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For clinicians  ·  For facilities  ·  For families  ·  For staff

Adopting the framework

For facility ownership and management

The evidence is unusually specific about what kind of program works, and it is not the kind most buildings run.

The finding that should drive the design

The 2023 Cochrane review of interventions to prevent and reduce physical restraint in long-term care covered 11 studies and 19,003 participants, all in residential care facilities, all including people with dementia, mean age around 85.

ApproachWhat it consisted ofResult
OrganizationalA least-restraint policy: staff education plus trained low-restraint champions plus components facilitating change in institutional policy and the culture of careProbably reduces residents with ≥1 restraint (RR 0.86, 95% CI 0.78–0.94) and probably produces a large reduction in belt restraint (RR 0.54, 95% CI 0.40–0.73). Moderate certainty. No adverse events in the one study reporting them.
Simple educationalEducation and attitude change, some with ward-based guidanceResults inconsistent; effect uncertain. Very low certainty. Probably little or no difference in restraint intensity.
Fall-risk information to staffProviding nursing staff with residents’ fall-risk informationMay make little or no difference to the mean number of restraints, or to falls. Low certainty.

The same distinction appears in the falls literature. Tailored multifactorial programs delivered according to individual residents’ circumstances and with facility staff engagement probably produce a large reduction in the rate of falls (rate ratio 0.61, 95% CI 0.54 to 0.69, moderate certainty) — significantly better than multifactorial programs not delivered that way, which probably have little or no effect on the rate of falls at all.

The active ingredient in both cases is not information. It is that the organization changed and the staff who deliver it were part of it.

What that translates into

  1. A written policy with a position in it. Not a training module. A statement of what this building does about medication review and restraint, owned at management level.
  2. Named people who own it — the “champions” component. Not a committee that meets quarterly.
  3. Prescriber engagement as a two-sided process. The randomized trials with the largest effects engaged the patient and the prescriber in parallel rather than one through the other. D-PRESCRIBE sent the patient a brochure and the physician an evidence-based opinion simultaneously: 43% versus 12% no longer filling the inappropriate prescription at six months. OPTIMIZE, which notified clinicians without the paired opinion across 3,012 patients, was null.
  4. Review on a schedule and on triggers. A fall or near miss, a medication change in either direction, a new behavior, a hospital return, a family raising something.
  5. A baseline before you start, so that change is detectable. Measuring what changed.
  6. Transmission across shifts. The care-plan item that fails most often is that the plan is known to everyone who works with the resident.

What it requires from staff, and what to give them

Staff see change first and are frequently the only people who see it. What stops that information reaching a prescriber is usually not unwillingness — it is not having a form of words that gets taken seriously, and not having a route. That is a fixable problem and it is addressed directly in the staff track: how to raise a concern.

What to tell families

Before the first review, not after the first change. A family that learns about a medication change from a difference in their parent has been given a reason to distrust everything else. The family track exists to be handed over: For families of residents.

Deprescribing does happen when the conditions are right

Following 1,843 nursing home residents on five or more medications, with a mean of 8.6 medications at baseline, deprescribing occurred in 658 residents — 35.7% — over twelve months, and the presence of a geriatrician on facility staff predicted it (odds ratio 1.41, 95% CI 1.15 to 1.72). Access to the right clinical expertise is a structural variable, and it is one you control.

What not to build

  • A target number of medications. There is no clinical threshold, and a target creates pressure to stop drugs rather than to think about them.
  • A percentage reduction goal on any class. The withdrawal evidence identifies a specific minority who relapse — those who responded well to an antipsychotic for psychosis, aggression or agitation, and those with more severe baseline symptoms. A program pursuing a number will find them the hard way.
  • A falls promise.

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

Back to the facility track.

References

  1. Möhler R, Richter T, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restraints for older people in all long-term care settings. Cochrane Database of Systematic Reviews. 2023;7(7):CD007546. PMID 37500094 · DOI 10.1002/14651858.CD007546.pub3.
  2. Dyer SM, Kwok WS, Suen J, et al. Interventions for preventing falls in older people in care facilities. Cochrane Database of Systematic Reviews. 2025;8(8):CD016064. PMID 40832852 · DOI 10.1002/14651858.CD016064.
  3. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018;320(18):1889–1898. PMID 30422193 · DOI 10.1001/jama.2018.16131.
  4. Bayliss EA, Shetterly SM, Drace ML, et al. Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians: The OPTIMIZE Pragmatic Cluster Randomized Trial. JAMA Internal Medicine. 2022;182(5):534–542. PMID 35343999 · DOI 10.1001/jamainternmed.2022.0502.
  5. Onder G, Vetrano DL, Villani ER, et al. Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors. Journal of the American Medical Directors Association. 2019;20(9):1116–1120. PMID 30853425 · DOI 10.1016/j.jamda.2019.01.130.
  6. Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. 2018;3(3):CD007726. PMID 29605970 · DOI 10.1002/14651858.CD007726.pub3.
  7. Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open. 2021;11(2):e035978. PMID 33568364 · DOI 10.1136/bmjopen-2019-035978.
  8. Persaud N, Workentin A, Rizvi A, et al. Interventions to Address Potentially Inappropriate Prescribing for Older Primary Care Patients: A Systematic Review and Meta-Analysis. JAMA Network Open. 2025;8(6):e2517965. PMID 40577011 · DOI 10.1001/jamanetworkopen.2025.17965.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.