This video discusses the best practices found in Avoiding Restraints in Older Adults with Dementia, a tool which nurses and others can use to avoid the use of chemical or physical restraints in older adults with dementia. Okay, we're here today to talk about Mr. Smith. He's a 76-year-old male who was admitted through the...
after sustaining a fall from home. I believe his daughter came to check on him and found him on the floor. He was admitted with a diagnosis of UTI and dehydration.
He has a prior history of Alzheimer's disease, diabetes... hypothyroidism and he does have osteoarthritis also. According to his daughter over the last few days he has had a reduction in eating, increased lethargy and weakness.
During his admission he had a Foley catheter placed which we have discontinued. He has IV fluids running continuous and IV antibiotics for the UTI. During the night shift he became agitated, pulled out the devices several times and they weren't able to reorientate him.
They did have to place soft wrist restraints on them. Mr. Smith, my name's Michelle. I'm going to be your nurse today.
You also have a student nurse, RJ, who's going to work with you. Okay? Why do I have these on? Well, Mr. Smith, last night you became restless and agitated and you were pulling out a lot of the devices we're using to treat you, so we had to place these on for your safety.
His vital signs have been very good all night. They're stable. His lungs are clear.
There's no edema on his feet. He's very fidgety. He's been like that for the last couple of hours. We checked the blood sugar at 6 o'clock.
It was 110, so he didn't need any coverage with that. Do you know if he lives at home? He does live alone at home.
He lives alone? Okay, I wasn't aware of that. The daughter was initially in the ED with him, had went home, and she's supposed to be back in this morning sometime.
So, Ang, do you know if he's been out of bed since he's been in the hospital? Not yet he hasn't been out of bed, not tonight. We did place him on the falls prevention protocol, the yellow bands on. Do you know if he's tried to get out of bed himself?
He hasn't tried to get out yet. So the doctor didn't start the delirium protocol on him? Not yet. He's looking at it. So no meds have been given?
No meds. Just the restraints at this point. So we don't know if therapy's been ordered or?
Doctors are to discuss it this morning. Okay. Okay, and so for today I will get a hold of physical therapy, get an order for that if it's not already written. Yes.
We'll get a hold of your daughter, Mr. Smith, and then we'll see if we can get the restraints loosened on you or at least off. Okay? Okay. So first we're going to start with our care, and Ang will be going home now.
I'm Michelle. I told you earlier I want to be your nurse today. Okay. Okay, Mr. Smith, can you tell me where you are?
I'm in a nursing home. Oh, Mr. Smith, you're at Metro Health Hospital. You fell at home, and so your daughter Diane brought you here.
Can you take these things off? Well, Mr. Smith, we're going to be doing care on you, and we're going to try to loosen the... up on you okay we're going to begin some of our morning care for you okay so Robert what we would like to do today of course we're going to do you know his a.m.
care I would like to get these restraints off of them so what we What we'd like to do is get with the doctor. Maybe we could switch the IV fluids to just Heplock if he still needs the antibiotics IV. Maybe they could switch him to PO, I don't know at this time. We also would like to try to get rid of the Foley catheter, but at the moment he does have it and I notice it's not anchored.
That might help prevent any of the discomfort and stop him from pulling from it. We also have him in a low bed, because he fell at home, so he's on falls. risk. And I have a control right over here.
I don't know, have you used one? I've not used one of these, no. Okay. It's really simple. This here will move the bed up and this will take it very low.
Mr. Smith, I'm just moving your bed. Okay, so if he hasn't attempted to get out of bed, but should he, then of course the bed is lower and it will help prevent any more injuries. Okay, now until you talk to the doctors about getting the IV discontinued or the Foley pulled out.
Is there anything that we can do to prevent his agitation or anxiety from having the restraints? Yes. Well, during our care, we're going to take him off.
And we're going to see how he does up in the chair. Maybe he'll become more comfortable with his surroundings. I'm also going to get what's called an arm sleeve, and we're going to place it over the IV that's sort of out of sight, out of mind. I'm also going to call his daughter, Diane. I would like to speak to her to see what his baseline is and see how he was actually moving at home, caring for himself.
While you were doing the care, I went and got the arm sleeve that I was telling you about. Have you used one of these? I have not. It's a stocking ad. It's got an area where the thumb comes out.
You just place it over the patient's arm. It will help camouflage that IV because as it is right now, we still have to keep the fluids going for 24 hours. Okay. So we like to put this on. Mr. Smith, I want to place this on your arm.
It's going to help you from pulling at this here. That's your IV tubing. Okay with you? It's okay if I put it on?
I have an area for your thumb to go through. If you could put your fingers through there. It's not too tight, is it? No, it's okay.
During your care, because it's covered, make sure you check the IV site. At least every two hours come in here. Hi Barb. Well it's nice to see you. Oh RJ is here with you also.
Have you met Robert before at all? Yes he's been on this floor with us so he's been walking around working here. But I'm glad to see Mr. Smith looking so well. Mr. Smith my friend. My name is Barb Halliday.
I'm a nurse on this floor also. And I'm just having an opportunity to see how you're doing. Nice to meet you.
Well, thank you. I see you have them in the low bed. I just brought this actual pad in so that we can use it as an adjuvant. adjunct to the low bed, so if he's getting out of bed or getting anywhere near the edge of the bed, he has a nice mattress area that he can use.
And we'll just show it as close as we can in there. Okay. So when we have him in the bed and we have the bed in a low position, we also keep the mat there for the patient's protection. Yes, absolutely. Okay.
Now, we put the arm sleeve on to protect from pulling the IV? Yeah, and I like the idea that you actually are using an alternative. I know that we... we had the physical restraints removed and it's great to be able to look at this.
When you look at all the alternatives, you can usually find something that actually suits your need. So that's great. And we're going to be able to discontinue Foley, so that's one more step.
Even better. Right, correct. Even better. I have been trying to get a hold of his daughter, Diane.
Have you been able to reach her at all? No I haven't. Do you need for me to call her? If you could call her, because we really need to know his baseline. That would be great.
And perhaps we could get her in. Yeah. So I'm going to go out and get that.
the chart and find out what her number is and I will come in here and actually make the phone call here. Because maybe he'll enjoy talking to her as well. We'll talk to your daughter if we get a hold of her.
That would be nice. Right, okay. I'll be right back.
Okay, thank you Barb. You know, it's interesting. I've been doing...
I've been doing a lot of research on how to get people to come to me and talk to me. studies on the use of physical restraints of the mid-1980s. I know I'm dating myself. And it began because of a British geriatrician who used to make rounds with the medical residents, making the statements that American nurses nurse strangely. They tether their patients.
And that's what started this whole issue of even looking at, well, why are we doing it, and how are we doing it? And I remember in those early days, These nurses were absolutely adamant, firmly believed that using that physical restraint truly was in the best interest. It was to protect that patient.
You were doing good for the patient. And over the years, we've gone from skepticism and cynicism that you can get rid of physical restraints now to the point where people that I've worked with start automatically questioning that use of physical restraint and how soon can we get rid of those physical restraints, that they don't like the physical restraint, that they don't like having to struggle with the patient to put them in physical restraints, and couldn't we do something better in taking care of our patients. So there certainly has, in my own personal experience, quite a change over the past 20, 25 years in how people perceive and use physical restraints. Some types of equipment or materials may at times be considered a restraint and at other times not considered a restraint. The intent in which the practitioner is using these materials is what determines whether it's a restraint.
So, for example, all four side rails or full side rails being raised, sometimes it's classified as a physical restraint because you are keeping a patient from desired movement out of bed. On the other hand, if you have a semi-conscious person or a person person who is with conscious sedation that is recovering from sedation could easily roll out of the bed, then if you have the side rails up, there's no desired movement, but you're protecting that patient from undesired movement of rolling out of the bed. In those cases, it would not be a restraint. So the intent of use is very important to keep in mind.
If you use an immobilizer on the arm to protect the therapy, that is not a restraint. a restraint because you're maintaining a catheter within that joint or that area. However, if you use that elbow mobilizer to keep the person from being able to reach up to their face and to pull off of the oxygen, to self-extubate themselves from a ventilator, now you are doing a restraint because it's that desired movement of the arm and it's not for the maintaining of the therapy within that arm area.
When we look at who in the hospital gets restrained, what we have found is that the greatest risk factors for those who get the physical restraints are those with cognitive impairment, and that cognitive impairment can either be from the fact that they are in a state of mental illness, delirium from an acute condition or it could also be from dementia or a chronic condition but either way having that cognitive impairment is a major risk factor and this has been demonstrated in a number of studies a second major issue or risk factor that leads to the use of physical restraints is cognitive impairment with an associated physical impairment. So if this is a person then who has more difficulty walking, ability to get in and out of bed independently, they are at a higher risk of having physical restraints. Now again, as we've gone on with some of our research over the years, we've also found that the presence of medical devices, so again, you're indwelling in your body, you're not just walking.
catheters, your IVs, your endotracheal tubes also are at risk for having a physical restraint in place. What we have is a growing body of work and evidence that has shown that physical restraints does not necessarily stop the fall, but what it is associated with is an increased rate of fall injury. So if you have a problem with your physical restraints, you can go struggling to get out of that physical restraint, or they are trying to climb out over a side rail, or they scoot down the bed and they're trying to get out over the end of the bed, they get caught up in the linens, these are the people who actually tumble out of the bed. of the bed and sustain head injuries, they have hip fractures. So what we have found is that the physical restraint doesn't necessarily stop the fall and it is more likely to have a fall injury with it.
So that is why you have seen such a decrease in the use of physical restraints primarily for falls. The same issue now seems to be occurring with the use of physical restraints to prevent the disruption of IVs, of endotracheal tubes. And study after study has shown that a large proportion of patients, anywhere from 20 to 40 percent, have physical restraints in place at the time that they're disrupting their therapies. So physical restraints, we found, has, you have increased agitation. It's a natural occurrence for a person, if they are tied down against their will, to fight against it.
So you have increased agitation, and they're going to work at it as much as they can. can to get out of it. It becomes a vicious cycle. So what do we do to treat the agitation?
We give them a sedative. And so then we have the problems of the side effects of the sedatives or of the psychotropics that then you have to be dealing with. So it is going against what we know is truly the best practice of mobilizing patients. We never hear anymore of keeping people on sustained bed rest.
We know from many, many conditions you get the the person up, you get them moving. Well here, it's a paradox that instead we're making them stay in their bed. So instead then they fight against it, try to get out of it, we give them a sedation, they get more immobilized, they continue to go downhill, they have the functional decline, they have increased risk of institutionalization or having to go through rehab to get back their conditioning.
One of our greatest challenges, you know, when we think about how would we get rid of physical restraints or how would we avoid the use of physical restraints, is being able to work through of identifying what is the underlying reason for the behavior and what becomes. such a challenge is that it's not always so obvious, and especially when we're talking about the hospitalized dementia patient that might have an overlying delirium. And so as the nurse gains experience, with doing the assessments that have been introduced in various other Tri-This series of can you determine if this is a delirious behavior using the confusion assessment method and identifying with the caregiver or the family member is this dementia that the person has, is this their typical underlying behavior? Do they tend to get restless during certain times of the day? day or around certain conditions or activities and knowing what is that baseline, how does that person typically behave.
So the nurse needs to be able to go in and to identify is this a dementia or a delirium, needs to identify how likely is the risk of this harm occurring, how likely is the risk of the fall, how likely is the risk or the probability that they will actually rip out their IV or their end- dwelling Foley catheter? And then what is the likelihood of harm to follow with that? Because you have to keep weighing out what are the risks of using the physical restraint against the use of not using the physical restraint. Because when you use that physical restraint, we know that there are a number of factors that can affect the older person.
And at the worst would be death. There have been a number of cases of death in physical restraint. And so the application of physical restraint must be done very judiciously, very carefully, after considering all of these other issues.
What we try to do is with the devices is first of all to identify do they really need that device. Sometimes we can substitute the provision of therapies without that particular device. Let me give you an example.
Perhaps a person is on eye contact with a patient. IV antibiotics. At some point they may be able to switch over to oral antibiotics.
So if you're restraining the person just to save the IV, if you remove the IV, you've gotten rid of the need to use the physical restraints. Another example is with the indwelling Foley catheters. Certainly we know that the risk of nosocomial urinary tract infections increase for every day you have this indwelling Foley catheter.
So as soon as possible, if there is not a medical need, such as an obstruction, that you need then to empty the bladder, then you try to get rid of the Foley catheter. In other words, you try not to make the device more important than the person. One of the main things to remember when we talk about physical restraints is that this is usually fairly complex syndromes we're talking about with falls or delirium. And nurses should...
and feel that they have to do it alone. This is where our other health care professionals are so important, whether we call in the physical therapist, occupational therapist with some of the gait issues, the balance issues, calling in the pharmacist to help review medications, checking in then with the physicians about perhaps having consultation specialties to be looking at the patient. But again, when we look at this, these are complex situations, that do require typically an interdisciplinary approach to best manage the person. We now have a number of products available to us as nurses to help assist with using these devices rather than physical restraints in the care of this older person. So when we talk about fall prevention, oh, we've got...
many many many strategies out there now the the furniture designs have changed radically in terms of even the hospital beds can now be lowered almost to the very ground it may not stop the person from rolling out of the bed, but if they do roll out of the bed onto the attached mat, they really haven't hurt themselves. And so now you don't really have that issue of that they might fall from a high height and then have a fracture. We have bed and chair alarms.
Now these will not stop a fall, but what they will do is that they allow the nursing personnel to know that that person is starting to get up out of bed. of the chair starting to get up out of the bed, it gives you a small time interval to get in there and to be able to assist the person. Please don't get up. Sit back down and use the call button to call for help.
Other types of alternatives that we use for falls, if some of these other measures don't work, that are still considered though not a restraint, are the types of belts that can go around the person. that they can release either like a seatbelt that you can just click it open or Velcro. And so sometimes this is sufficient to remind the person when they are starting to get up that they really need to call for the nurse first.
But if they still wanted to, they can remove that belt fairly easily so it is not considered a restraint. The last thing then to be thinking about is if that device is necessary. of using then less restrictive restraints. And so by that what I'm talking about is you are still restricting the person's freedom of movement but not totally tying down the limbs.
So this includes soft mitts. And so that's less restrictive because the person is still able to move their arm limbs but what they're not able to do then is feed themselves, bathe themselves, toilet themselves. because you have their hands in mitts.
But with these mitts, you prevent the person from being able to do the fine dexterity that they would need in order to grab the IV and pull it out. If that doesn't work, what also sometimes is used is the elbow immobilizer. If you have something that's up on the person's face that you want to protect.
So again, the NG tubes, the oxygen mask, the endotransmitter. tracheal tube. The person can still move their limbs about, but they're not able to, again, feed themselves, be able to drink, be able to bathe themselves.
So it's a restraint, but less restrictive. Camouflaging can be done for some of the devices. So again, when you're talking about peripheral IVs, you can put a sleeve or a stocking that over the arm that will camouflage or hide the tube from the person.
And sometimes that's just enough. if they don't see the device that they forget about trying to pull it out or remove this foreign object. Other devices such as your endotracheal tubes, your oxygen mask, you obviously cannot camouflage or hide those things. So what we try to do then with those type of devices is provide better anchorage so that it is much harder for the person to be able to remove them. And we have commercially available tube holders.
that can help with indwelling Foley catheters, that can help with endotracheal tube anchoring, so that, again, keeps the person from being able to remove it very easily. Thank you. There are certainly times when there is a need to use physical restraint. When this is in critical situations that if the disruption of the therapies could lead to major imminent harm, risk of death.
And so again, what we're talking about is the self-extubation from ventilators, pulling out intra-aortic balloon pumps. They can hemorrhage to death. So, So there are times when you need to get in there and to be able to restrain that person until such time that you're able to work out the delirium that's happening with that person and to be able to find ways to help calm them. Again, without heavy sedation, you need to maintain function, but to keep the person from risk of death from that disruption or from that. that behavior.
The major goal though is to get rid of those restraints as soon as possible. What we recommend is that the decision to order or maintain physical restraints should be done in an interdisciplinary process. That this is something that again with the fall syndrome or the delirium syndromes or the management of the dementia patient in the hospital setting truly does require a lot of time and effort.
an interdisciplinary approach. So the RN can initiate a restraint, but it's a licensed independent practitioner who must order the restraint and include this on a plan of medical care. The Try This assessment tool focuses on interventions at the individual level as well as what can be done at the organizational level.
And you will see when you go through the Try This series that what... What it's doing is pulling together from the various aspects of care of the hospitalized dementia older patient that starts pulling it all together. You have to do your assessment. What's the baseline function of that person?
What is their typical level of cognition? Find out from their caregiver, whether that's from home or a nursing home, do they have risk behavior, such as trying to get up and walk alone when they are obviously unsteady or dependent upon help. So your assessment becomes critical. You need to know if this cognitive impairment you're seeing, can you just assume that that's due to the dementia? And what we're saying is no, don't assume.
Make sure that this isn't due to either delirium. or some other underlying cause. It could be fecal impaction. It could be other causes of pain. You need to find that out.
Do not assume this behavior and this level of cognition is due to the dementia itself. You need to look at the environment, and there's a number of ways to keep your environment safe. For older people, we know that you have to keep noise levels down.
If you have a lot of noise, you can escalate problem behavior for these older dementia patients. You need proper lighting so that they can see well enough but without glare. You need to be able to have furniture that helps keeping them functional and being able to be up and about. Part of this assessment is also then looking at the distinct therapies and interventions that we discussed earlier. So all of these assessments has to be done with the focus of can I put in place, interventions that I never ever have to get to that physical restraint point.
There are a number of resources available now for nurses to be able to look at to help with best practices regarding the care of the hospitalized dementia patient. Certainly the companion article that goes with this. video from AJN. And in that article there are a number of resources and references listed. The website for the John A. Hartford Institute for Geriatric Nursing at NYC is www.johnahartford.com.
is a wonderful site with many resources for the care of the hospitalized elder and the Alzheimer's Association has a number of resources available in terms of what happens when the older patient with dementia is hospitalized. Okay, we're here today to talk about Mr. Smith. He was admitted with a diagnosis of UTI and dehydration. He has a prior history of Alzheimer's disease, diabetes, hypothyroidism, and he does have osteoarthritis also.
According to his daughter, over the last few days, he has had a reduction in eating, increased lethargy and weakness. During his admission, he had a Foley catheter replaced, which we have discontinued. He has IV fluids running continuous and IV antibiotics for the UTI.
During the night shift he became agitated, pulled out the devices several times, and they weren't able to reorientate him. They did have to place soft wrist restraints on him. And one of our primary goals for him was to eliminate using physical restraints.
I think that when you look at the evidence it's very clear that physical restraints on patients with dementia really leads to very poor outcomes whether those are psychosocial types of problems or they are actual physiological problems. So I know that you are going to see that more and more so I appreciate the fact that you both moved in and got alternatives and explored them. There seems to always be an alternative that is good to you.
So thank you so much for doing that. Well, we found that during his care, Robert, I believe you told me that he did have pain upon movement? Yeah, I got him up to sit him in the chair, and I think it was fairly obvious that particularly his right leg was very stiff and rigid, and you could tell he was grimacing. His leg, he was in pain.
Looking at his medication profile, he needs probably to be on acetaminophen 650 milligrams by mouth or oral preparation every six hours around the clock. And then maybe we can add some tramadol, 50 milligrams orally as well, every eight hours as needed for trying to help compensate for additional pain management. This is a mild to moderate type of pain, moderate in the mostly category. And also when you have the opportunity to talk to the doctor, I would like more information if there's been any history of taking over-the-counter medications at home.
Thank you. about this delirium phase for the patient. It could be exacerbated by taking Benadryl at home for trying to help him sleep.
Anticholinergic side effects from Benadryl might be not a good thing, especially in an Alzheimer's dementia patient. Potentiates confusion, agitation, over sedation, dizziness, so it's something we have to find out. Now Barb, you did talk to... His daughter, Diane? I did.
And could you tell us if you got any information about his baseline condition? Yeah, and I think that was our other problem. We had several really primary problems, and the second one really was to see what his baseline was. It was important for us to determine that as quickly as we could because we are always worried about dementia patients having this overlay of delirium and maybe missing our opportunity. You know, they present in a different way, and so we don't always see the same symptoms.
And I'm sure that's true. I believe, according to her, what we saw was a delirium that was present. However, she is more concerned about the fact now that he seems to have a progressive dementia occurring, and that is worrisome to her. This is not the first fall he's had.
She is very supportive of him and lives close to him, but she does have to work, and so she's concerned about that time frame where she's not available to him. So... I think Chris that's what we're looking for is to have some really good recommendations on what we might do as support care for her You know when she comes in we want to find out more about how she's feeling about managing him You know what are her stresses, and you know what are her concerns? I think social work needs to get involved to identify with her her Alzheimer's and elderly resources in the community opportunities for perhaps adult daycare or you know an assisted living situation something that may be more safe for him as it progresses, if it does. And then a physical therapy consult to identify what his needs are.
He could improve with the medication, with his pain, and be able to mobilize better, and as his delirium improves, we'll see a different picture. But we'll have to cross that bridge when we get to it. A home care referral will probably be helpful also, both for physical therapy needs and maybe a social work assessment of the home situation. And just. how things are going, if we can get him back home with his daughter, you know, work from there.
So I think we have really addressed the primary problems we wanted to do initially. We have eliminated using physical restraints and using alternatives. We have assessed his pain, and we thank you, RJ, for picking up on that.
That's one of the problems with patients with dementia. They feel pain in the same way, they just simply can't articulate it to you. So you need to...
to look for other things and thankfully you found that and we got a good pain treatment plan in place. And then we wanted to strive to have individualized care because that's going to be the best practice for him involving the family and getting as much support that's available to him. So our primary issues are taken care of, we just need now to meet with his daughter Diane.
Right, and she's coming in. And get the picture and we'll meet with her with the social worker as well. Okay. Okay. Thanks Mrs. Jacobs for coming in.
I was so glad I had a chance to talk to you on the telephone and especially in his room. He asked a lot about you and I know that you must be very important to him. And I wanted you to come in so that we could actually talk about a number of things.
I'm most concerned about what you see as his usual behavior and whether you have seen changes within any time frame, maybe several months or one month. Is there anything that you can share with me about his normal behavior? He's been diagnosed with dementia, Alzheimer's, for several years.
But I have noticed, especially during the past few months, that he seems to be getting more confused. He has been falling more, and I am concerned about that. I haven't noticed any injuries before, but I am concerned about this recent hospitalization. He was very agitated, and that's unlike him.
There's a change in his... his behavior. Sometimes I notice in the evening he is agitated.
I do try to stop over every day before and after work. I live nearby. I have concerns he's still living by himself in his own home. I'm his primary caregiver.
I can check with other family members whether they'll be willing to help out with his care, but those were some of the things I was hoping to address. I think we may be at the point that I need more. help more assistance with him at home. Had you given any thought to any relocation for him as opposed to having in-house help? I'm just putting it out there just as something to discuss.
I've thought about it. I'm not sure if he's willing to leave his home. Currently, right now, we don't have any home care supports in there. I'm not sure if he would be agreeable to that, but I'm willing to explore and research any alternatives.
that might be out there, if you can help me with that. So having like a home care opportunity might be well worth investigating? Especially in lieu of the frequent falls. I think that would be important.
And again, just his management day to day. We did also, in noting in his morning care, that he had a lot of ambulation problems. And we think that's related to his arthritis and his pain as well.
So. So we've asked for a physical therapy consult to evaluate him and we'd like to also have that physical therapist go into the home, examine and see what in the home situation could we also help and correct as well. So we think that part of his falling also might be partly because of his guarding his ambulation when his pain is so terrific.
So we'll see if that helps. It may not be the answer, but at least we can say we've at least eliminated one reason as to why. to why he might be falling. I have noticed that he's been limping a lot lately, but when I ask him about pain, he doesn't really acknowledge any type of pain. Yes.
If you are thinking of sending someone into the home, make sure that I know so that I can be there with him. Absolutely, yes. And it will be good because it will be a good resource for you as well.
And kind of keep that idea in mind as he gets further into his dementia. What we'll find is that he's going to be less apt to... to either remember his pain or be able to describe it. And the way you picked up on his non-verbal cues is what you're going to find yourself doing more and more.
You know, his limping and his guarding and his facial changes. And that'll be just a part of the disease progression. Well, I'm going to leave you with my card, and I need for you to promise me that you'll call if you think of anything that's incredibly important right now.
Otherwise, I'll set up the appointment with the social worker initially now, and then when the doctor comes in, I'll call you. When the physical therapist is coming out to do an evaluation, I'll make sure that you are present there as well. And we're hoping also to have home care as a possibility once you've spoken with a social worker. Thank you for coming in.
Thank you so much. And I so appreciate all the invested time you have with your father. He is very fortunate to have you. Well, thank you. Thanks.