Introduction
Restraints are used in various medical settings to control or restrict patient behavior through physical, chemical, or environmental means (Alzheimer Society of Canada, 2023a; Canadian Protective Nurses Society, 2021). Physical and chemical restraints are often used to address unsafe or concerning behavior during hospital care such as disturbances or suicidality (de Bruijn et al., Reference de Bruijn, Daams, van Hunnik, Arends, Boelens and Bosnak2020). In recent years, there have been medical, ethical, and political concerns regarding the use of restraints in hospitals, and as a result, alternatives to restraint use have been encouraged (de Bruijn et al., Reference de Bruijn, Daams, van Hunnik, Arends, Boelens and Bosnak2020; Funayama & Takata, Reference Funayama and Takata2020). Using alternatives to patient restraints should be a priority for health care providers (Smith et al., Reference Smith, Ashbridge, Davis and Steinmetz2015).
Many institutions recommend reserving restraints as a last resort to conflict management as the use of restraints could produce harmful psychological and physical effects on the patient (de Bruijn et al., Reference de Bruijn, Daams, van Hunnik, Arends, Boelens and Bosnak2020). For example, potential physical harms associated with the use of restraints include malnutrition, incontinence, and falling, while the psychological implications include provoking fear and anger, mental deterioration, and experiencing a loss of dignity (de Bruijn et al., Reference de Bruijn, Daams, van Hunnik, Arends, Boelens and Bosnak2020). In Newfoundland, the Mental Health Care and Treatment Act (Government of Newfoundland, 2015) is followed, which states that the purpose of the Act is:
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(a) to provide for the treatment, care and supervision of a person with a mental disorder that is likely to result in dangerous behaviour or in substantial mental or physical deterioration or serious physical impairment.
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(b) to protect a person with a mental disorder from causing harm to himself or herself or another and to prevent a person with a mental disorder from suffering substantial mental or physical deterioration or serious physical impairment.
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(c) to provide for the apprehension, detention, custody, restraint, observation, assessment, treatment and care and supervision of a person with a mental disorder by means that are the least restrictive and intrusive for the achievement of the purpose set out in paragraphs (a) and (b) and,
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(d) to provide for the rights of persons apprehended, detained, restrained, admitted, assessed, treated and cared for and supervised under this Act. (p. 31)
As shown above, The Mental Health Care and Treatment Act encourages using the least restrictive and intrusive measures possible that prevent and protect a patient from harm (Government of Newfoundland, 2015).
When caring for patients with Alzheimer’s disease, dementia, or other conditions that may impact cognition or mental well-being, it is important that there is an understanding of the aetiology of a patient’s condition (Alzheimer Society of Canada, 2023a). Knowing what to expect and how to care for a patient experiencing distress may be useful in preventing unnecessary restraint use. For geriatric patients, it is important to acknowledge that cognitive decline and psychiatric illness can be present in patients which could produce behavioral outcomes such as wandering, hallucination, irritation, and aggression (Alzheimer Society of Canada, 2023b). Taking into account that geriatric patients are a vulnerable population, it is important to consider how mental health impacts aggression and whether restraint use is appropriate.
Geriatric mental health
Geriatric psychiatric disorders are more commonly found in individuals living in long-term care (LTC) facilities than in the community (Seitz et al., Reference Seitz, Purandare and Conn2010). According to the Canadian Coalition on Seniors’ Mental Health, 80–90 per cent of residents living in LTC facilities suffer from a mental health disorder, and about 50 per cent suffer from depression (Canadian Mental Health Association, 2010).
According to projections, Newfoundland & Labrador (NL) will have the highest percentage of older adults in Canada by 2036 due to its rapidly aging population (Chappell et al., Reference Chappell, Bornstein and Kean2014). There has been an increasing demand within the province for LTC services for severely impaired residents due to the rapid aging of its population. In NL, between 35 and 50 per cent of antipsychotic medication is used in LTC facilities for residents without a medical condition requiring them (Chappell et al., Reference Chappell, Bornstein and Kean2014). Considering NL’s aging population and current chemical restraint use, it is evident that restraint use in geriatric settings needs further research. Studies show older adults with mental illness contributed to higher rates of health care resource use, longer hospital stays, and greater rates of readmission (Adams et al., Reference Adams, Koop, Quan and Norris2015). Older adults with cognitive decline and/or mental health concerns are a necessary population to consider in research on hospital treatment and restraint use.
Previous research has examined managing agitation and aggression in residents with dementia in LTC facilities within NL, noting that it is a high-priority issue in the province (Chappell et al., Reference Chappell, Bornstein and Kean2014). It was found that there is a close connection between dementia symptoms and agitation and aggression, which is a safety risk and quality of care concern for health providers and patients themselves. Given that geriatric aggression in LTC and psychiatric settings is of concern, it is necessary to consider the ways in which it is controlled, including restraint use.
Restraint types
Restraints are commonly used in psychiatric settings, including geriatric care (Canadian Protective Nurses Society, 2021). The use of restraints is often the final resort in controlling behavioral emergencies in patients, which are typically the result of unmet needs in terms of health, functionality, or psychosocial concerns (Canadian Protective Nurses Society, 2021). By fulfilling these needs in patients, it is possible to reduce behavioral outbursts without the use of restraints.
It is common for antipsychotics and antidepressants to be used as off-label treatments to treat aggressive behavior in elderly residents with dementia (Seitz et al., Reference Seitz, Purandare and Conn2010). Chemical restraints, or pharmacological restraints, are a form of restraint in which drugs are utilized to restrain a patient (de Bruijn et al., Reference de Bruijn, Daams, van Hunnik, Arends, Boelens and Bosnak2020). These are administered to gain better control over their behavior when necessary and are used primarily to alter or inhibit specific behaviors, such as aggression (Moosa & Jeenah, Reference Moosa and Jeenah2009). This type of restraint may include benzodiazepines, antipsychotics, and ketamine (Guerrero & Mycyk, Reference Guerrero and Mycyk2020). Evidence-based literature on the effectiveness and risks associated with using psychotropic medication on geriatric patients is scarce (Jeste, Reference Jeste2022).
Physical restraints act to limit a patient’s physical movement (College of Nurses of Ontario, 2022). The use of hand-control mittens, belts, restrictive vests, or jackets is considered a physical restraint (U.S. National Library of Medicine, 2017). The use of any device to restrict movement, as well as physically holding a patient to restrict movement, is also a form of physical restraint (U.S. National Library of Medicine, 2017). A Canadian study examining restraints in LTC facilities found that each type of physical restraint used in patient care was associated with cognitive decline and that both residents with and without dementia were likely to have increased cognitive decline after one or more exposures to physical restraints (Freeman et al., Reference Freeman, Spirgiene, Martin-Khan and Hirdes2017). An American study exploring the relationship between mechanical restraint use and assault found that decreasing mechanical restraint use for psychiatric in-patients did not increase the instances of assault inflicted by patients (Smith et al., Reference Smith, Ashbridge, Davis and Steinmetz2015). This shows that finding alternatives to restraint practices will not increase the risk of harm inflicted by patients. Physical restraints can cause pain to patients due to forced immobility (Moosa & Jeenah, Reference Moosa and Jeenah2009). This research illustrates the consequences of restraint use and supports limited use only when necessary.
Alternatives to restraints
It is important that alternatives to restraints are considered in mental health care settings. Restraint use can threaten an individual’s health and has not been shown to have long-term benefits when it comes to decreasing behaviors (Canadian Patient Safety Institute, 2017). It is recommended that as best practice, restraint use should be limited to extraordinary events (Moosa & Jeenah, Reference Moosa and Jeenah2009). Research has found that patients often have negative feelings towards restraint use, including feelings of anger, fear, and resentment (Bower & McCullough, Reference Bower and McCullough2000)
Newfoundland and Labrador Applied Health Research (NLCAHR) completed an Agitation and Aggression in Long-term Care Residents with Dementia in Newfoundland and Labrador report in 2014, which recommended evidence-based interventions for alternatives to chemical and physical restraints to manage aggression in LTC residents (Chappell et al., Reference Chappell, Bornstein and Kean2014). This included music, staff training, and decreasing improper antipsychotic use. It was recommended that reducing the use of antipsychotic medication should be standard clinical practice (Chappell et al., Reference Chappell, Bornstein and Kean2014). It is important that clinical staff in psychiatric settings have crisis training and are knowledgeable on conflict resolution and de-escalation techniques so that other considerations to restraints can be made during patient conflict (Moosa & Jeenah, Reference Moosa and Jeenah2009). Staff training targeting geriatrics and psychiatry creates a better understanding of cognitive impairment management and decreases the use of physical restraints (Karlsson et al., Reference Karlsson, Bucht, Eriksson and Sandman2001).
Restraint use in Newfoundland and Labrador
There is limited publicly available information on the frequency of restraint use, restraint types, and associated harms to patients in NL care facilities. While restraint use has been previously documented in LTC settings, it has not been documented in geriatric psychiatric facilities in NL. Knowing this information could aid in developing solutions that lower unnecessary restraint use and respond to undesired patient behavior in a way that does not impede the dignity, physical health, and psychological well-being of patients. This study’s objective is to examine the prevalence of restraint use on patients housed in a geriatric unit of a psychiatric health care facility in NL. The findings of this study will inform NL’s practices of using restraints on the geriatric psychiatric population and will make recommendations on improving patient outcomes as it is related to mental health and continuity of care specifically.
With the upcoming transition to a new mental health hospital in St. John’s, NL, this review provides insight into best practices and how to optimize the new unit to further minimize restraint use.
Methods
Setting
This observational study included secondary use of medical record data from the Geriatric Psychiatry Unit (GPU) located at the Waterford Hospital in St. John’s, NL. This is a 19-bed in-patient unit for people over the age of 65 with new onset of psychiatric illness or cognitive decline where they receive assessments, treatment, and diagnoses (Eastern Health, 2020).
Geriatric patients who present with challenging psychiatric or behavioral symptoms can also be assessed and treated at the GPU. The GPU is the only unit of its kind in NL, servicing patients across the entire province. Many patients admitted to the GPU have a moderate to severe major neurocognitive disorder with resulting behavioral and psychological symptoms of dementia (BPSD), resulting in significant challenges in providing care to them in the community, whether that be living at home or in a personal or LTC facility. In addition, the GPU services patients admitted for delirium and cognitively well patients who may present with mental illnesses including mood, anxiety, and psychotic disorders.
Data collection
The population of this study included all persons admitted to the GPU from June 1, 2019, to –June 1, 2021. Variables collected via medical chart review included the patients’ gender, age, diagnosis, length of stay, and whether there was a chemical restraint, physical restraint, or both administered during the period of observation. There are multiple chemical and physical restraints used to control patient behavior at the GPU in the Waterford Hospital. Chemical restraint type is documented in patient care notes, nursing care notes, and medication administration record forms. These chemical restraints are given on a pro re nata (prn) basis, i.e., as-needed basis. Physical restraint use is documented in patient care notes. All data were collected via the Meditech database, Newfoundland and Labrador Health Services.
Analysis
We assessed the number of patients who were admitted to the GPU from June 1, 2019, to –June 1, 2021. We assessed their gender, age, diagnosis, length of stay, and whether any type of restraint was used on each patient during this period of observation. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS), version 28. Descriptive statistics were conducted to describe the cohort.
Ethical approval was provided by the Health Research Ethics Board, Memorial University of Newfoundland, and the Research Proposals Approvals Committee, Eastern Health Authority.
Results
There were 277 admissions to the GPU during the 2-year period of observation for this study: June 1, 2019–June 1, 2021. Of these admissions, 135 (48.7%) were male and 142 (51.3%) were female (Table 1). Our study encompassed whether a chemical restraint, a physical restraint, or both was administered to a patient during this period of observation. Chemical restraints used at the Waterford Hospital encompass several different medications; the three main types of chemical restraints administered include benzodiazepines, antidepressants, and antipsychotics. Common benzodiazepines used in the GPU include lorazepam, clonazepam, and bromazepam. Trazodone is the main antidepressant used as a chemical restraint in the GPU. Frequent antipsychotics given include haloperidol, loxapine, risperidone, quetiapine, and olanzapine. Combinations of chemical restraints were used dependent on target behavior. The type of chemical restraint used depends on various factors, including behavior type and drug interactions with regular patient medication. Often, chemical restraints are used in conjunction with physical restraints to treat patient behavior on the GPU. Reasons noted for chemical restraint use include agitation, emotional distress, pain, anxiety, physical aggression, verbal aggression, irritability, care assists, hallucinations, paranoia, sleep aids, and facilitating discharge from facility. Chemical restraint use was additionally associated with health professionals calling a code white on a patient, indicating a perceived threat of violence. A combination of these factors frequently occurred simultaneously, resulting in chemical restraints.
Patient Demographics
There were multiple physical restraint types used to control patient behavior on the GPU in the Waterford Hospital. The main types of physical restraints used in the GPU included Geri chairs, thigh straps, pinel wrist and/or waist restraints, and seatbelts. The main reasons noted for the use of a physical restraint were physical aggression, delusion, safety, irritability, falls, confusion, agitation, and elopement attempts. Of the 277 admissions to the GPU from June 1, 2019, to June 1, 2021, 189 (68%) had a chemical restraint administered (Table 1). Of those patients that had a chemical restraint administered, 93 were male and 96 were female. Nearly half (49%; n = 135) of the patients had a physical restraint administered, which included 73 males and 62 females. A total of 123 patients (44%) had both a chemical and physical restraint administered while they were in-patients on the GPU during our period of observation. Sixty-seven males had both types of restraints administered, while 56 female patients had both restraints administered (Table 1).
A χ 2 analysis with a 95 per cent confidence interval was conducted (n = 277) to determine whether there was a significant relationship between the patient’s gender and whether any type of restraint was used throughout their admission on the GPU. χ 2 analyses found that there was no significant association between gender and chemical restraint use on a patient (p = .717) and no significant association between gender and physical restraint use on a patient (p = .083).
Patients’ diagnoses were found in the electronic medical record system through patient care notes through the psychiatrist’s impression. A patient’s most responsible diagnosis upon admission often changed throughout the duration of their stay once patients had been seen by a psychiatrist during their stay. A 40 per cent random sample of diagnoses revealed that patients had various neurocognitive disorders, including major and minor neurocognitive disorders due to various underlying conditions (e.g., Huntington’s or Parkinson’s), delirium, and various types of dementia (vascular, Alzheimer’s, Lewy body, etc.). In addition, patients were diagnosed with depressive disorders, such as major depressive disorder; anxiety disorders, such as generalized anxiety disorder; substance-related and addictive disorders such as alcohol use disorders; and bipolar and related disorders. Other diagnoses experienced on the unit include schizophrenia spectrum and other psychotic disorders, including schizoaffective disorder and unspecified psychosis; neurodevelopmental disorders such as intellectual disability; obsessive compulsive and related disorders; and trauma and stressor-related disorders including adjustment disorders. Many patients experienced co-morbid disorders. Some diagnoses were brought on by a general medical condition or polypharmacy/medication-induced. Various symptoms, such as behavioral and psychological symptoms of dementia, psychosis, anxiety and anxious distress, paranoia, confusion, hallucinations, and delusions were brought on by a patient’s broader diagnosis, such as the presence of mild neurocognitive disorder (mNCD, Major Depressive Disorder (MDD), and other diagnosis.
Discussion
There are numerous reasons that chemical and/or physical restraints may need to be used on a patient during their stay on the GPU. Restraints were found to be frequently used when patients were of high fall risk or for patient safety to protect the patient from harming themselves. They were also used when patients were experiencing agitation, confusion, or aggression that was unable to be verbally de-escalated and was difficult to redirect. In these cases, chemical restraints were often administered to settle the patient.
Through chart review, it was noted that, for many patients, restraint use decreased throughout the duration of their stay. Restraint use was often necessary upon admission for various factors. Patients arriving on the unit are often experiencing psychosis, delusions, or delirium, are in a new environment, and therefore can be agitated, scared, confused, and aggressive. As a patient continues their stay on the GPU and their medications are regulated, they often require less frequent restraint use. Physical and chemical restraint use can negatively impact geriatric psychiatric patients and impede successful and timely discharge planning.
Frequent use of prn chemical restraints is indicative of the patient’s symptoms being poorly controlled and not ready for discharge, resulting in a longer stay at the psychiatric unit. If a patient has to be transferred to a personal or LTC facility, there is a no-restraint policy for physical restraints in NL, which means the restraint must be discontinued prior to their transfer to a care home. This can exacerbate the issue of long lengths of stay and low turnover already stemming from long waitlists for LTC facilities. While this is an important consideration, as delayed discharges negatively impact flow through the unit and hamper the ability to help other older adults and their families who need care, this should be a distant consideration to the effect restraint use has on this vulnerable population. Restraints can also precipitate or propagate delirium in older adults.
Restraint use can be decreased if NL employs other models of care for similar patient populations, such as dementia village (DV), which has been evolving in European countries as a method of deinstitutionalizing dementia care and maintaining patient dignity (Røhnebæk et al., Reference Røhnebæk, Engen, Bast and Pfannstiel2023). It is an emerging psychosocial alternative care model first introduced in the Netherlands (Roberts, Reference Roberts2023; Røhnebæk et al., Reference Røhnebæk, Engen, Bast and Pfannstiel2023). DVs shift the environment for patients from an isolating institutional setting to one that is more comfortable, stimulating, and secure (Røhnebæk et al., Reference Røhnebæk, Engen, Bast and Pfannstiel2023). They combine aspects of traditional community-based home living with parts of health care settings to create an atmosphere where patients can continue regular living and maximize autonomy, but with proper medical care and safety measures (Roberts, Reference Roberts2023; Røhnebæk et al., Reference Røhnebæk, Engen, Bast and Pfannstiel2023). Exploring alternatives to restraints for geriatric patients is essential for providing safe, effective, and optimal care.
Fortunately, it is anticipated that the prevalence of restraint use could be decreased once this patient population has space in the new mental health and addictions facility currently under construction in NL (Government of Newfoundland and Labrador, 2023). This 102-bed adult mental health and addictions centre at the Health Sciences Centre is expected to be completed in spring 2025 (Government of Newfoundland, 2023). A portion of the Psychiatric ICU at this new centre will allow for geriatric psychiatric patients to be relocated there if they are agitated or require additional care. Furthermore, this area is staffed at a higher nursing-to-patient ratio and will allow the patient space to safely navigate through the unit while minimizing risk to them and others during episodes of responsive behavior, which should in turn decrease the need for restraint.
It is essential that evidence-based interventions for alternatives to restraints are explored to manage behavior in psychiatric settings for geriatric patients. As shown in Table 1, 68.2 per cent, a majority of the patients admitted to the GPU, were chemically restrained at a point during their stay, while 48.7 per cent were physically restrained. Considering the vulnerability and potential frailty of this population, it is necessary to consider options beyond restraints. Alternatives to restraints can include bed/chair/door alarms, lowering bed positions to minimize fall risks, personal strengthening and rehabilitation programs, therapeutic recreation, exercise-based therapy programs, art, music, horticultural and reminiscence therapies, and Snoezelen rooms. One on one interventions, use of activity blankets, appropriate prescribing and discontinuation of medications, addressing pain, minimizing constipation, use of distraction and de-escalation techniques including gentle persuasion, and removal from overly stimulating environments may be considered appropriate substitutes to restraints.
Strengths and limitations
Limitations
During the timeframe we captured, there were numerous circumstances that could have contributed to increased agitation and responsive behaviors in patients admitted to the GPU, potentially resulting in more restraint use than usual. We were unable to capture whether restraint use/frequency was impacted by some of these potentially aggravating factors.
The COVID-19 pandemic and associated factors could have potentially impacted our patient population given that our study timeline coincided with COVID-19 and various restrictions. As a result, visitor restrictions, staff shortages, infection, vaccination, isolation, and masking may have negatively impacted vulnerable patients in the GPU. COVID-19 visitor restrictions resulted in periods where caregivers were unable to visit the hospital, potentially contributing to distress and isolation from loved ones. Masking restrictions were a barrier to effective verbal and non-verbal communication for providers and patients. Providers were required to wear masks, and during outbreaks, patients were encouraged to wear masks and to isolate where possible. Isolation requirements were implemented during this period for patients prior to transfer to a personal or LTC facility, which increased agitation and deterioration in patients. Further isolation for patients resulted from group therapeutic recreation activities being put on hold to minimize infection. The physical symptoms from both contracting COVID-19 and vaccinations could have resulted in increased agitation and responsive behaviors, as well as delirium, which can exacerbate these symptoms.
Chronic staff shortages could have potentially impacted restraint use on our patient population, and this could have been exacerbated by the COVID-19 pandemic. Staff shortages resulted in difficulty for providers to have time to employ alternative strategies to responsive behavior, such as gentle persuasion. During shortages, staff were frequently floated from various units and therefore may neither know the patients nor be familiar with the typical techniques outside of restraint use employed to manage symptoms. Additionally, shortages were worsened during the pandemic due to outbreaks in staff. Staff psychiatrists during the COVID-19 pandemic worked in rota, which could have impacted the quality of patient care notes and therefore affected data collection accuracy.
Limitations with data collection could have potentially impacted our results as certain variables were unable to be captured. For example, we could not capture whether restraint use/frequency changed from the time of admission to discharge. The GPU provides service to the most severe and refractory presentations of BPSD across NL. Given the severity of some of these behaviors during admission, sometimes restraint use is warranted to ensure the safety of the patient and others. However, the GPU strives to provide multidisciplinary care, which includes a biopsychosocial approach for every patient that helps to reduce distress, agitation, and responsive behaviors and mitigate the need for restraint use.
Strengths
In addition to the noted limitations associated with this research, there are strengths worthy of consideration. This research is novel, as it is the first to quantify the use of restraints in geriatric psychiatry settings within the province of NL. Furthermore, the two-year period of observation for this study allowed our study team to conduct a more comprehensive analysis of restraint use within this population. This knowledge of restraint use within this population can help inform and guide future practices. Considering the lack of information on restraint use in geriatric psychiatry in current literature, the observations of this study can act as a stepping stone for future research that aims to describe restraint use.
Conclusion
This is the first time chemical and physical restraint use in the GPU at the Waterford Hospital in St. John’s, NL, has been quantified. Results of this study showed that between June 2019 and June 2021, of the 277 admissions to the GPU, 68.2 per cent had received a chemical restraint, while 48.7 per cent received a physical restraint. At times, chemical restraints have been used in tandem with physical restraints to treat patient behavior in this setting (44.4%). These results highlight that restraint use in the geriatric psychiatric unit (GPU) setting, specifically in NL, is a cause for concern. The use of restraints in this province, as well across Canada, requires further examination. This study aims to encourage researchers, policy makers, and health care providers to consider additional behavior modification practices and means of de-escalation for this patient population. Alternatives to restraint use that are effective yet inflict the least amount of harm and distress upon patients should be of priority as restraint use may impact discharge planning and foster adverse health outcomes.
