Several Cochrane reviews look at the evidence on interventions that might be used for older people in long-term care settings and these include reviews on ways to prevent or reduce the use of interventions that might do more harm than good. Among these, the review of interventions for preventing and reducing the use of physical restraints was updated in July 2023. We asked lead author, Ralph Möhler of the University Hospital Düsseldorf in Germany, to tell us about physical restraints and the latest findings of the review in this podcast.
Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Several Cochrane reviews look at the evidence on interventions that might be used for older people in long-term care settings and these include reviews on ways to prevent or reduce the use of interventions that might do more harm than good. Among these, the review of interventions for preventing and reducing the use of physical restraints was updated in July 2023. We asked lead author, Ralph Möhler of the University Hospital Düsseldorf in Germany, to tell us about physical restraints and the latest findings of the review in this podcast.
Ralph: Physical restrains are devices that aim to restrict or prevent a person's free movement. Examples are bed rails, belts and fixed tables in chairs, and these are commonly used in care homes in many countries, mainly for people with dementia. Although the rate of restraint use differs between different care homes, some studies have found that these devices were used with more than half the residents.
The main reason for using physical restraints is safety. For example, bedrails are often used to prevent people at risk of falling from leaving their bed unobserved and to prevent falls or fall-related injuries. However, this demobilisation can have negative implications on physical functioning and mobility, which may actually increase the risk of falling. Also, restraints can trigger or increase aggressive behaviour. In fact, restraint use does often more harm than good. For this reason, guidelines recommend avoiding physical restraints and their use is restricted by the law in several countries, including the Unites States and Germany.
In 2011, we published a Cochrane Review that investigated the effects of interventions aimed to reduce the use of physical restraints. However, the results of the five included studies were inconsistent and we were not able to draw clear conclusions. We have now updated the review, including six new studies so that we now have eleven studies with about 19.000 participants. The studies investigated different types of intervention to reduce physical restraints in care homes and we can now be confident in a conclusion that a clear policy change is needed at the organisational level, to emphasise that restraints should the last choice and only used when all other viable strategies have been explored.
This conclusion is driven by the four studies with approximately 18.000 participants that investigated organisational interventions intended to promote a least-restraint policy. The interventions comprise various components as a package and all offer education to the nursing staff to try to increase their knowledge about the unclear effects of restraint use and the potential for adverse events. The interventions also provide information about strategies to reduce restraints and overcome common barriers of restraint reduction. Further components seek to change the institutional policies and culture of care regarding the use of restraints. as ‘champions' were trained to develop and implement individual strategies to prevent the use of restraints within their facilities. This set of four studies provide the best evidence in the review, showing that organizational interventions probably reduce the number of residents with physical restraints in care homes by 14%, with no overall change in the number with falls or fall-related injuries and no increase in the prescription of psychotropic medication.
Elsewhere in the review, six studies investigated educational programmes addressing staff knowledge and attitudes regarding physical restraint use without further intervention components. The evidence from these revealed that educational interventions alone are not effective in reducing the use of physical restraints. Some of the studies found that education may reduce restraint use, but others did not or even found an increase of restraint use after the intervention was implemented. One explanation is that education alone often has little impact on behaviour and care processes.
In conclusion, therefore, our updated review shows that a clear policy change is necessary at the organisational level. This should emphasise that restraints should be seen as the last resort and used only when all other viable strategies have been explored.
Mike: If you would like to learn more about these organisational level changes, and the interventions that would help to implement them, you can find full details in the review. It's available online at Cochrane Library dot com with a search for 'reducing physical restraints in long-term care'.