Restraint-free care
A restraint is what a facility reaches for when the care plan has run out. CareGuard’s position is that this is a failure of planning rather than a clinical tool, and the safety review is built to test whether the planning was actually done.
The two kinds
Chemical restraint — a sedative or antipsychotic used to manage behavior rather than to treat a diagnosed condition. It is the more common of the two and the harder to see, because it appears in the chart as a medication.
Physical restraint — anything a resident cannot remove or leave, including some bed rails and some chairs. It causes injury, emotional distress, and loss of the ability to function independently, which then justifies more restraint.
The position
- No chemical restraints. Sedatives and antipsychotics that are not medically necessary are strongly discouraged, and alternative approaches to managing behavior are advocated in their place.
- No physical restraints. Residents should not be subjected to physical restraints that can cause injury, emotional distress or a reduction in independent function.
- Person-centered care. Individualized care plans that address the root causes of behavioral or mobility issues, honoring each resident’s autonomy and dignity.
What has to be true first
Eleven categories and 49 items of the safety review exist so that “we tried everything else” is a checkable claim rather than a sentence in a meeting: assessment for a root cause, eight non-pharmacological interventions, de-escalation training, pain assessment for non-verbal residents, environmental modification, passive monitoring such as bed and chair alarms rather than restraint, individualized care planning, psychotropic medication review, trigger identification, family involvement, and documented legal and ethical compliance. All 49 items.
The last item is the honest one
The review’s Legal & Ethical Compliance category includes using restraints “only as a last resort in emergencies, and with proper documentation and oversight,” and informing residents and families of their rights regarding restraint-free care. The position is not that a restraint is never used. It is that using one is an emergency event that gets documented as such, not a standing arrangement.
What better looks like
- Fewer medications means lower risk of side effects, drug interactions and hospitalization.
- Residents keep more independence, mobility and engagement in their day.
- An environment of freedom, respect and dignity, rather than one organized around containment.
DWARAA is the same work approached through the medication list.
What the evidence says
How common restraint is
A 2021 systematic review and meta-analysis of 85 papers reporting data from 2000 onward found pooled prevalence of 33% for physical restraint and 32% for chemical restraint in residential aged care facilities. The commonest forms were bedrails (44% of physical restraint) and benzodiazepines (42% of chemical restraint). North American studies reported lower physical-restraint prevalence than the pooled figure.
The bedrail number is the one that surprises operators. A great deal of what is counted as restraint in the literature is equipment that nobody in the building thinks of as a restraint.
What reduces it
The 2023 Cochrane review of interventions to reduce physical restraint pooled 11 studies and 19,003 participants, and the split in its findings is the practical lesson:
- Organizational least-restraint programs work. They probably reduce the number of residents with at least one use of physical restraint, RR 0.86 (95% CI 0.78 to 0.94; 3,849 participants, 4 studies), and produce a large reduction in belt restraint specifically, RR 0.54 (95% CI 0.40 to 0.73; 2,711 participants, 3 studies). Moderate certainty.
- Education on its own does not. The review found only very-low-certainty evidence and was uncertain about the effect of simple educational interventions.
- Removing restraints did not increase falls. Low-certainty evidence of little or no effect on falls or fall-related injuries — which answers the objection facilities raise first.
The review’s own framing of why this is still necessary is blunt: restraints remain in use “despite clear evidence for the lack of effectiveness and safety, and widespread recommendations that their use should be avoided.”
The harms
A systematic review of nine studies describes the consequences of physical restraint as lower cognitive and activities-of-daily-living performance, greater walking dependence, falls, pressure ulcers, and urinary and fecal incontinence. These are descriptive findings rather than pooled effect sizes, and are reported here as such.
What replaces it, and how well
A network meta-analysis of 163 studies and 23,143 patients compared interventions for aggression and agitation in dementia. Multidisciplinary care (standardized mean difference −0.50, 95% credible interval −0.99 to −0.01), massage and touch therapy (−0.75, −1.12 to −0.38) and music combined with massage and touch therapy (−0.91, −1.75 to −0.07) were clinically more efficacious than usual care. Its conclusion: non-pharmacologic interventions “seemed to be more efficacious than pharmacologic interventions.”
Where our own program has to be honest
The 2025 Cochrane review of music-based therapeutic interventions in dementia (30 randomized trials, 1,720 participants, mostly institutional) found that music likely did not improve agitation or aggression — standardized mean difference −0.05 (95% CI −0.27 to 0.17; 11 studies, 503 participants, moderate certainty). It probably did improve depressive symptoms slightly (−0.23, 95% CI −0.42 to −0.04; 9 studies, 441 participants), and there was no evidence of long-term effects.
So music belongs on the list as meaningful activity and as something that helps mood, which is how the checklist has it. It is not an agitation treatment, and a facility that installs a music program and expects its behavior incidents to fall will be disappointed.
Person-centered care: the trial, and its caveat
The WHELD cluster-randomized trial in 69 UK nursing homes (847 residents) found person-centered care training with person-centered activities improved quality of life (Cohen’s d 0.24), agitation (d 0.23) and neuropsychiatric symptoms (d 0.30), and reduced cost compared with usual care. The honest line from the same paper: “Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use.”
The companion factorial trial matters more for practice. Residents receiving antipsychotic review alone showed significant worsening in two quality-of-life domains — but there was no deterioration in the group receiving antipsychotic review and social interaction. Deprescribing without putting something in its place is not the same intervention.
References
- Lee DA, et al. 2021. Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: a systematic review and meta-analysis. International Journal of Nursing Studies 117:103856. [systematic review and meta-analysis, 85 papers] · PMID 33601305 · doi:10.1016/j.ijnurstu.2020.103856
- Möhler R, et al. 2023. Interventions for preventing and reducing the use of physical restraints for older people in all long-term care settings. Cochrane Database of Systematic Reviews 7(7):CD007546. [Cochrane review, 11 studies, 19,003 participants] · PMID 37500094 · doi:10.1002/14651858.CD007546.pub3
- Hofmann H, Hahn S 2013. Characteristics of nursing home residents and physical restraint: a systematic literature review. Journal of Clinical Nursing 23(21-22):3012-24. [systematic review, 9 studies] · PMID 24125061 · doi:10.1111/jocn.12384
- Watt JA, et al. 2019. Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis. Annals of Internal Medicine 171(9):633-642. [network meta-analysis, 163 studies, 23,143 patients] · PMID 31610547 · doi:10.7326/M19-0993
- van der Steen JT, et al. 2025. Music-based therapeutic interventions for people with dementia. Cochrane Database of Systematic Reviews 3(3):CD003477. [Cochrane review, 30 RCTs] · PMID 40049590 · doi:10.1002/14651858.CD003477.pub5
- Ballard C, et al. 2018. Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes (WHELD): a cluster-randomised controlled trial. PLoS Medicine 15(2):e1002500. [cluster-randomized trial, 847 residents, 69 nursing homes] · PMID 29408901 · doi:10.1371/journal.pmed.1002500
- Ballard C, et al. 2016. Impact of antipsychotic review and non-pharmacological intervention on health-related quality of life in people with dementia living in care homes: WHELD, a factorial cluster randomised controlled trial. International Journal of Geriatric Psychiatry 32(10):1094-1103. [factorial cluster-randomized trial] · PMID 27640872 · doi:10.1002/gps.4572
- Kales HC, Gitlin LN, Lyketsos CG 2015. Assessment and management of behavioral and psychological symptoms of dementia. BMJ 350:h369. [clinical review] · PMID 25731881 · doi:10.1136/bmj.h369
Ask for a safety review of your facility
A CareGuard safety review walks the building against 189 items in 54 categories and reports what it finds to you, not to your site manager. The registration form takes the facility and a contact for the ownership group; scope is settled in the conversation that follows.