Determinants of restraint use and pacification in long-term care homes
Some authors use the term pacifi cation to refer to the treatment of abusive residents in long-term care facilities. Pacifi cation includes the overuse of physical or chemical restraint, with restraint being used more in Canadian facilities than in the USA and some Western European countries. This study used the Minimum Data Set 2.0 to show that verbally disruptive residents are nearly four times more likely to be restrained daily and to receive antipsychotic medication than non-disruptive residents, even after controlling for cognition, functional capability, psychiatric diagnosis, and safety issues such as falls. These fi ndings raise questions about the ethical and effective treatment of verbally abusive residents in long-term care facilities.
Long-term care homes (LTCH) house one of our most vulnerable populations. Residents of these homes are often in advanced age and may suffer increased physical and cognitive impairment. As such, issues related to the quality of care that they receive are demanding greater attention than ever.
A high degree of quality care may be diffi cult to obtain since – by the time residents enter the home – they may suffer any number of comorbidities (deteriorating health, cognitive decline, and/or poor functional status). This directly impacts the type and level of care that LTCH residents require, as well as the LTCH’s ability to provide care. Already limited resources may be stretched, leaving front-line staff stressed, resulting in increased absenteeism, depression, anxiety, and burnout (Evers, Tomic, & Browers, 2001).
Health care professionals cite violence, confusion, poor judgment, interference with treatment, and falls as reasons for using restraint (Middleton et al., 1999). They may not know of, or consider alternatives to, restraints. Middleton et al. found that health care staff who participated in informative seminars about using restraints became less accepting of those practices, their attitudes toward those practices changed and they became more likely to acknowledge the undesirable side effects like confusion and falls.
Accepted techniques to manage patients in other health care settings (acute care, complex continuing care, or psychiatric care) such as physical and chemical restraints are often adopted by longterm care homes to manage residents. This may be especially true for residents who require a high level of care, are at risk of falling, who are verbally or physically disruptive, or wander aimlessly.
With respect to long-term care homes, some authors use the term pacification to refer to physical and chemical restraint for the purpose of management rather than for safety or the prevention of self-harm to the patient. Pacification in long-term care facilities may include physical restraint, chemical restraint, or both.
Earlier research suggests that, in response to the aforementioned trends, physical and chemical restraint may be used to manage physically or cognitively impaired residents (Bronskill, et al., 2004). Unfortunately, these management techniques are associated with increased cognitive and functional impairment, a greater likelihood of falling (Capezuti, Evans, Strumpf, & Maislin, 1996), and/or behavioral problems (Marks, 1992; McShane et al., 1997; Strumpf & Evans, 1991; Werner, Cohen-Mansfield, Braun, & Marx, 1989).
Compared to Canada, other countries have already recognized the problems associated with restraint use in long-term care homes. For example, during the mid-1990s the United States adopted policies restricting the use of restraints in nursing homes (the equivalent to Canadian long-term care homes). Attention focused on alternative interventions and research on more positive strategies in response to those restrictions, such as exercise (Beck, Modlin, Heithoff & Shue, 1992), and behavioural interventions (Fitzwater & Gates, 2002). Although staff may acknowledge the problems associated with restraint use, similar policies have yet to be realized in Canadian long-term care homes.
Physical restraint is defined by the Ontario Health Association (2001) as, “the use of any physical or mechanical device to involuntarily restrain the movement of all or a part of a resident’s body as a means of controlling his/her physical activities.” Lap buddies, belts, “geri” chairs, vests, and trays are employed to control mobility. When confinement is an issue, bedrails or belts are often used.
Chemical restraint is defined by the Ontario Health Association (2001) as “the use of psychopharmacologic drugs – not required to treat medical symptoms – for any purpose of discipline or convenience.” For example, antipsychotic medications are used to chemically restrain residents of long-term care facilities. The effects of these tranquilizers alleviate such symptoms as hallucinations, delusions and panic, hostility, confusion, withdrawal, emotional tension, and motor agitation. They may also contribute to falls.
The purpose of this study is to examine determinants of physical restraint (like a geri-chair) and chemical restraint (like sedatives) and the roll of pacification in long-term care homes.
Health information was collected between 2000-2001 using the Minimum Data Set 2.0 (MDS). The participants were residents of five long-term care homes in Ontario. Four discrete groups were created based on MDS 2.0 items relevant to the restraint used: 1) physical restraint, 2) chemical restraint, 3) both types of restraint, and 4) no restraint. The following indicators were included to predict restraint use:
- Functional impairment (activities of daily living),
- Cognitive impairment, delirium, or dementia,
- Presence of a psychiatric disorder (depression, schizophrenia, bipolar disorder, or anxiety disorder),
- Reported falls within the past 30 days, and;
- Disruptive behaviour (verbally disruptive behaviour and physically disruptive behaviour).
The MDS 2.0 has a number of scales embedded in it. These scales include measures of cognitive impairment (Cognitive Performance Scale; CPS; Morris et al., 1994) and functional status (Activities of Daily Living-Hierarchy Scale; Morris, Fries, and Morris, 1999), psychiatric diagnoses, dementia, delirium, falls, verbally disruptive behaviour, and physically disruptive behaviour.
Cognitive Performance Scale: The Cognitive Performance Scale (CPS; Morris et al., 1994) includes four items. The algorithm uses items that measure decision-making skills, memory ability, and level of understanding. Categories are defined by seven groups (0=intact, 1=borderline intact, 2=mild impairment, 3=moderate impairment, 4=moderate/severe impairment, 5=severe impairment, 6=very severe impairment). Existing research demonstrates the CPS provides an accurate and meaningful assessment of cognition among institutionalized populations (Hartmaier et al., 1995).
Activities of Daily Living-Hierarchy Scale: The Activities of Daily Living-Hierarchy Scale (ADL-H; Morris, Fries, and Morris, 1999) determines the degree of assistance required to perform ADL. Items used in the ADL-H algorithm include eating ability, personal hygiene, ability to toilet oneself, and locomotion. The ADL-H scale uses 4 items in the MDS 2.0. It includes seven categories (0=independent, 1=Supervision, 2=Limited, 3=Extensive-1, 4=Extensive-2, 5=Dependent, and 6=Total Dependence).
Psychiatric Disorder: Psychiatric disorder included depression, schizophrenia, bipolar disorder, or anxiety disorder. These conditions are physician documented. They do not include conditions that have been resolved or no longer affect the resident’s functioning or care plan.
Reported Falls: Falls are recorded in the MDS 2.0 using a single item. The intent of this item is to determine the potential risk of falls or injury. This item is measured on a four point scale: 1=Fell in past 30 Days, 2=Fell in Past 31-180 Days, 3=Hip Fracture (from any cause) in Last 180 Days, and 4=Other Fracture (from any cause) in Last 180 Days.
Verbally and Physically Disruptive Behaviour: Verbally disruptive behaviour and physically disruptive behaviour were measured using two items in the MDS 2.0. The measures are based on the previous seven days and measure occurrence on a four-point scale: 1=Behaviour not exhibited in last seven days, 2=Behaviour of this type occurred on one to three days in last seven days, 3=Behaviour of this type occurred four to six days but less than daily, and 4=Behaviour of this type occurred daily.
Delirium: Delirium was measured using the six indicators of delirium recorded in the MDS 2.0: 1=Easily Distracted - Difficulty paying attention; gets sidetracked; 2=Periods of Altered Perception or Awareness of Surroundings; 3=Episodes of Disorganized Speech; 4=Periods of Restlessness; 5=Periods of Lethargy; 6=Mental Function Varies Over the Course of the Day.
Dementia: Dementia was recorded dichotomously (yes, no). The condition must be physician documented. The MDS 2.0 does not record occurrences of dementia that have been resolved or no longer affect the resident’s functioning or care plan.
Statistical analysis were conducted using the windows version of the Statistical Package for Social Sciences (SPSS – Windows Version 11.0). Determinants of restraint use were examined using a statistical procedure called multinomial logistic regression.
The participants consisted of 399 long-term care residents (68% females, 32% males) living in five long-term care homes in Ontario. The average age of the residents was approximately 82 years.
Preliminary analyses revealed that 44% of residents were physically restrained, received antipsychotics, or both Table 1. Antipsychotic use was related to the presence of an active psychiatric diagnosis, delirium, verbally disruptive behaviour, and physically disruptive behaviour. Physical restraint was related to delirium, dementia, verbally disruptive behaviour, and physically disruptive behaviour.
Univariate analyses showed that residents at risk of receiving antipsychotic medication were more likely to have a psychiatric diagnosis, be at risk for delirium, display verbally disruptive behaviour, present with lower levels of functional impairment, and more severe cognitive impairment. Univariate analyses on the use of physical restraint showed that residents who are restrained are more likely to be at risk for delirium, be diagnosed with dementia, and suffer lower levels of functional impairment and higher levels of cognitive impairment.
A multinomial logistic regression was performed. All variables were entered simultaneously. The Likelihood Ratio Test showed four main contributors that increase the likelihood of restraint: they include psychiatric diagnosis (χ² [3, N = 399] = 26.78, p > .001), cognitive impairment (χ² [3, N = 399] = 17.25, p = .001), functional impairment (χ² [3, N = 399] = 75.05, p > .001), and verbally disruptive behaviour (χ² [3, N = 399] = 8.79, p = .032). Residents suffering functional impairment (OR = 12.18, CI: 5.72- 25.93) or cognitive impairment (OR = 3.17, CI: 1.41-7.16) were more likely to be physically restrained. Residents presenting with a psychiatric diagnosis (OR = 4.08, CI: 1.98-8.38) or suffering from cognitive impairment (OR = 4.70, CI: 1.84-11.97) were more likely to receive antipsychotic medication. Residents with a psychiatric diagnosis (OR = 3.58, CI: 1.47-8.72), were functionally impaired (OR = 9.01, CI: 2.68-30.32), or were verbally disruptive (OR = 4.27, CI: 1.56-11.63) were more likely to be physically restrained and receive antipsychotic medication.
The purpose of this study was to examine determinants of physical restraint and antipsychotic medication use in long-term care homes. Studies such as this one are an important first step in risk management. Identifying factors associated with restraint use can then be applied and an alternative plan of care developed to address the needs of residents who may be at risk.
There are instances when either technique may be warranted. Unfortunately, it appears that they may be employed far too often. For example, earlier studies report that 67.5% of longterm care residents are physically restrained (Sundel, Garrett, & Horn, 1994) and 24% are chemically restrained (Bronskill et al. 2004). This study found that 44% of all long-term care home residents in this study have experienced some form of restraint and it is likely that they may be used for reasons other than the safety and well-being of the residents.
Pacification is a term to describe behavioural management that refers to physical and chemical restraint for the purpose of convenience rather than for safety or prevention of self-harm. Pacification in long-term care homes can include physical restraint, chemical restraint, or both.
Multivariate analyses showed that physical restraint is related to cognitive impairment. Residents who are diagnosed with a psychiatric diagnosis or suffer cognitive impairment are more likely to receive antipsychotic medication. Determinants of physical restraint and antipsychotic use include psychiatric diagnosis, cognitive impairment, and verbally disruptive behavior. Results show some evidence of pacification, that risk of physical and chemical restraint for residents who are verbally disruptive is over four times that of the reference group.
The results of this study suggest that long-term care residents who are verbally disruptive are more likely to be chemically and physically restrained. Possible reasons include the following. First, residents who are verbally disruptive are given antipsychotic drugs to sedate them. Second, due to the side effects of these drugs (i.e., dizziness and confusion), these individuals might be physically restrained for safety reasons. Perhaps a more effective method of dealing with this type of behaviour is to address the cause of the verbally disruptive behaviour rather than to mask it with mind altering medications.
Informative seminars help staff to recognize that restraint use in long-term care may be different from that of other health care settings. It may give them the means to consider appropriate alternatives. After all, there would be a huge public outcry if verbally disruptive children were drugged and bound. Why, then, is it acceptable for their grandparents to endure this humiliating, inhumane treatment? It may be time that common practices and techniques used in long-term care facilities are re-evaluated and alternatives that are more consistent with professional practice and quality care in long-term care be adopted.