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COMMENTARY
Physical restraint in older people: an opinion from the
Early Career Network of the International Psychogeriatric
Association‡
..................................................................................... ........................................................................................... .......................................................................................... .......................................................................................... .................................................................................... ........................................................................................... .....................................................................
Mustafa Atee,1
,
2
,
3
,
4Claire V. Burley,5
,
6Victor Adekola Ojo,7
,
8
,
9
Agboola Jamiu Adigun,10 Hayoung Lee,11 Daniel Jake Hoyle,12
Olufisayo Elugbadebo,13 and Tomas Leon14
,
15
1The Dementia Centre, HammondCare, Osborne Park, WA, Australia
2Curtin Medical School, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
3Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
4Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
5UNSW Medicine and Health Lifestyle Clinic, School of Health Sciences, University of New South Wales, Sydney, NSW, Australia
6Centre for Healthy Brain Ageing (CHeBA), University of New South Wales, Sydney, NSW, Australia
7Royal Perth and Bentley Group, Bentley, WA, Australia
8Nissi Healthcare Telehealth, Clyde, VIC, Australia
9Vita Healthcare, Mount Eliza, VIC, Australia
10Royal Cornhill Hospital, Aberdeen, United Kingdom
11Faculty of Health Sciences, University of Pécs, Pécs, Hungary
12School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
13Department of Psychiatr y, College of Medicine, University of Ibadan, Ibadan, Nigeria
14Memory and Neuropsychiatric Clinic (CMYN) Neurology Department, Hospita l del Salvador and Faculty of Medicine, University of Chile, Santiago, Chile
15Global Brain Health Institute, Trinity College, Dublin, Ireland
Emails: matee@dementia.com.au;mustafa.atee@curtin.edu.au
ABSTRACT
The International Psychogeriatric Association (IPA) has expressed significant concerns over the use of physical
restraints in older people across diverse aged care settings. Following an extensive analysis of the available
literature, the IPA’s Early Career Network (ECN) has formulated a collection of evidence-based
recommendations aimed at guiding the use of physical restraints within various care contexts and demographic
groups. Physical restraints not only infringe upon human rights but also raise significant safety concerns that
adversely impact the physical, psychological, social, and functional well-being of older adults. Furthermore, their
effectiveness in geriatric settings remains inadequate. Given these considerations, the IPA and its ECN firmly
assert that the use of physical restraints should only be considered as a final recourse in the care of older people.
Key words: physical restraint, older adults, evidence-based statement, care settings, dementia, disability, recommendations, ethics, neuropsychiatric
symptoms
Background
Globally, the number and proportion of older people
(i.e. those aged over 60 years) continues to rise (United
Nations, 2019). Between 2019 and 2050, the number
of people aged over 60 years is expected to double to 2.1
billion people, accounting for 22% of the population
(WHO, 2022). Neurocognitive and neuropsychiatric
disorders (e.g. dementia, depression, anxiety, and
substance abuse) are estimated to affect over 20% of the
older population (WHO, 2017), with many exhibiting
neuropsychiatric symptoms. Recently, the Interna-
tional Psychogeriatric Association (IPA) expressed
renewed concern over the inappropriate use of physical
restraints for the management of neuropsychiatric
symptoms in older people, considering high prevalence
rates in various parts of the world, both in high- and
low-to-middle income countries (IPA, 2022b).
The IPA is the peak international body for
psychogeriatrics, a branch of psychiatry that forms
part of the multidisciplinary delivery of mental
health care to older people (Silva and Wertheimer,
1996). It was formed to serve the interests,
disciplines, and communities representing the full
spectrum of geriatric mental health (IPA, 2022a).
‡This article was originally published with an error in the title. The error has
been corrected and a correction notice prepared. The PDF and HTML
versions have been updated.
International Psychogeriatrics: page 1 of 12 ©International Psychogeriatric Association 2023. This is an OpenAccess article,distributed underthe terms of theCreative Commons
Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permitsunrestricted re-use, distribution, and reproduction in any medium, provided theoriginal work is
properly cited.
doi:10.1017/S1041610223000728
https://doi.org/10.1017/S1041610223000728 Published online by Cambridge University Press
The IPA has a wide range of members from over 50
countries that encompass physicians (such as
psychiatrists, neurologists, geriatricians, and pri-
mary care consultants), nurses, pharmacists, social
workers, occupational therapists, psychologists,
scientists, and epidemiologists. The IPA’s core
mission is to advance IPA members and the geriatric
mental health of older people everywhere through
education, research, professional development,
advocacy, health promotion and service develop-
ment (IPA, 2022a).
While the recommended standard of care is a
restraint-free care environment (Bellman, 2016),
guidance on using physical restraints is critically
needed to inform best practice. In 2001, the
American Nursing Association (ANA) published a
position statement, titled “Reduction of Patient
Restraint and Seclusion in Health Care Settings”,
which recognized that restraints may be necessary
but should only be used when “clinically appropri-
ate”, and “adequately justified”(ANA, 2001). The
Australian Medical Association’s (AMA) position
statement, published in 2001 and revised in 2015
and 2022, firmly opposes the use of environmental,
mechanical, and physical restraints, including
seclusion, when caring for people living in long-
term care (LTC) facilities due to their impact on the
rights and safety of the individual (AMA, 2022). The
Australian Centre for Evidence-Based Care (ACE-
BAC) developed a standardized care process for
public sector residential aged care services intending
to promote evidence-based practice in seeking
alternatives to physical restraint for older people
who live in these settings (ACEBAC, 2018). Dutch
hospitals have established guidelines to support
clinical decisions around physical restraints, but
adherence to these guidelines remains poor (van der
Kooi et al.,2015). Despite local guidelines and
resources in various countries, the lack of interna-
tional consensus on how and when to use physical
restraints in older adults contributes to disparities
and poor care outcomes in this population (Hwang
et al., 2022). The position held by the IPA is that
restraint is not to be used at all, if possible, and only
if serious harm is imminent and there are no other
strategies.
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 patients' dignity, safety and medical
treatment, and the caregivers’safety and responsi-
bility. This statement represents the official policy
position of the IPA. The purpose of this statement is
to provide clear and concise evidence-based guid-
ance on the clinical and ethical considerations of
using physical restraints in older adults, from an
international perspective.
Methods
In May 2022, the IPA Director Board commis-
sioned a Working Group from the IPA Early Career
Network (ECN) to develop this statement. Mem-
bers of the Working Group comprised of the eight
authors who have an interest and expertise in
physical restraint use in older people. The group
had four planning and progress meetings between
May and November 2022. Existing literature on
physical restraint use in older adults was reviewed
and summarized from July culminating in the
submission of a first draft of this statement to the
IPA Board in November 2022. After review and
amendment, the IPA Board endorsed this state-
ment in May 2023.
Current situation on physical restraint
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.,2016). 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,
2017). 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
2 Commentary
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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 conse-
quences 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 situa-
tions that are not considered to be physical
restraints. These include assisting care recipients
during activities of daily living (ADL) and thera-
peutic 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, 2017).
The fundamental rationale for employing physi-
cal restraints is ostensibly to ensure the safety of the
patient and others. Four common justifications for
resorting to physical restraints include:
1. To prevent interference with medical treatment.
2. To safeguard active or open wounds and recent
medical and operative procedures.
3. To reduce the risk of falls or accidents in ambulant
patients with safety concerns.
4. To protect other patients, staff, and caregivers
against unsafe behaviors, severe injury, or physi-
cal 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., 2011). 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., 2003). Other adverse consequences
include impaired cognitive and ADL performance
(Hofmann and Hahn, 2014). Further, restraints can
expose the restrained person to psychological distress
and may increase agitation (Engberg, et al., 2008).
Physical restraint use in different care
settings and with different clinical
populations
Physical restraints such as bed rails, tables with fixed
chairs, belts, and chairs are routinely implemented
for patient safety (Sharifiet al., 2021) in many care
settings despite research demonstrating a lack of
efficacy and safety (Abraham et al., 2020). The
following sections outline physical restraint use in
hospital settings, LTC facilities, and home care
community settings. Restraint use in people living
with dementia and older people with disabilities is
also discussed.
Hospital settings
Older people represent a large proportion of the
patients admitted to hospitals. Hospital environ-
ments 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., 2017). These factors can precipitate the
occurrence of iatrogenic harms, particularly among
people living with dementia (AIHW 2020). Iatro-
genesis 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., 2023).
The prevalence of physical restraint use in
hospitalized older adults is as high as 33–68%
(Lim and Poon, 2016). Furthermore, older adults
are three times more likely to be physically restrained
during their hospitalization than their younger
counterparts (Said and Kautz, 2013). Guidelines
recommend that the use of physical restraints in
hospital settings is reduced or stopped entirely
(Joseph, 2016; Lachance and Wright 2019;
ANZSGM, 2012;Cuiet al., 2021). In some
countries, the use of physical restraints in these
circumstances is illegal (Abraham et al.,2020).
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., 2021;Leeet al.,
2021). The most common forms of physical
restraints in this setting are (in descending order)
bedrails 44%, force/pressure used in medical
Commentary 3
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treatment or ADL (14%), chair belts (8%), chair
restraints (8%), surveillance/sensors/tracking sys-
tems (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., 2021). The duration of restraint use
in LTC ranges from less than 1 day to 180 days (Lee
et al., 2021).
Physical restraint use serves as a defined
benchmark that aids in identifying domains where
care might be suboptimal and demands enhance-
ment. 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., 2016; Scheep-
mans et al., 2017,2018). In older adults living with
cognitive impairment at home, the prevalence of
physical restraint use can reach 42% (Moermans
et al., 2018). 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., 2017).
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, 2014; Scheepmans et al., 2014,2019).
•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, 2006; Hamers and Huiz-
ing, 2005).
•Culture of home care organization (Gastmans and
Milisen, 2006; Hamers and Huizing, 2005).
•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.,
2009; Hamers, 2017; Selbaek et al., 2016; Mamun
and Lim, 2005). 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., 2014). 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.,
2010). 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., 2005; Foebel et al., 2016; Freeman
et al., 2017;Linet al., 2009;Luoet al., 2011;te
Boekhorst et al., 2013; Selbaek et al., 2016; Voyer
et al., 2011).
Neuropsychiatric symptoms associated with
dementia (also known as behaviors and psychologi-
cal 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
4 Commentary
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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 relation-
ship between neuropsychiatric symptoms and falls.
However, evidence demonstrates that physical
restraint does not prevent falls or fall-related injuries
(Qureshi, 2009) and can instead exacerbate symp-
toms, such as agitation, and cause injuries (Capezuti
et al., 1998; Sung et al., 2006). 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., 2021), 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, “I'd like people to not restrict me, drug me
or tie me in a chair”(Burley et al., 2022). Participants
discussed alternative nonpharmacological and psy-
chosocial 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 diag-
nosis of dementia or cognitive impairment. It has
been demonstrated that people with dementia
consistently experience more restraint use com-
pared to other LTC residents (Luo, et al., 2011).
Other predictors for restraint use include advanced
age, reduced mobility, reduced functional capacity,
and perceived fall risk (Hofmann and Hahn, 2014;
Pu and Moyle, 2022). Triggers for neuropsychiatric
symptoms are multifactorial (Macfarlane et al.,
2021) and may include underlying pain, infections,
caregiver approach, and over or understimulation.
These triggers must be carefully considered and
thoroughly evaluated to identify management strat-
egies 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 recom-
mended 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: para-
graph 3). Physical restraints deprive this population
of these basic civil rights. Thus, these rights should
be carefully considered before planning and pre-
scribing 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.
Statement and recommendations
Ethics and physical restraint
Physical restraint is a restrictive practice that
severely impacts the patient’s autonomy, freedom,
dignity, and personhood and violates the indivi-
dual’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 opportu-
nity 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 attempt-
ing 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
Commentary 5
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departments, and surgical wards. This is a reminder
that context-specific legislation is a vital tool for
reducing the use of physical restraints (Demir,
2007). 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 mem-
ber), 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.,
2020). 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.
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., 2013; Gulpers
et al., 2012,2013) and builds on the knowledge that
education alone is not effective (Huizing et al.,
2006,2009).
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., 2017; Chenoweth et al., 2019,2023), though
staff need to be supported at the organizational level,
so their responses are not impeded by structural or
procedural constraints within the facility (Cheno-
weth et al., 2019; Rapaport et al., 2018).
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 chal-
lenges 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., 2019).
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 engage-
ment 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 nonpharma-
cological interventions are primarily aimed at
symptom management (Moniz-Cook et al., 2011;
McDermott et al., 2019).
Person-centered care is deemed the gold stan-
dard for older adults across various care settings, as
it focuses on a more humanistic approach as
opposed to a traditional biomedical one. Minimiz-
ing, discontinuing, or ceasing the use of physical
restraints helps promote a more person-centered
6 Commentary
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and compassionate approach to caring for older
adults, such as nursing home residents living with
dementia (Jacobsen et al., 2017). The provision of
person-centered care protects the safety of the
individual and others while respecting and enhanc-
ing the values of autonomy, dignity, and well-being
(Kitwood and Bredin, 1992). High-quality care
should be centered around personhood, which
entails recognition, respect, and trust (Fazio et al.,
2018). In contrast, using physical restraints contra-
dicts personhood principles of care as it abolishes or
threatens these values (Scheepmans et al., 2020).
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., 2018; Whitlatch
and Orsulic-Jeras, 2018).
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 implemen-
tation 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 govern-
ment 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., 2020).
In the Netherlands, the national law is focused on
preventing the use of involuntary treatment, includ-
ing 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
Table 1. Examples of care optimization strategies and principles applied to reduce the use of physical restraint in
older adults
EXAMPLE STRATEGY CARE OR ETHICS PRINCIPLES APPLIED
............................................ ................................................... ................................................ ................................................... .................................................. ................................................... ............................
Care should be focused on upholding the persons’healthcare rights
while respecting age, culture, language, and spiritual differences and
allowing for differences in health literacy.
Autonomy and respect
Embracing positive, respectful, and collaborative relationships with
individuals, their caregivers, and families, using care approaches that
emphasize person-centered care principles and practices and respect
human dignity.
Person-centered and relationship-based care
and respect
Healthcare professionals have a greater understanding of the perspec-
tives, experiences, and preferences of individuals who experience
neuropsychiatric symptoms.
Knowledge, awareness, education, and train-
ing of healthcare team (e.g. registered nurses
in long-term care facilities)
Formulating individualized behavior support plans for people with a
greater risk of developing agitated or aggressive behavior, particularly
if they have a history of being physically restrained.
Personhood and person-centered care
Assessment and treatment of the person’s physical and mental health
condition(s) and associated symptoms using evidence-based guide-
lines.
Holistic assessment and comprehensive man-
agement of all medical conditions
Conducting a rigorous behavioral assessment that identifies environ-
mental triggers or contributing factors, level of distress and risk of
neuropsychiatric symptoms, such as increased agitation and/or
aggression using validated screening and assessment tools, such as
the Neuropsychiatric Inventory (NPI), Cohen-Mansfield Agitation
Inventory (CMAI), and 4AT delirium screening.
Holistic assessment and understanding of the
underlying cause(s) of behaviors (e.g.
delirium-induced agitation)
Commentary 7
https://doi.org/10.1017/S1041610223000728 Published online by Cambridge University Press
harmful and greatly restrict the freedom of the
person receiving them. Only if there are no other
alternatives possible, involuntary treatment may be
applied.
Conclusions
Physical restraint use remains high in geriatric care
settings. The IPA and its ECN believe that the use of
physical restraints is not aligned with human rights
and encourages taking every step possible to avoid
physical restraint use. When considered absolutely
necessary, the clinician should document the
rationale in the medical record and justify why
physical restraint is considered the only option.
Documentation should indicate the frequency of
periodic reviews to evaluate for adverse effects and
the opportunity to discontinue. Physical restraints
have significant safety concerns that affect older
adults' physical, psychological, social, and func-
tional well-being and lack effectiveness in geriatric
settings. Embracing positive and collaborative
relationships with individuals, person-centered
care principles, staff education and training, and
organizational-level policy change can help avoid its
use. Policy on preventing physical restraints in LTC
for older persons should be implemented on the
national/regional/local levels. Further research is
needed to inform the use of alternative interventions
to prevent or minimize physical restraint use in older
adults and clarify ethical issues concerning physical
restraint policies.
Conflict of interest
The authors have no conflicts of interest to declare.
Description of authors’roles
All authors contributed to the conceptualization,
literature review, and writing and approval of the
manuscript.
Acknowledgments
The authors thank the IPA Board for reviewing and
approving the manuscript.
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A
PRACTICAL GUIDE FOR CLINICIANS WHEN DEALING WITH PHY SICAL RESTRAINT IN OLDER ADULTS
............................................ ................................................... ................................................ ................................................... .................................................. ................................................... ............................
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