used
Understanding the behaviours associated with dementia can help you choose alternatives to the use of restraints. Dementia will cause changes in the way people react and respond to situations. These reactions may be the only way the person 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). These may lead to the person responding with behaviours that caregivers find difficult to understand.
- Lost communication skills: A person may no longer be able to express basic needs, such as the need to eat, drink, sleep or 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, using 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.
When restraint-free strategies are 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 dementia and others?
There may be some circumstances in which minimal restraint is needed. If restraints are used, the least restrictive restraints must be chosen and they must 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, or when used for the benefit of staff. For example, the use of a restraint that decreases the person’s ability to participate in activities of daily living creates stress and has a negative effect on quality of life.
Making decisions about 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 dementia.
One of the most successful strategies for dealing with difficult behaviours without using restraints is to use a 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 the next. Talking to other caregivers, a doctor or someone from the local Alzheimer Society may explain why the strategy was unsuccessful. They may have suggestions for other possible approaches.
When you are considering minimal restraints, carefully measure and monitor the positive and negative consequences for the person with the disease. When you do use restraints, make sure the physical and mental well-being of the person being restrained is not compromised.
Risks and concerns about restraint use
The following chart gives examples of uses and risks associated with the three types of restraints.
Concerns for people with dementia
Research has shown that inappropriate use of restraints can hold back people with dementia. Here are some of the concerns:
Restriction of freedom: Restraints can make her less active and less independent. For example, a chemical restraint may leave her sedated and inactive. A physical restraint, such as a tray on a geriatric chair, may prevent her from moving freely, which can lead to frustration. The excessive or inappropriate use of some caregiving strategies may result in her 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, if a bed rail is used, he may try to climb over it 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, if she is sedated for long periods, she may never regain abilities that existed before the sedation.
Concerns for family members, health-care professionals and other caregivers
Risk of harm or injury: You may want to consider restraints if the person with dementia is at risk of harming himself or others. For example, a person who reacts aggressively to a situation may put someone close by at risk of harm. Or a person who responds aggressively to a situation may put other residents and staff 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. This could lead to them using restraints themselves or requesting that health-care professionals use them.
Lack of understanding, training and human resources: Some health-care professionals lack understanding of the issues of dementia and behaviour. Consequently, they may not implement the preferred care strategies. Long-term care facilities may also lack the resources to provide quality care for people with the disease.