Choosing Wisely:

Don’t use physical or chemical restraints, outside of emergency situations, when caring for long-term care residents with dementia who display behavioral and psychological symptoms of distress; instead assess for unmet needs or environmental triggers and intervene using non-pharmacological approaches as the first approach to care whenever possible.

Rationale and Comments: BPSD include aggression, agitation, wandering, disruptive vocalizations, anxiety, apathy, hallucinations, and depression. The majority of people living with dementia will experience these symptoms. They result in poor quality of life, more rapid cognitive and functional decline, high risk for abuse, caregiver burden, and tremendous cost to the US healthcare system. In fact, dementia care is among the most costly of diseases including diabetes, cancer, and heart disease; and BPSD account for a staggering 30% of total dementia costs. Despite the high human and dollar costs associated with these symptoms, their treatment continues to challenge practitioners and remains a top research priority in long-term care settings. Because BPSD are often triggered by a change in physical condition, an unmet need or an environment that exceeds the person’s stress threshold, it is important that these triggers be addressed as the first line of treatment rather than resorting to physical or chemical restraint, which carry a risk for adverse effects.
Sponsoring Organizations:
  • American Academy of Nursing
  • Sources:
  • Expert consensus
  • Disciplines:
  • Neurologic
  • Psychiatric and Psychologic
  • Geriatric Medicine
  • References: • Evans LK, Strumpf NE. Tying down the elderly. A review of the literature on physical restraint. Journal of the American Geriatrics Society. 1989;37(1):65-74.
    • Kales HC, Gitlin LN, Lyketsos CG, Detroit Expert Panel on Assessment and Management of Neuropsychiatric Symptoms of Dementia. Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society. 2014;62(4):762-769.
    • Kolanowski AM, Litaker M, Buettner L, Moeller J, Costa P. A randomized clinical trial of theory-based activities for the behavioral symptoms of dementia in nursing home residents. Journal of The American Geriatrics Society. 2011;59(6):1032-1041.
    • Kovach CR., Logan BR, Joosse LL, Noonan PE. Failure to identify behavioral symptoms of people with dementia and the need for follow-up physical assessment. Research in Gerontological Nursing. 2012;5(2):89-93.
    • Kovach CR, Logan BR, Noonan PE, Schlidt AM, Smerz J, Simpson M, Wells T. Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia. American Journal of Alzheimer’s Disease and Other Dementias. 2006;21(3):147-155.
    • Maust DT, Kim HM, Seyfried LS, Chiang C, Kavanagh J, Schneider LS, Kales HC. Antipsychotics, other psychotropics, and the risk of death in patients with dementia: Number needed to harm. JAMA Psychiatry. 2015;72(5):438-445.

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