To the Editor:

I am disappointed to see the author of “Nursing Home Violence: Occurrence, Risks, and Interventions”1 stating, “Traditionally, NHs [nursing homes] have relied on physical restraints,” then later continue with, “Generally the hierarchy of restraints goes from a Posey vest or reclining chair with or without lockable tray to a two-point restraint….” I don't know how long ago this author stepped foot in a NH in Wisconsin, but this is NOT true in Wisconsin—and especially not true in the facility where I am the Director of Nursing. Hospitals still have the liberty to utilize all these venues regardless of the potential for injury to the patient. NHs in Wisconsin do not allow Posey restraints or wrist restraints, and a geri-chair with a tray table or reclining chair would be far, far down the list. There are multiple, far less restrictive alternatives that are not restraints, which the author should list in all fairness (nonslip material in chair seats, chair- or bed-pad alarms, pummel cushions, lap buddies, self-release seat belts). NHs are once again being portrayed as “lock ‘em up, tie ‘em down, keep ‘em safe” places, which is old, old thinking from the 1970's. The new mantra we are beset with from the state operations codes and guidelines could almost be, “set ‘em free, let ‘em fall.” We who work in NHs are between a rock and a hard place, as we cannot use many alternatives (which I agree is in the correct spirit of compassionate care), and yet on the other hand, our state/national survey system penalizes us if a resident has an injury or, heavens be, a FALL! Please be fair in these articles!

Melody Ziemke-Matchett, RN/BSN, MSEd
Director of Nursing
Pleasant View Nursing Home
Green County, WI

Reference

1. Hall RCW, Hall RCW, Chapman MJ. Nursing home violence: Occurrence, risks, and interventions. Annals of Long-Term Care: Clinical Care and Aging 2009;17(1):25-31.

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To the Editor:

The review of NH violence1 does not differentiate between residents who are institutionalized for mental diseases and residents who have dementia. While mentally ill residents may initiate aggressive behavior, most residents with dementia are not aggressive when left alone. Actually, calling them “aggressive” perpetuates the misperception that when an assault of the nursing staff by a resident with dementia happens, the resident is at fault. Most of these situations happen during hands-on care when the resident does not understand why the care has to be provided and resists a caregiver’s advances. If the caregiver insists on providing care, the resident perceives the caregiver to be an aggressor, defends himself/herself, and may strike out. Incidence of “aggressive” behavior increases with decreased ability to understand because resistiveness to care is more common in residents who cannot understand staff communication.2

However, not all residents who are abusive to staff are resistive to care. Another significant factor related to aggressive behavior is depression.3 After adjustment for depression, gender, and impairment in activities of daily living, there was no association between physically aggressive behavior and the presence of either delusions or hallucinations. This study suggests that antidepressants, not antipsychotics, should be the first-line medication used in a resident who is physically aggressive and depressed.3 This suggestion is supported by results of the Depression in Alzheimer Disease Study, which found that treatment with sertraline decreased behavioral disturbance and caregiver distress in full responders.4

Negative results of some studies investigating the effects of serotonin reuptake inhibitors on aggressive behavior can be caused by two factors: first, the doses of antidepressants used in these studies might not have resulted in significant improvement of depression, and as the above study shows, improved behavior can be expected only in full responders4; and second is the inclusion of residents who are not depressed and who are just resistive to care. These residents require behavioral strategies to prevent escalation of resistive behavior into combative behavior that can be perceived as aggression. This escalation may be prevented by delaying the intervention, distraction of the resident, or by changing caregiving strategies.5

Authors of the review provide evidence that neuroleptic use and restraints were found to be related to increased aggressive behavior but still recommend their use in the review’s summary. The evidence provided above indicates that antidepressant treatment should be initiated in residents with dementia who do not respond to behavioral modifications. Diagnosis of depression in individuals with dementia is sometimes difficult, and there is evidence that up to 40% of medically ill older adult NH residents have underdiagnosed depression.6 Neuroleptics and restraints should be used only as a last resort in those residents who did not respond to maximal doses of antidepressants or who suffer from bothersome delusions or hallucinations. Although antidepressants may cause adverse reactions,7 they are less severe than adverse effects of neuroleptics, which may cause cerebrovascular incidents and increase mortality rate.8

Ladislav Volicer, MD, PhD, FAAN, FGSA
Courtesy Full Professor
School of Aging Studies
University of South Florida
Tampa, FL

References

1. Hall RCW, Hall RCW, Chapman MJ. Nursing home violence: occurrence, risks, and interventions. Annals of Long-Term Care: Clinical Care and Aging 2009;17(1):25-31.

2. Volicer L, Bass EA, Luther SL. Agitation and resistiveness to care are two separate behavioral syndromes of dementia. J Am Med Dir Assoc 2007;8:527-532.

3. Lyketsos CG, Steele C, Galik E, et al. Physical aggression in dementia patients and its relationship to depression. Am J Psychiatry 1999;156:66-71.

4. Lyketsos CG, DelCampo L, Steinberg M, et al. Treating depression in Alzheimer disease: Efficacy and safety of sertraline therapy, and the benefits of depression reduction: The DIADS. Arch Gen Psychiatry 2003;60:737-746.

5. Sloane PD, Honn VJ, Dwyer SAR, et al. Bathing the Alzheimer's patient in long term care. Results and recommendations from three studies. Am J Alzheimer Dis 1995;10:3-11.

6. Depression Guideline Panel. Depression in Primary Care: Treatment of Major Depression. Rockville, MD: Agency for Health Care Policy and Research; 1993.

7. Thakur M, Blazer DG. Depression in long-term care. J Am Med Dir Assoc 2008;9:82-87.

8. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934-1943.

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Response from Drs. Hall and Ms. Chapman:

We understand Ms. Ziemke-Matchett’s frustration and share many of her feelings. NH staffs are often placed in the double-bind of having to try to protect the rights of the individual as well as the safety of the individual and others. Although we are not directly familiar with the laws of Wisconsin when it comes to use of restraints in NHs, we are not surprised to learn that the state of Wisconsin (with its strongly progressive history towards rights of the individual superseding treatment needs, as evident from the district court case of Lessard v Schmidt1) would have restrictive policies in regard to the use of restraints. However, it needs to be remembered that all 50 states have their own laws in regard to how restraints are used. For example, in the state of Florida, where the authors practice, Florida Statute § 400.022, Residents' rights (Nursing Homes and Related Health Care Facilities) reads:

The right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints authorized in writing by a physician for a specified and limited period of time or as are necessitated by an emergency. In case of an emergency, restraint may be applied only by a qualified licensed nurse who shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety.2

The use of the word traditionally was intentionally used in our article, as it was likely used in the referenced Burgio et al3 article, to indicate that in the past, NHs had relied on the use of restraints to protect and/or control agitated and violent residents as well as to protect residents with gait instability from falling. Other recent publications, also referenced in our article, refer to the use of restraints and pharmacological interventions in NH patients and individuals with dementia.4,5 Although the use of restraints in NHs has diminished from the “old, old thinking from the 1970’s,” it is still a practice that does occur. Our article discussed: (1) using restraints sparingly; (2) the adverse reactions/injury that could occur from using restraints; and, most important, (3) that restraints should be used as a last resort after all appropriate behavioral and/or environmental changes had already been tried and found to be ineffective. In addition, our article clearly indicated that there has been a national movement to diminish the use of restraints in the NH, as indicated by the reference to the Omnibus Budget Reconciliation Act, which specifically addresses the issue of diminishing the reliance on restraints, as well as initiatives from NH organizations.

As for other actions that can be utilized aside from restraints, our article did address the importance of staff training, staff education, environmental interventions, and family involvement as ways to prevent NH violence. Although the use of bed alarms can be beneficial for certain patients, the authors have not found them to be particularly useful in stopping NH violence. From personal experience, bed alarms work best in patients who are fall risks and who are prone to occasionally wandering unassisted. Non-slip coverings can be placed in chairs to prevent falls, but the coverings do not appear to do much to prevent a violent individual from attacking or striking another individual.6

Although the state of Wisconsin might not consider strapping a patient down to a chair with the use of a seat belt a form of restraint, many other states do. In the state of Florida, a restraint is defined as “restricting the movement of a person’s limbs, head or body by the use of mechanical or physical devices for the purpose of preventing injury to self or others.”7 In our article, we did not intend to describe a full list of potential ways to restrain an individual. The two examples given (ie, use of a Posey vest and a geri-chair) are less restrictive than the use of wrist restraints, and they were mentioned to indicate that there is a hierarchy. We could also have mentioned the use of a lap belt or a seat belt, but again our intention was to indicate that restraints were an option, but not to focus on every type of available restraint, as these are often regulated differently in different jurisdictions.

Finally, the letter writer appears to be addressing the prevention of falls in patients with gait instability. Our article described NH residents who are violent, which is a very different patient population. For example, the authors were recently involved as expert witnesses in a legal case where a 70-year-old NH resident with paranoia secondary to dementia stalked and killed another resident, even after staff had tried to redirect the individual on multiple occasions. Although long-term use of restraints would not have been feasible, their short-term use until the resident was able to be seen and evaluated by medical professionals would have been an appropriate interaction and prevented a homicide. This is an example of a specific situation where restraints could have been used to keep the staff, the resident, and other residents safe.

In response to Dr. Volicer, our article was written considering the entire population of NH residents, including those with illness (mental or physical) and those without (individuals with lifelong personality traits or with lifelong violent tendencies). When the literature was reviewed, the factor found to be most prevalent for individuals who were reported to be violent was that they had a primary diagnosis of dementia, usually of the Alzheimer’s type.8-13 In a study by Colenda and Hamer11 of residents with mental illness who were followed after a hospitalization, a finding of “a persistently higher prevalence of aggression and a higher rate of physical aggression [was seen] among dementia patients than among other patients.” This does not imply that all residents with dementia will be violent, but of the residents who are violent, many of them will suffer from some form of dementia. In a study by Brodaty et al13 looking at NH residents with behavioral and psychological symptoms of dementia (BPSD), it was noted that 60% had evidence of psychosis, 42% had symptoms of depression, and 82% had frequent episodes of agitation. So, although depression is common in patients with aggression, psychotic symptoms generally occur more often.

We agree with Dr. Volicer that the identification and treatment of depression is important, and is often overlooked in the elderly in general and in individuals with dementia in particular.14 Our article addressed the issue and made reference to the same articles by Lyketsos et al15,16 that were cited in the letter. Treatment of depression in individuals with dementia and depression may reduce irritability, improve cognition, and reduce fear and anxiety, thus reducing the potential for violence. However, the evidence for the use of SSRIs for the treatment of aggression in the elderly is conflicted in the literature. For example, the findings from the meta-analysis by Sink et al17 published in Journal of the American Medical Association (JAMA) found “five trials of antidepressants [meet criteria for inclusion and] showed no efficacy for treating neuropsychiatric symptoms [(eg, aggression)] other than depression, with the exception of one study of citalopram.” Similar results and conclusions have been found in other studies, meta-analyses, and treatment guidelines since the JAMA meta-analysis was published.18-21 The recent work of Dorey et al21 notes that “the management of BPSD is complex and often needs recourse to psychotropic drugs. Though widely prescribed, there is a lack of consensus concerning their use, and serious side effects are frequent. This is particularly the case with antidepressant treatment based on the assumption that BPSD is depressive in nature.”21

As for restraints and the use of neuroleptics, we emphasized that these interventions should not be used casually or as a first-line intervention.22 Although we mentioned a study by Voyer et al23 that indicated the use of these techniques could lead to worsening of agitation, we also provided additional comments and justification for why and when these interventions should be used. Multiple articles were cited in the original article that showed that neuroleptics were efficacious, especially in the population with severe dementia. In addition, potential methodological issues related to the use of restraints and neuroleptics such as sample error (eg, an already acutely agitated population being studied) were discussed.

It needs to be remembered that restraints are used not just to protect the agitated resident, but to protect all individuals in the NH. So even if there is the potential for an initial increase in the level of agitation for the resident, the potential safety benefit to other residents and staff may outweigh the risk.

Respectfully,

Ryan C. W. Hall, MD
Richard C. W. Hall, MD
Marcia J. Chapman