Dementia patients do better without restraints

They are less confused, more mobile and independent: Study

Elderly patients with dementia in hospitals have been found to have better health outcomes if they are not tied down with physical restraints, and if their autonomy is respected.

The local study has also found that such a restraint-free system is cost-effective and can be implemented on a wider scale.

Done by researchers from Khoo Teck Puat Hospital (KTPH), the study showed that patients under this form of care had 32 per cent more improvement in well-being and 15 per cent improvement in mobility and function than patients under conventional care.

They also displayed a reduction of 45 per cent in challenging behaviour, despite less use of psychotropic medication, and, most significantly, there was no increase in their rate of falls.

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This is the first such study here to examine the efficacy and cost-effectiveness of person-centred care in patients with dementia, including forgoing the use of physical restraints, in an acute care setting.

Its findings have since been submitted to an international medical research journal.

"Persons with dementia are often subjected to enforced dependency and experience functional decline and emotional distress during the hospital stay," said Associate Professor Philip Yap, director of the geriatric centre at KTPH, who oversaw the study. "We wanted to find out if adopting person-centred care and a restraint-free practice would improve patient outcomes, and the results show it did."


Senior Staff Nurse Ng Xin Yi checking on a patient at Khoo Teck Puat Hospital. Instead of using restraints, nurses at the dementia unit employ a person-centred approach, such as getting to know the patients better and building trust between them. PHOTO: DIOS VINCOY JR FOR THE SUNDAY TIMES

To answer critics who bemoan that such care would inevitably require more manpower and would not be cost-effective, the study also calculated how much more it would cost for each patient per day to be under such care compared with the usual care arrangements.

It found that it costs $100 more for each patient per day, but given the gains in quality of life, it is deemed to fall within the threshold for cost-effectiveness overall, according to the World Health Organisation's (WHO) definition.

WHO defines cost-effectiveness as a specific ratio of the added cost per unit of quality of life gained compared with the country's gross domestic product per capita.

Data for the study was collected from 170 patients in KTPH's Care for the Acute Mentally Infirm Elder (Camie) unit over six months in 2014, and their data was compared with 60 patients in the usual care wards in the same hospital.

The Camie, or dementia, unit has been operating without physical restraints for more than four years.

A geriatric ward in Tan Tock Seng Hospital is the only other place in Singapore to have a physical restraint-free practice.

The use of restraints is not uncommon in hospitals and nursing homes here, though some are moving towards minimising its use.

Restraints are usually used in the case of patients who cannot cooperate with treatment, such as during the administration of intravenous fluids and antibiotics, or when using urinary catheters and feeding tubes.

As these interventions are invasive and intrusive, patients who are confused, commonly from delirium or dementia, attempt to remove them. To prevent them, physical restraints, such as body vests and limb restrainers, are used.

Patients with unsteady gait and a high risk of falls are also restrained so that they do not attempt to walk or move about on their own.

  • 32%

    Increase in the improvement of well-being of patients who were not tied down with physical restraints.

    15%

    Improvement in the mobility and function of such patients.

    45%

    Decrease in patients' challenging behaviour, despite less use of psychotropic medication.

To some medical professionals, the use of such restraints can be an effective and convenient way to prevent falls or necessary tubes from being pulled out.

"But restraints can worsen confusion, agitation and precipitate aggression. They thwart patient autonomy and can break the spirit. Excess dependency is created and the overall physical and psychological well-being of the patient suffers," said Prof Yap, adding that frail older patients who already suffer from gait instability will lose their ability to ambulate with limited opportunities to walk.

Instead of using restraints, nurses in the Camie unit find other ways to monitor the patients and get them to cooperate.

One key way is by enabling them to trust the nurses, so that they do not have to be forced to do things or attempt to leave the hospital.

Nurses there make it a point to get to know the patient's life history, preferences and habits, so that they are able to better connect with them and replicate routines that patients are familiar with. There is a board above each bed in the ward that lists information such as the patient's occupation and interests for nurses to refer to.

The hospital also uses technology such as pressure-sensor mats around the beds to alert staff if the patient has attempted to get out of bed, thereby allowing them to attend to him promptly to avert falls.

Instead of inserting feeding tubes into patients, who may feel compelled to pull them out, the hospital gets family members and volunteers to help feed them slowly.

Said Ms Phyu Phyu Aye, staff nurse at the Camie unit: "At first, it was more difficult to do our jobs without the restraints because some patients can get violent. But slowly we began to see the beauty of not using them. Patients get out of delirium more quickly, are less confused and it is better in the long term not to have frustrated patients."

Prof Yap hopes that more hospitals, daycare centres and nursing homes can adopt such practices.

He said: "Older persons have so much residual abilities and we need to enable them rather than create an environment that fosters dependency."

A version of this article appeared in the print edition of The Sunday Times on August 13, 2017, with the headline 'Dementia patients do better without restraints'. Print Edition | Subscribe