RESTRICTIVE PRACTICES IN OLDER ADULT CARE.

JAMES RIDLEYSENIOR LECTURER (LEARNING DISABILITIES)

EDGE HILL UNIVERSITY

edgehill.ac.uk

AIMS

1. IDENTIFY SERVICE MODELS WHERE ‘RESTRICTIVE PRACTICE’ IS

MORE WIDELY USED IN THE SUPPORT OF OLDER ADULTS.

2. HIGHLIGHT HOW RESTRICTIVE PRACTICES MAY BE DEVELOPED

IN RELATION TO VULNERABLE OLDER ADULT GROUPS.

3. HIGHLIGHT THE LEGAL AND ETHICAL FRAMEWORKS WHICH

CAN SUPPORT PRACTITIONERS WHEN SUPPORTING OLDER

PEOPLE.

4. REVIEW EVIDENCE AND ASSESSMENTS WHICH CAN BE USED

TO SUPPORT THE REDUCTION OF RESTRICTIVE PRACTICE.

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“PREDICTABLE ENVIRONMENTS”

• ACUTE PSYCHIATRIC SETTINGS (INCLUDING

FORENSIC SETTINGS)

• SERVICES FOR PEOPLE WITH LEARNING

DISABILITIES AND CHALLENGING BEHAVIOUR

• OLDER ADULT SERVICES WHERE INDIVIDUALS MAY

BECOME AGITATED OR CONFUSED.

• (DOH 2014)

REACTIVE MANAGEMENT

• CLINICIANS ARE COMMONLY ASKED TO INTERVENE IN SITUATIONS OF

ACUTE DISTURBANCE IN CARE PLACEMENTS.

• INTENSIVE AND HIGH-QUALITY SUPPORTIVE OR BEHAVIOURAL

INTERVENTIONS MAY NOT BE AVAILABLE.

• DEMAND IS USUALLY FOR IMMEDIATE ACTION TO MANAGE

BEHAVIOUR IN ORDER TO AVOID PLACEMENT BREAKDOWN.

• (GLOVER ET AL, 2014)

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RESTRAINT!

•“THE INTENTIONALRESTRICTION OF A PERSON’S VOLUNTARY MOVEMENT OR

BEHAVIOUR”• COUNSEL AND CARE (2002).

“RESTRAINT is a RESTRICTIVE PRACTICE”

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RESTRICTIVE PRACTICE

• “RESTRICTIVE INTERVENTIONS CAN DELAY

RECOVERY, AND CAUSE BOTH PHYSICAL

AND PSYCHOLOGICAL TRAUMA TO PEOPLE

WHO USE SERVICES AND STAFF.”

• (DEPARTMENT OF HEALTH, 2014)

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FORMS OF RESTRICTIVE PRACTICE

•CHEMICAL

•MECHANICAL

•PHYSICAL

•PSYCHOLOGICAL• (RCN, 2008)

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RISK GROUPS

• PEOPLE WHO ARE DIFFICULT OR THREATENING.

• PEOPLE WHO ARE NON-CONFORMING,

THEREFORE CAUSING A MANAGEMENT

PROBLEM

• PEOPLE WHO ARE LESS PHYSICALLY OR

MENTALLY ABLE

CSCI (2007)

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WHAT IS “DEMENTIA”.

• DEMENTIA DESCRIBES A SET OF SYMPTOMS THAT MAY INCLUDE; MEMORY LOSS, DIFFICULTIES WITH

THINKING, PROBLEM-SOLVING OR LANGUAGE. A PERSON WITH DEMENTIA MAY ALSO EXPERIENCE

CHANGES IN THEIR MOOD OR BEHAVIOR.

• DEMENTIA IS CAUSED WHEN THE BRAIN IS DAMAGED BY DISEASES, SUCH AS ALZHEIMER’S DISEASE

OR A SERIES OF STROKES.

• ALZHEIMER’S DISEASE IS THE MOST COMMON CAUSE OF DEMENTIA BUT NOT ALL DEMENTIA IS DUE

TO ALZHEIMER’S.

• THE SPECIFIC SYMPTOMS THAT SOMEONE WITH DEMENTIA EXPERIENCES WILL DEPEND ON THE

PARTS OF THE BRAIN THAT ARE DAMAGED AND THE DISEASE THAT IS CAUSING THE DEMENTIA.

• ALZHEIMER’S SOCIETY (2014)

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PREVALENCE COMPARISON.

Comparative Rates of Dementia -Down’s syndrome, Learning disabilities, General Population

Cooper, personal

communication

DSLD

GP

British Psychological Society, Royal College of Psychiatrists, 2009

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ASSESSMENT DIFFICULTIES

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DIFFICULTIES IN THE ASSESSMENT OF DEMENTIA FOR PEOPLE WITH LEARNING

DISABILITIES;

• ALREADY HAVE UNDERLYING COGNITIVE DEFICITS AND IMPAIRED LIVING SKILLS.

• PRONE TO HEALTH PROBLEMS – MIMIC SYMPTOMS.

• LACK OF COMMUNICATION SKILLS TO REPORT ON SYMPTOMS EXPERIENCED.

• CARERS CHANGE FREQUENTLY – LACK OF DETAILED KNOWLEDGE OF CHANGES

IN FUNCTIONING

• GENERIC ASSESSMENTS CANNOT BE USED DUE TO THEIR LEARNING DISABILITY.

• THEREFORE IT IS VERY DIFFICULT TO IDENTIFY ANY COGNITIVE CHANGES DUE TO

DEMENTIA, FROM A ONE OFF ASSESSMENT E.G. “MINI MENTAL STATE”.

• (JANICKI, DALTON, (1999)

“DIAGNOSTIC OVERSHADOWING”

• BOTH PEOPLE WITH LEARNING DISABILITIES AND PEOPLE WITH

MENTAL HEALTH PROBLEMS EXPERIENCE “DIAGNOSTIC

OVERSHADOWING”.

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WHAT ARE THE BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS

OF DEMENTIA (BPSD).

• BPSD INCLUDES;

• AGITATION, ANXIETY, IRRITABILITY AND MOTOR RESTLESSNESS,

OFTEN LEADING TO BEHAVIOURS SUCH AS WANDERING, PACING,

AGGRESSION, SHOUTING AND NIGHT-TIME DISTURBANCES,

PSYCHOSIS, AND, MOOD DISORDERS.

• OTHER SYMPTOMS INCLUDE SEXUAL DISINHIBITION, EATING

PROBLEMS AND ABNORMAL VOCALIZATIONS (SHOUTING,

SCREAMING AND DEMANDING ATTENTION, ETC).

• BALLARD, O’BRIEN, JAMES, SWANN, (2003),

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MANAGEMENT OF BPSD.

“Restraint amongst the

institutionalised elderly with

dementia and problem behaviour is

inevitable”Testad, Aasland, Aarsland (2005)

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HOW TIMES CHANGE!!!!!!

• CHALLENGING

BEHAVIOUR IS AN

INEVITABLE ASPECT

OF DEMENTIA,

• (STOKES AND GOULDIE, 1990)

• CHALLENGING BEHAVIOUR IS NOT AN INEVITABLE CONSEQUENCE OF THE CONDITION.

• KERR (2007)

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MENTAL CAPACITY ACT, 2005

SECTION 6:

•RESTRAINT IS ONLY PERMITTED

TO;

•PREVENT HARM,

•MUST BE PROPORTIONATE.

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HUMAN RIGHTS BASED APPROACH.

“A HUMAN RIGHTS BASED

APPROACH OFFERS ONE METHOD

FOR FACILITATING POSITIVE RISK

MANAGEMENT”.• WHITEHEAD, GREENHILL, CARNEY, (2009)

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FREDA PRINCIPLES

•FAIRNESS

•RESPECT

•EQUALITY

•DIGNITY

•AUTONOMY

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HUMAN RIGHTS RISK SCREEN.

• “USED AS A PROMPT TO

QUESTION WHETHER

APPROPRIATE

INTERVENTIONS ARE IN

PLACE.”

• GREENHILL, WHITEHEAD, CARNEY, (2009)

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REDUCING RESTRICTIVE PRACTICES.

• HEALTH NEEDS ASSESSMENT

• HEALTH ACTION PLANS

• “LIFE STORIES”

• “PERSON CENTRED PLANS”

• BEHAVIOURAL ASSESSMENTS

RIDLEY AND JONES (2012

• PAIN MANAGEMENT.

• ENVIRONMENTAL ASSESSMENT.

• MEDICATION REVIEWS

• CAPACITY ASSESSMENTS

• COMMUNICATION ASSESSMENTS.

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CONCLUSION.

• “IF ALL YOU HAVE IN

YOUR TOOL BOX IS

A HAMMER, ALL THE

WORLD LOOKS LIKE

A NAIL.”

• ABRAHAM MASLOW

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CONTACT DETAILS

• JAMES RIDLEY (SENIOR LECTURER (PRE-REGISTRATION NURSING))

• EDGE HILL UNIVERSITY

• ST HELENS ROAD

• ORMSKIRK

• LANCASHIRE

• L39 4QP

• TEL; 01695 657010

• E-MAIL; RIDLEYJ@EDGEHILL.AC.UK

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REFERENCES

• BALLARD, C, O’BRIEN, J, JAMES, I, SWANN, A, (2003), DEMENTIA; MANAGEMENT OF THE BEHAVIOURAL

AND PSYCHOLOGICAL SYMPTOMS, OXFORD UNIVERSITY PRESS, OXFORD.

• BRAUN, J, LIPSON, S, (1993), TOWARD A RESTRAINT FREE ENVIRONMENT; REDUCING THE USE OF

PHYSICAL AND CHEMICAL RESTRAINTS IN LONG TERM AND ACUTE CARE SETTINGS, HEALTH

PROFESSION PRESS, SYDNEY.

• BRITISH PSYCHOLOGICAL SOCIETY, ROYAL COLLEGE OF PSYCHIATRISTS, (2009), DEMENTIA AND PEOPLE

WITH LEARNING DISABILITIES, BPS/RCP, LONDON

• BURNARD, P, CHAPMAN, C, (2005), PROFESSIONAL AND ETHICAL ISSUES IN NURSING, BALLIERRE TINDALL,

EDINBURGH.

• BOWLES, L, (1996), HOW MUCH SHOULD PATIENTS BE TOLD ABOUT THEIR MEDICATION, BRITISH JOURNAL

OF NURSING, 5, 3, 157 – 164, CITED BY; CARESS, A, L, (2003), GIVING INFORMATION TO PATIENTS,

NURSING STANDARD, 17, 43, 47 – 54.

• CARE QUALITY COMMISSION (NEE COMMISSION FOR SOCIAL CARE INSPECTION), (2007), RIGHTS, RISKS

AND RESTRAINTS; AN EXPLORATION INTO THE USE OF RESTRAINT IN THE CARE OF OLDER PEOPLE,

CSCI, NEWCASTLE UPON TYNE.

• CARESS, A, L, (2003), GIVING INFORMATION TO PATIENTS, NURSING STANDARD, 17, 43, 47 -54.

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REFERENCES

• COUNSEL AND CARE, (2002), SHOWING RESTRAINT; CHALLENGING THE USE OF RESTRAINT IN CARE HOMES, COUNSEL AND

CARE UK, LONDON.

• DEPARTMENT OF HEALTH, (2001), VALUING PEOPLE, DOH, LONDON.

• DEPARTMENT OF HEALTH, (2014), POSITIVE AND PROACTIVE CARE: REDUCING THE NEED FOR RESTRICTIVE INTERVENTIONS,

HMSO, LONDON

• DISABILITY RIGHTS COMMISSION, (2006), EQUAL TREATMENT; CLOSING THE GAP, DISABILITY RIGHTS COMMISSION, LONDON

• HOME OFFICE (2005), MENTAL CAPACITY ACT (2005), HMSO, LONDON.

• HOUSE OF LORDS, HOUSE OF COMMONS, JOINT COMMITTEE ON HUMAN RIGHTS, (2008), A LIFE LIKE ANY OTHER? HUMAN

RIGHTS OF ADULTS WITH LEARNING DISABILITIES, SEVENTH REPORT, HMSO, LONDON.

• GASHMANS, C, MILISEN, K, (2006), USE OF PHYSICAL RESTRAINT IN NURSING HOMES; CLINICAL ETHICAL CONSIDERATIONS,

JOURNAL OF MEDICAL ETHICS, 32, 148 – 152

• GREAT BRITAIN. HUMAN RIGHTS ACT 1998: ELIZABETH LL. CHAPTER 42. (1998). LONDON: THE STATIONERY OFFICE

• JANICKI, M, DALTON, A, (1999), DEMENTIA, AGING, AND INTELLECTUAL DISABILITIES: A HANDBOOK, ROUTLEDGE, NEW

YORK.

• KERR, D, (2007), UNDERSTANDING LEARNING DISABILITY AND DEMENTIA, JESSICA KINGSLEY, LONDON.

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REFERENCES

• LEADBETTER, D, (2002), GOOD PRACTICE IN PHYSICAL INTERVENTION, IN ALLEN, D, (ED), ETHICAL APPROACHES TO PHYSICAL

INTERVENTIONS, BILD, P114-133.

• OSMAN, L, ET AL, (1994), REDUCING HOSPITAL ADMISSION THROUGH COMPUTER SUPPORTED EDUCATION FOR ASTHMA

PATIENTS, BRITISH MEDICAL JOURNAL, 308, 6928, 568-571, CITED BY; CARESS, A, L, (2003), GIVING INFORMATION TO

PATIENTS, NURSING STANDARD, 17, 43, 47-54

• RIDLEY, J, JONES, S, CLAMPING DOWN ON THE SE OF RESTRICTIVE PRACTICES, LEARNING DISABILITY PRACTICE, 15, 2, 33-36

• ROLLINS, M, (2006), SAFETY ISSUES SURROUNDING THE USE OF BEDRAILS, NURSING OLDER PEOPLE, 17, 10, 20 – 21.

• ROYAL COLLEGE OF NURSING, (2008), LETS TALK ABOUT RESTRAINT: RIGHTS, RISKS, AND RESPONSIBILITIES, RCN, LONDON

• STOKES, G, GOULDIE, F, (1990), WORKING WITH DEMENTIA, WINSLOW PRESS, BICESTER.

• TESTAD, I, AASLAND, A, M, AARSLAND, D, (2005), THE EFFECT OF STAFF TRAINING ON THE USE OF RESTRAINT IN DEMENTIA: A

SINGLE-BLIND RANDOMISED CONTROLLED TRIAL, INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, 20, 587-590.

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REFERENCES

• TINETTI, M, ET AL, (1994), A MULTI-FACTORIAL INTERVENTION TO REDUCE THE LIKELIHOOD OF

FALLING AMONG ELDERLY PEOPLE LIVING IN THE COMMUNITY, NEW ENGLAND MEDICAL JOURNAL,

331, 13, 821 – 827, CITED BY; KELLY, A, DOWLING, M, (2004), REDUCING THE LIKELIHOOD OF FALLS

IN OLDER PEOPLE, NURSING STANDARD, 18, 49, 33 – 40

• WATSON, R, (2001), RESTRAINT; ITS USE AND MISUSE IN THE CARE OF OLDER PEOPLE, NURSING

OLDER PEOPLE, 13, 3, 21-25.

• WHITEHEAD, R, CARNEY, G, GREENHILL, B, (2009), ENCOURAGING POSITIVE RISK MANAGEMENT;

SUPPORTING “A LIFE LIKE ANY OTHER” USING A HUMAN RIGHTS BASED APPROACH, IN, LOGAN, C,

WHITTINGTON, R (EDS), SELF-HARM AND VIOLENCE: BEST PRACTICE IN MANAGING RISK,.

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OF THE WHO SCIENTIFIC GROUP ON SENILE DEMENTIA, WHO, GENEVA, CITED BY; BALLARD, C,

O’BRIEN, J, JAMES, I, SWANN, A, (2003), DEMENTIA; MANAGEMENT OF THE BEHAVIOURAL AND

PSYCHOLOGICAL SYMPTOMS, OXFORD UNIVERSITY PRESS, OXFORD.

Useful Reading• Abbey, J., Piller, N., Bellis de, A., Esterman, A., Parker, D., Giles, L. & Lowcay, B. (2004) The

Abbey pain scale: a 1-minute numerical indicator for people with end stage dementia.

International Journal of Palliative Nursing, 10, 6 - 14.

• Deb S., Clarke D. & Unwin G. (2006) Using medication to manage behaviour problems

among adults with a learning disability: Quick Reference Guide (QRG), University of

Birmingham, MENCAP, The Royal College of Psychiatrists.

• Department of Health (2008) End of Life Strategy; Promoting high quality care for all

adults at the end of life. TSO (The Stationery Office).

• Dodd, K., Kerr, D. & Fern, S. (2006) Down’s Syndrome and Dementia Workbook for Staff.

Down’s Syndrome Association. Down’s Syndrome Association.

• Dodd, K., Turk, V. & Christmas, M. (2002) Resource Pack for carers of adults with Down’s

Syndrome and dementia. BILD Publications.

• Evenhuis, H.M., Kengen, M.M.F., & Eurlings, H.A.L. (2007). Dementia Questionnaire for People

with Learning Disabilities (DLD). UK adaptation. Harcourt Assessment.

• Holland, A.J. (2004) Down’s Syndrome and Alzheimer’s Disease: A guide for Parents and

Carers. Down’s Syndrome Association.

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Useful reading.

• Kerr, D. (1997) Down’s Syndrome and dementia: a practitioner’s guide. Venture Press.

• Kerr, D. (2007) Understanding Learning Disability and Dementia: Developing Effective

Interventions. Jessica Kingsley Publishers.

• Kerr, D., Cunningham, C. & Wilkinson, H. (2006) Responding to the Pain Needs of People

with a Learning Disability. York Publishing Services.

• Prasher, V.P. (2005) Alzheimer’s Disease and Dementia in Down’s Syndrome and

Intellectual Disabilities. Radcliffe Publishing.

• Thomas, K. & Department of Health (2005) Gold Standards Framework. Department of

Health.

• Watchman, K. (2006) Keep Talking about dementia: Information for Siblings and

professionals about Down’s Syndrome and dementia. Scottish Down’s Syndrome

Association.

edgehill.ac.uk

• WWW.BILD.ORG.UK (AGEING WELL PROJECT)

• WWW.CBF.ORG.UK

• WWW.LD-MEDICATION.BHAM.AC.UK

• WWW.DSSCOTLAND.ORG.UK

• WWW.ALZHEIMERS.ORG.UK

• WWW.PSS.ORG.UK

• WWW.DISDAT.CO.UK

Useful websites

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