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Restraint-free care

For facility ownership and management

A restraint is what a building reaches for when the care plan has run out. The position here is that this is a failure of planning rather than a clinical tool — and that saying so requires being honest about what the evidence on restraints does and does not establish.

The two kinds

  • Chemical restraint — a sedative or antipsychotic used to manage behavior rather than to treat a diagnosed condition. It is the more common of the two and the harder to see, because it appears in the chart as a medication rather than as an event. The distinction is not the drug. It is the reason, and whether the reason was written down at the time.
  • Physical restraint — anything a resident cannot remove or leave, including some bed rails and some chairs.

In pooled international data from 85 papers, physical restraint prevalence was 33% and chemical restraint 32%, with bedrails the most prevalent physical form at 44% and benzodiazepines the most prevalent chemical form at 42%. Those are pooled proportions across heterogeneous definitions and measurement methods, and North American studies reported lower physical-restraint prevalence. They are not a US figure.

The harms — and what kind of evidence they rest on

This is where honesty costs something, so it is worth being exact. The evidence on restraint harms is observational.

A systematic review of 12 observational studies across acute and residential care concluded that “observational studies suggest that physical restraint may increase the risk of death, falls, serious injury and increased duration of hospitalization. However, there is little information to enable the magnitude of the problem to be determined.” No pooled effect estimate is available, and this site does not attach a number to restraint harm.

A separate systematic review identified 174 deaths due to physical restraint in nursing home residents across eight studies, with neck compression the most common mechanism, resulting in death by mechanical asphyxia. That is a count of reported deaths across studies. It is not an incidence rate and must not be converted into one.

Why the causal claim is not made here

The most important caveat in this subject: the characteristics that predict being restrained — cognitive impairment, immobility, prior falls, agitation — are also the outcomes measured afterward. That is confounding by indication in its textbook form. The correct statement is that restraint use is associated with these outcomes on observational evidence. “Restraints cause decline” is not a statement this literature supports, and overstating it invites a rebuttal that discredits the parts that are solid.

What restraint-reduction programs achieve — a split verdict

In long-term care: they work, if built the right way

The 2023 Cochrane review — 11 studies, 19,003 participants, all in residential care facilities, all including people with dementia, mean age around 85 — found that organizational interventions building a least-restraint policy into the institution probably reduce the number of residents with at least one restraint (relative risk 0.86, 95% CI 0.78 to 0.94) and probably produce a large reduction in belt restraint (relative risk 0.54, 95% CI 0.40 to 0.73), both moderate certainty. Quality of life showed little or no difference at high certainty, and no adverse events occurred in the one study reporting that outcome.

Simple educational interventions — training staff without the policy and culture components — produced inconsistent results, and the review rates their effect as uncertain on very low-certainty evidence.

This is the finding to build on: reducing restraint is an organizational change, not a training exercise.

In hospitals: still uncertain

The 2022 Cochrane review of the same question in general hospital settings found only four studies, three at high risk of selection bias, with data unsuitable for meta-analysis. Organizational least-restraint interventions had an uncertain effect on very low-certainty evidence. Bed and chair pressure sensor alarms for people at increased fall risk probably have little to no effect on the number of patients restrained, at moderate certainty. No study reported fall-related injuries, and none systematically assessed adverse events related to restraint use itself.

The honest summary

In nursing homes and other long-term care, organizational programs that build a least-restraint policy into the institution — not staff education by itself — probably reduce restraint use, at moderate certainty. In hospitals the same question has four small studies behind it and the answer is still uncertain. Neither review found evidence that reducing restraints increases falls; in hospitals, neither found evidence that anything reduced falls either.

What has to be true before “we tried everything else” is a checkable claim

  1. A comprehensive assessment for a root cause of the behavior. Assessment.
  2. The eight non-pharmacological approaches, actually attempted and recorded. The non-pharmacological step.
  3. Regular pain assessment designed for residents who cannot report pain, and non-drug relief tried first.
  4. Environmental modification — light, signage, clocks, noise, temperature.
  5. De-escalation training that staff have actually had.
  6. Passive monitoring rather than restraint where monitoring is the real need.
  7. Individualized care planning that every shift knows.
  8. A psychotropic medication review with a stated target symptom for every psychotropic.
  9. Trigger identification, and family input on what has worked before.
  10. Documented legal and ethical compliance, including informing residents and families of their rights.

The position, stated plainly

It is not that a restraint is never used. It is that using one is an emergency event that gets documented as such, with a root cause and a review, rather than a standing arrangement that nobody revisits. Every psychotropic prescribed for behavior should have a target symptom recorded at the time of prescribing, because a prescription with no stated target cannot be evaluated later — and an evaluation that cannot happen is how a treatment becomes a restraint without anyone deciding that it should.

CareGuard, the AHRQ-listed Patient Safety Organization operated by the same foundation, publishes the facility safety review that several of these items come from: careguard.ai.

Back to the facility track.

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.

References

  1. Lee DA, Robins LM, Bell JS, et al. Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: A systematic review and meta-analysis. International Journal of Nursing Studies. 2021;117:103856. PMID 33601305 · DOI 10.1016/j.ijnurstu.2020.103856.
  2. Evans D, Wood J, Lambert L. Patient injury and physical restraint devices: a systematic review. Journal of Advanced Nursing. 2003;41(3):274–282. PMID 12581115 · DOI 10.1046/j.1365-2648.2003.02501.x.
  3. Bellenger EN, Ibrahim JE, Lovell JJ, Bugeja L. The Nature and Extent of Physical Restraint-Related Deaths in Nursing Homes: A Systematic Review. Journal of Aging and Health. 2018;30(7):1042–1061. PMID 28553823 · DOI 10.1177/0898264317704541.
  4. 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.
  5. Abraham J, Hirt J, Richter C, Köpke S, Meyer G, Möhler R. Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings. Cochrane Database of Systematic Reviews. 2022;8(8):CD012476. PMID 36004796 · DOI 10.1002/14651858.CD012476.pub2.
  6. Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. The American Journal of Psychiatry. 2016;173(5):543–546. PMID 27133416 · DOI 10.1176/appi.ajp.2015.173501.
  7. Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065. PMID 21765198 · DOI 10.1136/bmj.d4065.

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.