Professor Joseph Ibrahim is Head, Health Law and Ageing Research Unit at Monash University’s Department of Forensic Medicine and the Clinical Director of Geriatric, Rehabilitation and Palliative Care Medicine, at a large regional health service in Australia. Joseph has a keen interest in promoting better care for older people and edits the Communiqués printed educational material designed for health professionals to learn from cases investigated by the Coroners Court. Learn more about Joseph on his personal website.
Joseph and the team recently completed a landmark Australian study published in Age and Ageing, examining deaths due to physical restraint of people living in nursing homes. The study found that five deaths were recorded in nursing home residents due to physical restraint over the 13-year period. The median age of the residents who died was 83 years; all residents had impaired mobility and had restraints applied for falls prevention; four had diagnosed dementia. The mechanism of harm and cause of death were ascertained by a forensic pathologist following autopsy and in all cases, were formulated as ‘neck compression and entrapment by the restraints’. Neck compression, from slipping down in their chair resulting in the lap restraint applying direct pressure on the neck, occurred in two residents. Entrapment occurred in three residents where the person fell out of bed, became entrapped in the cotside webbing or between the bed rails, resulting in mechanical asphyxia.
The frequency of deaths from restraints is rarely collated, and when it is, it is not often publically available, making it almost impossible for any genuine international comparisons. While the number of deaths identified in this study is small, the true figure is likely to be much greater because deaths due to restraint may not be reported.
Any physical restraint use in nursing homes is of concern because of the potential for physical harm, including death, psychological harm and infringement of human rights. The perception that restraining residents prevents falls is misplaced as despite the use of restraint, residents still fall from chairs or beds with potentially serious ramifications, including death.
Physical restraint use varies greatly within different countries with the proportion of care home residents who are restrained estimated in Australia (12-49%), Canada (31%) and up to 37% in the United States. Residents with dementia are three times more likely to be physically restrained. As the number of people with dementia is estimated to be 225 million globally by 2050, with over half residing in nursing homes, the use of physical restraints and the related harm is likely to increase unless action is taken.
Over the last decade, a ‘restraint free’ model of care in nursing homes has been promoted, however physical restraint remains overused. Behavioural symptoms exhibited by persons with dementia must cue staff to consider unmet needs of the resident and not simply trigger restraint. Aged care facilities must focus on creating a dementia-enabling environment and utilising alternatives to restraint.
Read his Age and Ageing Paper: Physical restraint deaths in a 13-year national cohort of nursing home residents