Free Research Proposal About Reduction Of Restraint Usage In Confused/Dementia/Alzheimer’s Patients

Introduction

Older adults suffering from dementia are at greater risk than other patients when placed in restraints. There are many negative physical and psychological effects related to the use of restraints. Many nurses agree that restraints control behavioral symptoms while preventing falls. They also reduce the disruption of therapies in dementia patients focused on sustaining life. Before reducing the use of restraints in such patients, it is important to interpret patient behavior . Interpreting helps determine whether there are any unmet needs, changes in physical or mental status, as well as individualized care related to communication, surveillance, consistency, and dialogue. Researchers agree that when clinicians use restraints frequently and deem them necessary, they become the rule instead of the exception. Restraint use may be avoided in dementia patients through responding to the behaviors of the patients and fostering positive organizational change and leadership regardless of the setting (Evans & Kotter, 2008). This paper examines the challenge of reducing restraint usage in dementia/confused/ Alzheimer’s patients through review of literature and synthesis of evidence.

Statement of the problem

The use of physical restraints among older adults has been associated with poor outcomes. These outcomes include functional decline, cardiovascular stress, decreased peripheral circulation, muscle atrophy, incontinence, infections, pressure ulcers, social isolation, agitation, serious injury, psychiatric morbidity and even death. Of all the patients, old adults with dementia or Alzheimer’s have the greatest risk for requiring restraint when hospitalized. Dementia’s are one of the most –distressing disorders of later life. Late-life dementias cause not only deficits in self-care and cognition, but also have behavioral and non-cognitive psychiatric symptoms. Alzheimer’s disease and similar disorders make up more than 90% of all old age dementia cases (Desai & Grossberg, 2001). These patients have difficulty in adapting to hospital settings because of impaired judgment, memory and comprehension. They may try to “resist” or “escape” because they usually feel “lost” and “afraid.” In addition, language deficits related to dementia and Alzheimer’s restrict their ability to express these concerns clearly. In some cases, brain damage resulting from dementia introduces a great risk for acute confusion, delirium, increased agitation, hysteria, and disorientation. These problems necessitate increased research in determining ways in which the use of restraints for such patients can be reduced to become a necessity rather than the norm. Researchers have examined this problem from various perspectives that are both theoretical and practical. They have also called for improved leadership in healthcare administration, quality, standards of practice, regulations, strategic planning, and information and accreditation systems.

Review of Literature

According to ADI (2009), a study indicated that 50 to 70% of people with dementia need some degree of care while others need a lot of care. People with mild dementia require care 30% of the time, while those with moderate dementia need care 69% of the time. Severe dementia cases require intense care 88% of the time. There are two types of restraints: physical and chemical. Physical restraints are manual methods or the use of machines/ devices to restrict physical movement of the patient. Chemical restraints involve the use of antipsychotic medications to restrict unwanted movement or verbal outbursts.
McCloskey (2004) indicates that the Progressively Lowered Stress Threshold (PLST) model may be used in determining how to reduce the use of restraints. The model indicates that dementia patients have problems in the receipt, process, and response to environmental stimuli. These difficulties arise from the gradual deterioration of their cognitive, affective as well as functional abilities as a result of dementia. The PLST model holds that behavior for dementia patients is either baseline, anxious or dysfunctional. The behavior at any time depends on perception of environmental stimuli and the stage of the dementia. Using this model, McCloskey (2004) asserts that careful assessment of the environment may help establish factors that contribute to patient stress. These factors may be modified for future care.
Desai & Grossberg (2001) developed a theoretical framework to manage behavioral disturbances in dementia patients. They insist on the need to approach the problem in a systematic and structured fashion. The reason behind patient agitation is not usually apparent. It is crucial that delirium is diagnosed early because it has potentially fatal consequences. The theoretical framework comprises of symptom clusters that determine the best approach for the treatment. Figure 1 shows this theoretical framework.
Figure 1: Theoretical framework for management of behavioral disturbance among dementia patients (Source: Desai & Grossberg, 2001)
According to Zimmerman et al,. (2005) there are four main strategies for effective dementia care in residential settings. First, it is important to encourage adoption of the Alzheimer’s Association’s recommended practices in nursing homes and assisted-living residences. Secondly, incorporation of practice recommendations in quality assurance systems used in nursing homes, and similar residences are important. Towards this end, the Alzheimer’s Association continues to work with policy-makers at the federal and state levels. The association realizes that the issue of restraint usage for Alzheimer’s and dementia patients is a policy issue that requires the involvement of policy-makers at all levels. The third strategy involves encouraging quality among healthcare providers for dementia and Alzheimer’s disease patients. The association offers training as well as education programs to care staff at all levels in nursing homes and assisted-living homes. The fourth strategy involves empowering dementia patients and their caregivers with the knowledge and skills to make informed decisions. The Alzheimer’s Association has developed an online interactive guide known as Carefinder™ (Zimmerman et al., 2005). This interactive guide educates consumers on how they can recognize quality care, choose the best options and advocate quality within their chosen care options.
Evans & Cotter (2008) also established through research a set of recommendations for effective dementia care. These recommendations largely involve person-centered care- the type of care tailored to meet the abilities and needs of each patient/resident. The Alzheimer’s Association has identified three priority care areas in which intervention can make a considerable difference in the patients’ quality of life. Patients with good quality of life are less likely to require the use of restraints as compared with those with poor quality of life. Three priority care areas include food and fluid consumption, social engagement, and pain management. Insufficient consumption and poor choices of foods and fluids may contribute to the decline of the resident’s wellbeing or overall health (Evans & Cotter, 2008). Caregivers should ensure proper preventive and screening systems for nutritional care. Proper hydration is also important. Mealtimes should be made into enjoyable and pleasant activities where staff watch and interact with their residents. Pain management is also crucial to the well-being of patients with dementia. Patient restraint is usually necessitated by excessive pain leading to erratic behavior by residents. Proper pain management through therapy and medication may reduce the need to implement patient restraints. Social engagement is a critical element of proper dementia care. Social activities help residents by enhancing their quality of life and maintaining their functional abilities. These activities also provide a setting with personal meaning, a feeling of community, fun and the ability to make choices.

Conclusion and suggested courses of action

In keeping with the findings of research, as well as the theories and models,, it is important for nurses and other caregivers to minimize agitation and causes of stress in individuals with dementia. This approach may be possible by modifying and controlling factors that contribute to stress. For example, according to the PLST model, environmental factors may be altered to avoid agitation. Other factors such that may be used to reduce behavioral disturbance that necessitates restraint include those that improve the patient’s quality of life (Zimmerman et al., 2006). These include pain management, proper nutrition, and social interactions. Patients and their family members or friends should look for quality care. It is also important for nurses to recognize that behavioral disturbances are common in dementia patients and should be anticipated. Restraint-based interventions may not be necessary unless the behavior of the patients poses a risk to the individual patient, other patients, or caregivers. To reduce the need for restraint usage, nurses should attempt to accommodate the behavior while ensuring that it does not escalate to dangerous levels. The PLST model can help nurses identify, anticipate and reduce behavioral disturbances, allowing them to maintain high-quality care.

References

Alzheimer’s Disease International (ADI). (2009). World Alzheimer Report. Retrieved May 17, 2011
Desai, A., & Grosserg, G. (2001). Recognition and Management of Behavioral Disturbances in Dementia. The Primary Care Companion To The Journal Of Clinical Psychiatry, 03(03), 93-109. doi:10.4088/pcc.v03n0301
Evans, L., & Cotter, V. (2008). Avoiding Restraints in Patients with Dementia. AJN, American Journal Of Nursing, 108(3), 40-49. doi:10.1097/01.naj.0000311827.75816.8b
McCloskey, R. (2004). Caring for patients with dementia in an acute care environment. Geriatric Nursing, 25(3), 139-144. doi:10.1016/j.gerinurse.2004.04.006
Zimmerman, S., Sloane, P., Williams, C., Reed, P., Preisser, J., & Eckert, J. et al. (2005). Dementia Care and Quality of Life in Assisted Living and Nursing Homes. The Gerontologist, 45(Supplement 1), 133-146. doi:10.1093/geront/45.suppl_1.133