Why is it essential for IPA to make a statement on physical restraint?

Physical restraint is a primary example of the violation of human rights in older people (American Journal of Geriatric Psychiatry, 2021) and should be avoided as much as possible. When avoidance is not possible (e.g. the risk of harm is imminent and there are no other strategies), physical restraint involves complex ethical considerations crossing dimensions related to older patientsʼ dignity, safety and medical treatment, and the caregivers’ safety and responsibility. This statement represents the official policy position of the IPA. The purpose of this statement is to provide clear and concise evidence-based guidance on the clinical and ethical considerations of using physical restraints in older adults, from an international perspective.

What is physical restraint, and what are the different types of physical restraint?

There are various definitions of physical restraint in the literature. An international consensus study defines physical restraint as “any action or procedure that prevents a person’s free body movement to a position of choice and/or normal access to his/her body by the use of any method, attached or adjacent to a person’s body that he/she cannot control or remove easily” (Bleijlevens et al., Reference Bleijlevens, Wagner, Capezuti and Hamers2016). A common description of physical restraint is a physical device, material, or piece of equipment with mechanical or manual properties that limits or obstructs the person’s ability to mobilize freely and is not easily removed or controlled by the involved individual (Negroni, Reference Negroni2017). This involves the use or action of physical force to deliberately restrict, immobilize, or subdue the movement of a part or whole of a person’s body to control or influence their behavior for a period of time (Australian Government, 2020).

Physical restraints can be classified according to the attached body location, such as limb (e.g. leg or hand), chest or abdominal restraints, and/or the materials or objects used or worn. Examples include straight jackets, wrist-cuff belts, lap belts and bed-tied wrist, ankle cuffs, bed rails, bean bags, Posey bed chairs with tables attached, water chairs, tip-back chairs, confined or curved edge mattresses, and wheelchair brakes. Care should be exercised when categorizing specific types of restraints, as certain types are more widely acknowledged as restraints than others. This consideration carries potential consequences for an individual’s autonomy and mobility. For example, the intentional use of wheelchair brakes by an individual to prevent forward movement is significantly distinct from another person using wheelchair brakes to restrict their freedom.

Physical restraint does not include reasonable care practices, such as gently guiding, redirecting, or alerting a person away from a potential injury or a dangerous situation. There are specific care situations that are not considered to be physical restraints. These include assisting care recipients during activities of daily living (ADL) and therapeutic activities where the care recipient has requested assistance or been unable to perform these tasks independently. For instance, assisting care recipients during showering or dressing and prescribing orthopedic devices as part of a treatment process are not classified as physical restraints.

Where and why is physical restraint used?

Physical restraints are not limited to nonmedical uses such as law enforcement, but are also related to psychiatry, geriatrics, and other medical fields (Negroni, Reference Negroni2017).

The fundamental rationale for employing physical restraints is ostensibly to ensure the safety of the patient and others. Four common justifications for resorting to physical restraints include:

1. 1. To prevent interference with medical treatment.

2. 2. To safeguard active or open wounds and recent medical and operative procedures.

3. 3. To reduce the risk of falls or accidents in ambulant patients with safety concerns.

4. 4. To protect other patients, staff, and caregivers against unsafe behaviors, severe injury, or physical harm.

These well-intended motives, however, are not supported by the evidence. On the contrary, many studies show that restraints do not prevent falls and can instead increase the likelihood of injury from falls (Luo, et al., Reference Luo, Lin and Castle2011). Restraint use has also been associated with increased falls, walking dependence, abrasions, pressure injuries, urinary and fecal incontinence, aspiration, suffocation, and death (Evans, et al., Reference Evans, Wood and Lambert2003). Other adverse consequences include impaired cognitive and ADL performance (Hofmann and Hahn, Reference Hofmann and Hahn2014). Further, restraints can expose the restrained person to psychological distress and may increase agitation (Engberg, et al., Reference Engberg, Castle and McCaffrey2008).

Hospital settings

Older people represent a large proportion of the patients admitted to hospitals. Hospital environments can be particularly stressful for older adults due to its busy environment, disruptions to the person’s routine, frequent bed moves and clinical contact, and the use of physical restraints (Jackson et al., Reference Jackson, Gladman, Harwood, MacLullich, Sampson, Sheehan and Davis2017). These factors can precipitate the occurrence of iatrogenic harms, particularly among people living with dementia (AIHW 2020). Iatrogenesis refers to injury experienced by patients resulting from medical care and may include falls, sepsis, pressure ulcers, fractures, delirium, and neuropsychiatric symptoms, such as agitation (Chenoweth et al., Reference Chenoweth2023).

The prevalence of physical restraint use in hospitalized older adults is as high as 33–68% (Lim and Poon, Reference Lim and Poon2016). Furthermore, older adults are three times more likely to be physically restrained during their hospitalization than their younger counterparts (Said and Kautz, Reference Said and Kautz2013). Guidelines recommend that the use of physical restraints in hospital settings is reduced or stopped entirely (Joseph, Reference Joseph2016; Lachance and Wright Reference Lachance and Wright2019; ANZSGM, 2012; Cui et al., Reference Cui2021). In some countries, the use of physical restraints in these circumstances is illegal (Abraham et al., Reference Abraham, Hirt, Kamm and Möhler2020). Several interventions have been implemented to reduce physical restraint use in hospital settings. They include staff education and training, policy change at the organizational level, and alternatives to less restrictive restraints (see Section “How could physical restraint be avoided?”).

LTC facilities

On average, one-third (33%) of LTC residents are exposed to physical restraints, with an estimated range of 6–85% (Ambrosi et al., Reference Ambrosi2021; Lee et al., Reference Lee2021). The most common forms of physical restraints in this setting are (in descending order) bedrails 44%, force/pressure used in medical treatment or ADL (14%), chair belts (8%), chair restraints (8%), surveillance/sensors/tracking systems (8%), trunk restraints (7%), “other physical restraints” (7%), “any belt restraint” (6%), chairs or wheelchairs with locked tables (5%), sleep suits (5%), chairs to prevent rising (Geri chairs, deep or overturned chairs, and chairs on a board) (5%), bed sheet restraints (4%), bed belts (3%), limb restraints (including mittens) (3%), locked bedroom doors (2%), physical retention (2%), removal of walking aids from residents (1%), and bed rail protectors (1%) (Lee et al., Reference Lee2021). The duration of restraint use in LTC ranges from less than 1 day to 180 days (Lee et al., Reference Lee2021).

Physical restraint use serves as a defined benchmark that aids in identifying domains where care might be suboptimal and demands enhancement. Alongside several other indicators, the consistent integration of physical restraint use as a crucial element of care quality and safety – denoted as a “Quality Indicator” (QI) – is observed in international LTC reporting. This underscores its clinical significance and the acknowledged value it holds. The use of physical restraints has been included as part of routine monitoring of quality and safety for LTC recipients in the United States, Canada, New Zealand, and the United Kingdom. However, the interpretation of physical restraint use for the purposes of LTC QIs differs across countries. For example, the Canadian Institute for Health Information (CIHI) maintains the Continuing Care Reporting System (CCRS) QIs, a set of 19 indicators for use in residential care that includes daily physical restraints as a surrogate measure of the quality-of-life domain. The CCRS definition of “Daily physical restraints” refers to the percentage of residents who were physically restrained daily over 7 days before assessment, using trunk restraint, limb restraint, or chairs that prevent rising. Recently, Australia has added physical restraint as a key QI for residential aged care services as part of the National Aged Care Mandatory Quality Indicator Program. Under this QI, the intent to restrain and use of physical restraint devices are set as two metrics with a zero tolerance for each as the recommended reference range.

Home care community settings

The prevalence of restraint use in home care varies between 7 and 25% (Hamers et al., Reference Hamers, Bleijlevens, Gulpers and Verbeek2016; Scheepmans et al., Reference Scheepmans, Dierckx de Casterlé, Paquay, Van Gansbeke and Milisen2017, Reference Scheepmans, de Casterle, Paquay and Milisen2018). In older adults living with cognitive impairment at home, the prevalence of physical restraint use can reach 42% (Moermans et al., Reference Moermans, Bleijlevens, Verbeek, Tan, Milisen and Hamers2018). There are multiple examples of physical restraints used in home care, including bed rails, bed-against-the-wall (positioned to prevent a person from falling out of bed), locked room or house doors, a deep chair that prevents rising, and restrictive clothing and belts (Scheepmans et al., Reference Scheepmans, Dierckx de Casterlé, Paquay, Van Gansbeke and Milisen2017).

There are several risk factors for physical restraint use in home care, including:

• Personal characteristics, e.g. impaired mobility and cognition, dependency in ADL.

• Contextual factors, e.g. frequent requests from the family to use restraints, the dissatisfied attitude, and poor well-being of the informal caregiver (Hofmann and Hahn, Reference Hofmann and Hahn2014; Scheepmans et al., Reference Scheepmans, Dierckx de Casterlé, Paquay, Van Gansbeke, Boonen and Milisen2014, Reference Scheepmans, Milisen, Vanbrabant, Paquay, Van Gansbeke and de Casterlé2019).

• Knowledge and attitudes of healthcare providers, e.g. lack of awareness and/or knowledge regarding the negative impact of restraint use, person-centered care, and behavioral communication and support (Gastmans and Milisen, Reference Gastmans and Milisen2006; Hamers and Huizing, Reference Hamers and Huizing2005).

• Culture of home care organization (Gastmans and Milisen, Reference Gastmans and Milisen2006; Hamers and Huizing, Reference Hamers and Huizing2005).

• Policy and legislation, e.g. a lack of clear policy within the organization and informed consent.

• Neuropsychiatric symptoms, such as increased agitation.

People living with dementia

The prevalence of restraint use ranges from 6 to 65% among people living with dementia (Feng et al., Reference Feng2009; Hamers, Reference Hamers, Schüssler and Lohrmann2017; Selbaek et al., Reference Selbæk2016; Mamun and Lim, Reference Mamun and Lim2005). According to a national report on dementia in South Korea in 2011 (Bundang Seoul National University Hospital, 2011), 86.3% of nursing hospitals use physical restraints, and only 52.3% of care facilities for older people kept a record of physical restraints. There is a link between increased antipsychotic use and reduced physical restraint use in LTC residents living with dementia (Konetzka et al., Reference Konetzka, Brauner, Shega and Werner2014). Evidence suggests that residents with dementia living in special care units (SCUs) are less likely to have bed rails than those living in regular units without an SCU (Luo et al., Reference Luo, Fang, Liao, Elliott and Zhang2010). Adverse outcomes associated with using restraints in residents with dementia include cognitive and ADL decline, increased agitation, risk of falls and fractures, delirium, and death (Allen et al., Reference Allen, Burgio, Fisher, Michael Hardin and Shuster2005; Foebel et al., Reference Foebel2016; Freeman et al., Reference Freeman, Spirgiene, Martin-Khan and Hirdes2017; Lin et al., Reference Lin, Wu, Kao, Tzeng, Watson and Tang2009; Luo et al., Reference Luo, Lin and Castle2011; te Boekhorst et al., Reference te Boekhorst, Depla, Francke, Twisk, Zwijsen and Hertogh2013; Selbaek et al., Reference Selbæk2016; Voyer et al., Reference Voyer, Richard, Doucet, Cyr and Carmichael2011).

Neuropsychiatric symptoms associated with dementia (also known as behaviors and psychological symptoms of dementia [BPSD], noncognitive symptoms, and changed or responsive behaviors) include symptoms, such as verbal/physical agitation, aggression, psychosis, and sexual disinhibition. Individuals with cognitive impairment who experience these symptoms are more likely to be physically restrained. Neuropsychiatric symptoms are almost ubiquitously experienced by people living with dementia. In the context of dementia, physical restraint is most often used to address the relationship between neuropsychiatric symptoms and falls. However, evidence demonstrates that physical restraint does not prevent falls or fall-related injuries (Qureshi, Reference Qureshi2009) and can instead exacerbate symptoms, such as agitation, and cause injuries (Capezuti et al., Reference Capezuti, Strumpf, Evans, Grisso and Maislin1998; Sung et al., Reference Sung, Chang, Lee and Lee2006). Aggressive behavior toward care staff or other residents may result in the use of physical restraints in LTCs. However, a qualitative study investigating the views of people living with dementia revealed that feelings of worry, fear, and stress are sometimes expressed as anger or frustration (Burley et al., Reference Burley, Casey, Chenoweth and Brodaty2021), suggesting that approaches to reduce worry and fear may be more effective and reduce the likelihood of staff resorting to physical restraints. Further, people living with dementia and their families/caregivers express strong views against physical and chemical restraints, “Iʼd like people to not restrict me, drug me or tie me in a chair” (Burley et al., Reference Burley, Casey, Chenoweth and Brodaty2022). Participants discussed alternative nonpharmacological and psychosocial approaches, such as suggesting that staff “look at it (behavior change) holistically” and “talk to me and see if they can help me.”

Many LTC residents have a documented diagnosis of dementia or cognitive impairment. It has been demonstrated that people with dementia consistently experience more restraint use compared to other LTC residents (Luo, et al., Reference Luo, Lin and Castle2011). Other predictors for restraint use include advanced age, reduced mobility, reduced functional capacity, and perceived fall risk (Hofmann and Hahn, Reference Hofmann and Hahn2014; Pu and Moyle, Reference Pu and Moyle2022). Triggers for neuropsychiatric symptoms are multifactorial (Macfarlane et al., Reference Macfarlane, Atee, Morris and Cunningham2021) and may include underlying pain, infections, caregiver approach, and over or understimulation. These triggers must be carefully considered and thoroughly evaluated to identify management strategies other than physical restraints.

Older people with disabilities

Globally, over 46% of older persons have disabilities and more than 250 million older people experience moderate-to-severe disabilities (United Nations, 2022). Several articles by the UN Convention on the Rights of Persons with Disabilities (CRPD) have suggested that the use of restraint on persons with disabilities constitutes a violation of human rights, such as: the right to be free from torture or cruel, inhuman or degrading treatment or punishment; to be free from exploitation, violence, and abuse; and the right to respect their physical and mental integrity on an equal basis with others (CRPD, 2015). The CRPD has consistently vocalized its concerns about the use of restraint and recommended action to reduce or abolish restraint (CRPD, 2007). Older adults with disabilities have the right to live life with respect, dignity, liberty, and security, as indicated by the Universal Declaration of Human Rights (1948). This entails “freedom from injury to the body and the mind, or bodily and mental integrity” (Human Rights Committee, 2014: paragraph 3). Physical restraints deprive this population of these basic civil rights. Thus, these rights should be carefully considered before planning and prescribing restraints in any healthcare setting. Because physical restraints can be harmful and counter-therapeutic, their use may not be justified in older adults with disabilities.

Ethics and physical restraint

Physical restraint is a restrictive practice that severely impacts the patient’s autonomy, freedom, dignity, and personhood and violates the individual’s rights across these ethical domains. Informed consent is essential before using physical restraints. Informed consent should discuss the purpose, potential risks (maleficence), benefits (beneficence), and alternatives and provide an adequate opportunity to review and ask questions about using physical restraints. For people with no capacity to provide informed consent, such as those with cognitive impairment or dementia, a discussion with a proxy, legal guardian, or representative (i.e. substitute decision-maker) should be initiated before attempting to obtain informed consent.

Healthcare professionals must provide the best care without stereotyping or discrimination. Thus, the risk of self-harm or harm to others (e.g. caregivers) should be carefully weighed against using physical restraints.

The responsibility for decisions surrounding using physical restraints varies by setting and country. For example, for legislative reasons, Australian physicians have a limited role in making such decisions for LTC residents. But they consistently advocate on behalf of the resident to ensure the clinical appropriateness of these restraints (AMA, 2022). Nurses play a significant role in determining when physical restraints are used and the type and duration of use. A 2007 study across four Turkish hospitals found that only one-third of nurses involved physicians when deciding on using physical restraints in ICUs, emergency departments, and surgical wards. This is a reminder that context-specific legislation is a vital tool for reducing the use of physical restraints (Demir, Reference Demir2007). Sadly, the decision to use physical restraints is often based on unfounded beliefs and perceptions about benefits and underestimated harmful effects of these restraints.

The decision to use physical restraints should be informed by a collaborative approach after seriously weighing human safety versus personal freedom (ANZSGM, 2016). The decision-making process should involve consultation with the individual or their substitute decision-maker (e.g. family member), nursing staff, medical practitioner, and other relevant clinicians. Before making this decision, documentation of a comprehensive care plan on restraint use should be in place. The plan should consist of an extensive review of the individual by a medical practitioner, the rationale for restraint use and its intended duration, a regular review and monitoring of use, and a list of potential alternatives to restraint use.

Why should physical restraint be avoided?

Recent literature has shown that physical restraints are neither necessary nor effective for preventing falls and injuries in older persons (Abraham et al., Reference Abraham, Hirt, Kamm and Möhler2020). The use of restraints in older persons increases the risk of physical and psychological complications, such as agitation, risk of suffocation, and muscle loss. Furthermore, physical restraints may violate or disrespect the autonomy of the patient. According to the United Nations Principles for Older Persons (United Nations, 1991): “Older adults should have the privilege of enjoying their human and fundamental rights when residing in any care home or treatment facility, with full respect for their dignity, beliefs, needs, and privacy and right to make decisions about their health.” Physical restraint should only be reserved for emergency crises as a “last temporary resort” intervention.

How could physical restraint be avoided?

Every attempt should be made to remove, if not minimize, physical restraint use in older adults. Restraint removal or minimization strategies can include early preventative actions and improving approaches toward care. Some examples of these are listed in Table 1.

Table 1. Examples of care optimization strategies and principles applied to reduce the use of physical restraint in older adults

In the Netherlands, an effective program named EXBELT has been developed that combines these recommendations through policy change, staff education and training, using alternative strategies (e.g. hip protectors and special pillows) and a consultation nurse (Bleijlevens et al., Reference Bleijlevens, Gulpers, Capezuti, van Rossum and Hamers2013; Gulpers et al., Reference Gulpers, Bleijlevens, Capezuti, van Rossum, Ambergen and Hamers2012, Reference Gulpers, Bleijlevens, Ambergen, Capezuti, van Rossum and Hamers2013) and builds on the knowledge that education alone is not effective (Huizing et al., Reference Huizing, Hamers, Gulpers and Berger2006, Reference Huizing, Hamers, Gulpers and Berger2009).

Physical restraint is sometimes used in response to behavior that is perceived by healthcare staff as aggressive. Staff training in person-centered approaches so they better understand how to respond to neuropsychiatric symptoms and unmet needs has been shown to reduce agitation (Ballard et al., Reference Ballard2017; Chenoweth et al., Reference Chenoweth, Stein-Parbury, Lapkin, Wang, Liu and Williams2019, Reference Chenoweth2023), though staff need to be supported at the organizational level, so their responses are not impeded by structural or procedural constraints within the facility (Chenoweth et al., Reference Chenoweth, Stein-Parbury, Lapkin, Wang, Liu and Williams2019; Rapaport et al., Reference Rapaport2018).

The use of physical restraints can be reduced or eliminated by creating an environment that is friendly toward older adults, embraces aging with compassion, promotes safe mobility by making the physical environment accessible to people with disabilities, and caters for the needs of older people. In addition, educating family members, caregivers, and healthcare professionals on the ethical challenges and underlying factors associated with the use of restraints for the older population is crucial in advocating for the avoidance of the use of restraints among older persons (Scheepmans et al., Reference Scheepmans, Milisen, Vanbrabant, Paquay, Van Gansbeke and de Casterlé2019).

Strong organizational leadership and culture in a restraint-free care environment have been linked to reduced restraint use across a care home (Australian Government, 2014). Nonrestraint strategies should be attempted first. Many alternatives to restraint use focus on optimizing the physical environment (e.g. access to the outdoors and adequate lighting), increasing meaningful engagement activities and programs (e.g. physical exercise, personalized activities and hobbies, music therapy, and socialization), using validation techniques (e.g. reassurance), and addressing unmet needs (e.g. sensory impairment, pain, and caregiver approach). However, there is little evidence for alternative interventions to physical restraints in older adults. Furthermore, the scarcity of studies that concentrate on singular interventions adds complexity to the evaluation of such measures.

Both psychosocial and nonpharmacological interventions are essential alternatives to physical restraints in older adults. Psychosocial interventions are usually focused on improving the well-being and functioning of the individual, whereas nonpharmacological interventions are primarily aimed at symptom management (Moniz-Cook et al., Reference Moniz-Cook, Vernooij-Dassen, Woods, Orrell and Network2011; McDermott et al., Reference McDermott2019).

Person-centered care is deemed the gold standard for older adults across various care settings, as it focuses on a more humanistic approach as opposed to a traditional biomedical one. Minimizing, discontinuing, or ceasing the use of physical restraints helps promote a more person-centered and compassionate approach to caring for older adults, such as nursing home residents living with dementia (Jacobsen et al., Reference Jacobsen2017). The provision of person-centered care protects the safety of the individual and others while respecting and enhancing the values of autonomy, dignity, and well-being (Kitwood and Bredin, Reference Kitwood and Bredin1992). High-quality care should be centered around personhood, which entails recognition, respect, and trust (Fazio et al., Reference Fazio, Pace, Flinner and Kallmyer2018). In contrast, using physical restraints contradicts personhood principles of care as it abolishes or threatens these values (Scheepmans et al., Reference Scheepmans, Dierckx de Casterlé, Paquay, Van Gansbeke and Milisen2020). Thus, not surprisingly, the WHO, the Dementia Care Practice Recommendations and Alzheimer’s Association have listed person-centered care as a critical focus area of quality care in older adults and dementia (WHO, 2015; Fazio et al., Reference Fazio, Pace, Flinner and Kallmyer2018; Whitlatch and Orsulic-Jeras, Reference Whitlatch and Orsulic-Jeras2018).

Cultural adaptations concerning physical restraints

Culture is an agreed and accepted set of values, principles, norms, and acts by individuals, peoples, and societies. Inspired by cultural differences, countries and geographic regions may have different laws, legislations, policies, and views when dealing with restraint use. Intercultural differences such as personal agency, authority, control, weighed assessment of benefits versus harm and risks, the urgency of the situation encountered, and views on ageism may influence the use of physical restraints on older adults. As such, cultural adaptations have been translated into local laws or policy implementation to restrict restraint use. For example, in South Korea, the Enforcement Rule of the Medical Act was revised in 2020 to include standards for physical restraint use in medical institutions, but further recommendations from the National Human Rights Commission of Korea (NHRCK) were made to improve programs and procedures in local government and welfare facilities (NHRCK, 2023). Some countries, such as the United Kingdom, the United States, Germany, the Netherlands, and Australia, have enacted criteria for the use of physical restraints. This has subsequently reduced the use of restraints in these countries (Scheepmans et al., Reference Scheepmans, Dierckx de Casterlé, Paquay, Van Gansbeke and Milisen2020).

In the Netherlands, the national law is focused on preventing the use of involuntary treatment, including physical restraints (Law care and force, 2018). This law is based on the principle that no treatment may be provided without the consent of the person receiving it. If a clinician wishes to apply involuntary treatment, they need to follow a multidisciplinary, person-centered plan (Table 2). Before using physical restraints, this plan must be followed regardless of consent, because these measures are harmful and greatly restrict the freedom of the person receiving them. Only if there are no other alternatives possible, involuntary treatment may be applied.

Table 2. A practical guide for clinicians to eliminate or reduce physical restraint in older adults