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Avoiding Drugs Used as Chemical Restraints: Changing the Culture of Care

A Consumer Education Campaign

Used appropriately, medications can cure disease, ease pain and enhance quality of life.  Inappropriate use of drugs, however, can cause disability, pain, and decrease quality of life. Antipsychotic drugs are of special concern.  Used appropriately, these drugs can greatly improve the well-being of people with diagnoses such as Schizophrenia.  They pose special risks, however, for older people and increase the risk for harm in persons with dementia.  When antipsychotic drugs are used to stop a person from acting in a way that is challenging or disturbing to caregivers or others, they are called chemical restraints.

Antipsychotic drugs are not treatments for dementia or Alzheimer’s disease. They are appropriate for specific mental disorders.

The October 2019 issue of The Resident Advocate, a newsletter for residents of long-term care facilities, provides information about knowing your medications.

What are Chemical Restraints?

What are Chemical Restraints?

Antipsychotic drugs used to treat behavioral symptoms in place of good care are called chemical restraints. They pose special risks for older people and can have serious and life-threatening side effects.  Use of antipsychotic drugs increase a person’s chance of:

  • Falling
  • Developing pressure sores
  • Becoming incontinent
  • Having infections

Other side effects you might notice include:

  • Thinks, talks and moves slowly
  • Has less ability to care for him/herself
  • Sleeps through meals
  • Has a dry mouth
  • Licks lips repeatedly
  • Appears more confused
  • Inability to sit or stand straight

Many of these symptoms can be caused by other illnesses as well, thus it is important to monitor an individual’s condition carefully and ask for an assessment when you have concerns.

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 How are These Drugs Being Used?

How are These Drugs Being Used?

People express feelings of displeasure or distress through words and actions. Those who are unable to use words, due to a medical condition such as dementia, express themselves through actions.  Sometimes those actions are expressing distress.  Examples include:

  • Anger
  • Agitation
  • Screaming
  • Swearing
  • Spitting
  • Hitting
  • Continuous wandering
  • Pacing
  • Disrobing
  • Crying, sadness
  • Repetitive actions
  • Paranoia
  • Delusions
  • Fear

These actions, or behaviors, are signals telling us that something is wrong.  Caregivers should work to identify the problem being expressed, rather than turning to a drug to change the action. Unfortunately, we sometimes hear references to “problem behaviors” or “problem individuals.”   By labeling the individuals or actions as “problems,” caregivers and families may miss the signs of distress, or fail to address the underlying problem, which could be pain, fear, anger, boredom, hunger, or something else.

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What Should Happen Now? Assess and Plan for Individualized Care

What Should Happen Now? Assess and Plan for Individualized Care

Instead of turning to drugs, caregivers should first work to identify and treat the underlying problem the individual is trying to communicate, by assessing (or evaluating) both the individual and the environment.  The assessment is used to understand and plan care that supports each resident to prevent behavioral symptoms from occurring.  It is also used to plan care when behavioral symptoms do occur.

The assessment gathers information about the individual’s physical, mental, emotional, and social well-being. It can also help caregivers identify signs of distress, agitation, or confusion can be caused by untreated infections, dehydration, pain, medication reactions, boredom, loneliness, or other reasons. Ask the doctor or nurse to evaluate possible medical causes of any concerns.

A person’s environment can be a major factor in his or her well-being.  Noise, lighting, smells, comfort, food, and interactions with others, are all examples of environmental factors that can support an individual or contribute to their distress.

After an assessment, the caregivers and the individual should work together to develop a plan of care that is designed to meet the needs of the individual.

Additional Resources:

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What Can I Do If I Have Concerns?

What Can I Do If I Have Concerns?

  • Ask for care plan conference and ask why each drug was ordered, the potential side effects of each drug, and possible drug interactions.
  • Question what other approaches to care have been tried, when they were attempted, what results or response from the individual.
  • Keep the focus on the residents’ needs.
  • Monitor the care plan – if it’s not being following, or the plan is not working, speak up. 
  • Know your rights under the law.
  • Work closely with caregivers to help them get to know the individual.
  • If drugs are being considered for behavioral symptoms, ask that other approaches be tried first.
  • Speak with the doctor about medication concerns.  Ask about the risks and side effects of any drugs.
  • Contact your long-term care ombudsman – find them at www.theconsumervoice.org/get_help.

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What Are My Rights?

What Are My Rights?

For residents of nursing homes, the federal Nursing Home Reform Act of 1987 specifically protects residents from the use of chemical and physical restraints, except when needed to treat a medical condition.

The law also requires that nursing homes provide:

  • Quality of Care for residents enabling them to attain and maintain their highest functional level;
  • Quality of Life deriving from supportive caregiving in a homey environment;
  • Resident dignity;
  • Freedom of Choice in care and treatment decisions – to know the purpose of the treatment, alternative treatments, and whether the likely benefits outweigh the risks before saying “yes” or “no” to the treatment;
  • Individualized, person-centered care based on a thorough evaluation by an interdisciplinary team that includes both the individual’s physician and a nurse;
  • Involvement of each individual receiving care and his/her family (if s/he wishes) in planning care.
  • Prompt response to complaints.

Read more about what the federal rules say about Unnecessary and Antipsychotic Drugs.

For other care settings – assisted living, board and care, personal care homes – state laws and rules must be followed.  Contact your long-term care ombudsman (www.theconsumervoice/get_help) for more information.

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Where Can I Go for Help?

Help is available if you have concerns about the drugs prescribed or issues with care. 

  • Work with the facility or care provider to solve the problem.  Share your concerns, ask for solutions.
  • Many facilities have family councils.  Discuss the problems you are having and get a sense of whether other families are also concerned.  Sometimes it’s easier to work together for change.
  • Contact the Long-Term Care Ombudsman Program which advocates for individuals living in long-term care facilities.  Learn more about the Long-Term Care Ombudsman Program.
  • Contact the State’s Survey Agency which assesses whether a facility meets standards of care.

Find your Long-Term Care Ombudsman Program or State Survey Agency at www.theconsumervoice.org/get_help.

 

Learn more about the Misuse of Antipsychotic Drug Use on our issue page.