REVIEW
Restraint free care in older adults with dementia
Valerie T. Cotter
University of Pennsylvania School of Nursing, Philadelphia, PA USA(Received for publication on January 12, 2005)(Accepted for publication on February 17, 2005)

Abstract. During the past two decades, signiﬁcant research and several government and health carequality groups have advised against the use of physical restraints in hospitals and nursing homes, yetolder adults are continuing to die, become injured or experience the iatrogenic complications associated with this practice. Deaths are usually caused by asphyxiation, but also occur from strangulation,or cardiac arrest. Older adults with dementia are at high risk for restraint use because of impaired
memory, language, judgment and visual perception. In moderate to severe dementia, the risk of falls isgreater because of gait apraxia and unsteadiness. Agitation, disorientation, and pacing behaviors fromdelirium or dementia can precipitate staff to use restraints to prevent harm to the older adult or toothers. Physical restraints should be eliminated as an intervention in older adults with dementia
because they are also very likely to cause acute functional decline, incontinence, pressure ulcers andregressive behaviors in a short period of time. The purpose of this paper is to disseminate the dangersof this clinical practice and to summarize the latest research in restraint free care and restraint alternatives in the United States. (Keio J Med 54 (2): 80–84, June 2005)
Key words: physical restraint, dementia, aged, falls

Introduction• From 1995-2004: 112 patient death or
injury in restraints

Physical restraints are well documented by researchand several U.S. government and health care quality
groups to cause death, signiﬁcant injury and iatrogenic
complications, yet this practice continues in hospitals
and nursing homes. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has
tracked death and injury from restraints as sentinel
events since 1995 as shown in Fig. 1.1,2 Deaths areusually caused by asphyxiation, but also occur fromstrangulation, or cardiac arrest. Bed rail-related entrapment deaths by asphyxiation are caused by beingcaught between the bed mattress or air pressure mattress and the bed rail or the headboard and the bed rail,
getting the head stuck in the bed rail or being strangulated by a vest restraint between the rails.2–4 Physicalrestraints are also very likely to cause acute functional
decline, incontinence, pressure ulcers, and regressive
behaviors in a short period of time (Fig. 2).5,6
A physical restraint is ‘‘any manual method or
physical or mechanical device, material, or equipment• From 1995-2001: 237 deaths, 73 injuries
from bed rail entrapment• 53% occurred in nursing homes• 20% occurred in hospitals• 35 deaths involved air pressure mattresses

JCAHO Sentinel Event Statistics, 2002; 2004

Fig. 1

Patient safety is paramount.

attached or adjacent to the individual’s body that theindividual cannot remove easily which restricts freedomof movement or normal access to one’s body’’.7 Physical restraints include vest jackets, lap belts or sheets,
mitts and wrist ties, bed rails, or restraining chairs if it
has the effect of restricting freedom of movement. How
do we identify the patient with dementia at high risk for

Presented at the 1364th Meeting of the Keio Medical Society in Tokyo, July 30, 2004
Reprint requests to: Ms. Valerie T. Cotter, University of Pennsylvania School of Nursing 420 Guardian Drive, Philadelphia, PA 19104 USA,cottervt@nursing.upenn.edu
80Keio J Med 2005; 54 (2): 80–84

Physical Iatrogenic outcomes: Increased risk for falling, pressure
ulcers, incontinence, muscle deconditioning, acutefunctional decline
 Serious injuries: Hip fracture, head trauma

Psychological, Behavioral
 Combativeness, aggression
 Increased disorientation
 Regression, dependency

Lofgren et al, 1989; Strumpf et al, 1997

Fig. 2

Negative consequences associated with restraints.

• Impaired memory, language,
judgment, visual perception• Behaviors in moderate to severe
stages such as agitation, anxiety,psychosis or pacing• Psychoactive medications• Impaired function in activities of dailyliving• Gait apraxia, unsteadinessFig. 3

Restraints and dementia.

restraint use? The three common reasons staff restrain
patients are to: 1) manage behaviors common in dementia, 2) prevent falls, and 3) prevent treatment interference (removal of intravenous infusions, catheters
or tubes).

81

however, do not involve serious injuries. When staff
judge that the patient is at risk for falls, restraints arefalsely believed to provide safety despite evidence thatthey increase the risk of falls and serious injuries.8 This
often occurs as the patient struggles to get out of therestraint, becomes agitated and trapped between the
bed rail and the mattress, climbs over the bed rail andfalls from a higher bed height or is fatigued and unsteady once out of the bed or chair. Visual impairment
related to cataracts, glaucoma, macular degeneration
or not wearing eyeglasses affects one’s ability to navigate the environment safely. Medications with anticholinergic or extrapyramidal adverse effects or interactions can affect mental status and gait. A history offalls increases a person’s risk for future falls and many
patients become anxious about falling, thus limiting
their ambulation to avoid falls. Falls are frequently thepresenting symptom of acute medical problems, such as
infection, heart failure, dehydration, and pneumonia inolder adults.
Restraints and Treatment Interference
Treatment interventions such as intravenous lines,
urinary catheters, nasal oxygen, nasogastric or gastrostomy feeding tubes or wound dressings require cooperation from the patient to maintain. A patient withdementia may perceive the intervention as uncomfortable, or misunderstand and forget the necessity of
its use and remove it forcefully.
Reducing Restraints: Relevant Law and Regulations

Individuals with dementia are at high risk for restraint use due to impaired memory for both recent andremote events and cognitive declines in language,
judgment and visual perception (Fig. 3). They are more
likely to experience delirium and behavioral symptoms
such as agitation, anxiety, psychosis or pacing, and receive psychoactive medications that contribute to postural hypotension, sedation, or extrapyramidal reactions.
Acute change in behavior or level of alertness is frequently a symptom of an unrecognized physiologic need,such as hypoxia, dehydration, pain or medication toxicity. In moderate to severe dementia, gait apraxia, unsteadiness and limited mobility increase risk of falling.

Since 1987, several U.S. government and healthquality groups have established laws and guidelines
around the use of restraints. The Nursing Home ReformAct of 1987 mandated that nursing home residents havea right to be free from restraints. In 1992, the Food andDrug Administration (FDA) put forth their ﬁrst safety
alert and label warning on vest and limb restraints
identifying potential serious injuries associated with
their use. A similar FDA warning for bed rails was also
issued in 1995. The JCHAO, a survey organization for
hospitals and some nursing homes in the U.S., emphasizes restraint alternatives, such as wheelchair adaptations, wedge seats, assisted ambulation and individualized, regular voiding schedules, among others. The
legal standard has moved from liability associated withthe failure to restrain to one that presumes appropriate
care relies on interventions other than restraints.9

Restraints and FallingResearch Findings

Falls are a signiﬁcant problem for frail older adults
and especially for those with dementia. Most falls,

While the dangers of restraints are apparent, evidence exists that when frail older adults with cognitive

Restraints and Dementia

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Cotter VT: Restraint free care in older adults with dementia• “I felt like a dog and cried all night. It hurt
me to have to be tied up…The hospital isworse than a jail.”• “If there was a fire, I’d be caught. Whensomeone is tied and chained in a fire, howwill you save the person? How would I get
out?”
Strumpf & Evans, 1988

Fig. 4

Voices of restrained patients.

• Restraint education and unit-based nursing
consultation showed reduction in restraint
prevalence without increases in staff,
psychoactive drugs or serious fall-related
injuries• 3 months post-intervention, decline 20% (7%restraint education only; 7% control)• 6 months post-intervention decline 18% (4%restraint education only; 6% control)
Evans et al, 1997

Fig. 5 Reducing restraints in nursing homes: education and gerontologic nurse specialist intervention.

changes, such as dementia are restrained in the hospital, they experience negative emotional responses suchas anger, fear, resistance, humiliation and demoralization and frequently recall the restraint event once discharged (Fig. 4).10 An early cross-cultural study comparing nursing homes in Scotland with those in the U.S.
demonstrated that frail older adults, similar to patientsin U.S. nursing homes with multiple co-morbidities
and dementia, could be well cared for without useof restraints.11 Signiﬁcant differences in prevalence ofrestraint use were attributed to the unavailability ofrestraints and nursing staff’s low acceptance of theiruse, and greater tolerance for behavioral disturbances.
In a randomized clinical trial to reduce restraints
in nursing homes, intensive restraint education and 12
hours per week of unit-based consultation by a mastersprepared gerontologic clinical nurse specialist (CNS)
increased staff knowledge about restraint hazards andled to signiﬁcant restraint reduction (Fig. 5).12 In thisstudy, 3 nursing homes were randomly assigned to restraint education, restraint education with CNS consultation, or control (usual care). The 6-month restraint
education program included ten 30 to 45-minute sessions focused on the effects of physical restraint, mini-

mizing fall risk, preventing treatment interference, andunderstanding and responding to resident behaviors. At
3 months (post-intervention), restraint prevalence was
reduced to 20% and at 6 months to 18%. Overall, thesesigniﬁcant reductions occurred without increases instaff, psychoactive drugs or serious fall-related injuries.
These ﬁndings suggest that while education is helpful in
reducing restraints, it is the inﬂuence and expertise of
the master’s prepared gerontologic CNS that changes
practice and maintains change in the clinical setting.13
A study comparing fall and injury rates in nursing
home residents whose restraints were removed (n ¼ 38)
to those who continued to be restrained (n ¼ 88) foundthat restraint removal signiﬁcantly decreased thechance of minor injuries due to falls.14 The nursing
home with the least restraint reduction had a 50%
higher rate of falls (p < 0:01) and more than twice therate of fall-related minor injuries (p < 0:001). In thesubsequent secondary analysis of 319 nursing homeresidents with consistent bilateral bed rail use during
the nighttime, those with dementia and behavioral
symptoms were more likely to be restrained despite theﬁnding that the bed rails did not signiﬁcantly reduce thelikelihood of falls, recurrent falls or serious injuries.15
A gerontologic CNS intervention coupled with staff
education was successful in reducing restraint use in
hospitalized nursing home patients.16 This randomized
controlled trial engaged the gerontologic CNS in an
admission assessment to assess fall risk within 12 to 36
hours, develop an individualized care plan to meet thepatient’s needs (especially to prevent restraint use), andto reassess and monitor high risk patients regularly.
Using a multiple logistic regression model, treatment
interference was found to be the strongest independent
predictor of restraint use as compared to fall risk or
disruptive behavior: 41.2 odds ratio (95% CI of thedifference ¼ 12; 141) versus fall risk odds ratio 3.1 (95%
CI of the difference ¼ 1:1; 8:6) versus disruptive behavior odds ratio 3.8 (95% CI of the difference ¼ 0:9; 16:1).
The intervention signiﬁcantly reduced the rate of daily
restraints during hospitalization: odds ratio 11.3 (95%
CI of the difference ¼ 2:3; 81:0). Findings suggest thislevel of clinical nursing leadership enhanced communication among all staff and led to less restraint use.
Individualized Interventions
Individualized physiologic, psychosocial, activity andenvironmental interventions to prevent restraint use inindividuals with dementia are based on the assessmentof the patient’s needs (e.g., those at risk for falls, treatment interference, or behavioral disturbances). See Fig.
6 for examples of individualized interventions to avoid
restraints.17
One should perform a thorough medication review

Keio J Med 2005; 54 (2): 80–84

83

Fall Risk

TreatmentInterference

Physiologic

Behavior

Medication
review

Pain relief

Correct underlying
problem, e.g.,dehydration

Anticipation ofneed

Maintenance ofcommunication

Attention tounderlying meaningof behavior

Activities

Physicaltherapy

Distraction

Outlets for anxious
behavior

Environmental

Low beds,
contouredchairsCamouflaged orpadded treatment
siteMusic, lighting,alarmsPsychosocial

Fig. 6 Individualized interventions. Strumpf et al., 1998. Adapted with permission from N.E. Strumpf, J.P. Robinson, J.S. Wagner, L.K. Evans,
Restraint-Free Care: Individualized Approaches for Frail Elders, Springer Publishing Company, Inc., New York 10012.

assessing for adverse effects and interactions and determine whether doses could be reduced or medication
discontinued. Evaluate motor and sensory functions,such as gait, balance, range of motion and whether the
person relies on assistive devices, such as a cane,walker, wheelchair or commode. Based on this assessment, integrate a regular walking program or utilize aphysical therapy consultation as activity interventions
to prevent falling, functional decline and restraint use.
Assess functional abilities by observing the person
perform basic activities of daily living (ADLs), as wellas eliciting a history from a family member or someone
who knows the patient about ADLs and instrumental
activities of daily living (IADLs). A baseline functional
assessment on admission to the hospital or nursing
home is helpful to determine functional declines anddevelopment of acute illness or difﬁcult to diagnose
exacerbations of chronic illness, especially in older
adults with dementia. Functional urinary incontinence
occurs when patients are restrained and unable to express their need to urinate or access the bathroom.
With regular prompting, patients in late moderate tosevere stage dementia can remain continent. Theseroutines for voiding and bathroom use need to continue
into the nighttime as voiding increases during the nightwith advanced age and most falls occur in patient rooms
and bathrooms.
Identifying acute or chronic pain in an individualwith dementia requires assessment of nonverbal andverbal expression of pain. Refusing to get out of bed or
participate in usual ADLs in a patient with a physiologic basis for pain, such as osteoarthritis is often a signof undiagnosed or under-treated pain. Discomfort
associated with treatment interventions like nasogastricor oxygen tubing or indwelling urinary catheters should
be addressed through analgesics or other pain relieving measures. Brief activities and communication appropriate to the person’s abilities and interests serve
as distractions to prevent treatment interference.
Often, these interventions can be reduced or eliminatedsooner than they frequently are. Alternative interventions such as wrapping or covering the tube or
dressing with clothing or gauze can help distract thepatient.
Psychosocial and behavioral needs are better understood if a history is obtained about baseline behavior,social activity and interactions, and relationships withothers. Agitated, anxious or aggressive behavior occurs
when new environments or routines overwhelm aperson with dementia. Providing care activities at areasonable pace with reassuring communication is
helpful. Maximizing function in ADLs at whatever level
the patient is capable of doing independently or withassistance is important to reduce fall risk and overall
functional decline. Although frail older adults withdementia may require more time with bathing, dressing, toileting and walking activities, a rehabilitation
approach that encourages self care or assistance when

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Cotter VT: Restraint free care in older adults with dementia

needed is more appropriate than utilizing wheelchairs
for short distances, eating in bed or other procedures
more convenient for staff. Sound and lighting can beover stimulating for individuals with dementia, yetmusic can be a useful environmental intervention toattend to behavioral symptoms like trying to elope frombed during the night.
Low beds, contoured chairs that are comfortable forthe older adult, bedside commodes and bed alarms are
just a few environmental adaptations recommended toreduce risk of injury and avoid use of restraints.18
Organizational Interventions
No restraint free program can be successful without
the commitment from clinical and administrative staff
with a vision and mission to individualizing care forolder adults with dementia. Educational programs andconsultation with a gerontologic CNS have shown positive outcomes in restraint reduction for patients in hospital and nursing home settings. Standardized clinicalprotocols for falling and dementia care can help toidentify and manage patients at high risk for restraintuse.
Conclusion
Based on recent research evidence from both crosscultural and U.S. studies, physical restraints should be
eliminated as an intervention in older adults with dementia. Physical restraints lead to psychological distress, acute functional decline, and increase risk of falls,
serious injuries and death. Careful, comprehensive
assessment that addresses individual patient needs isnecessary to develop restraint alternative interventions.
Educational programs and consultation with a gerontologic CNS are critical elements to reducing restraints
and a successful restraint free philosophy in hospitaland nursing home settings.
Acknowledgements: The author would like to thank Yukiko Lau of
Keio University Faculty of Nursing and Medical Care, Dr. Nobuyoshi
Hirose of Keio University School of Medicine, and Dr. Yoshinori
Ebihara of Keio University Hospital for graciously arranging my lecture at Keio University Hospital upon which this article is based; andDr. Neville Strumpf, Dr. Lois Evans and Dr. Christine Bradway at the
University of Pennsylvania for their assistance in preparing this lecture. Ms. Cotter is funded by NIA grant P30 AG01024.

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