The terminal phase of dementia is initiated by the inability to swallow. New techniques of enteral alimentation permit more effective, longer intubation. To assess the application of these new techniques to late-stage demented aged patients, all current intubations in a teaching nursing home were reviewed. Of 52 feeding intubations, 26 had been in situ for more than 1 year. A randomly selected comparison group of nonintubated patients was also studied. Weight increased for 48% of the intubated group versus 17% of the nonintubated group (P less than .01). Aspiration pneumonia occurred more often in the intubated group (58%) than in the nonintubated group (17%) (P less than .01). Decubitus ulcers were also more common in the intubated group (21%) than in the nonintubated group (14%). Restraints were used more in the intubated group (71%) than in the nonintubated group (56%). These differences did not reach statistical significance. All of the intubated patients were severely demented, with MMSE scores of zero. Seventy-one percent of the nonintubated group were demented, with MMSE scores of less than 23. Prolongation of the terminal phase of dementia in the aged by tube feeding is now feasible. The implications of this change in the life-span of demented nursing home patients need attention by families, nursing homes, and those who make public health policy.
A substantial decrease in restraint use occurred without an increase in serious injuries. Although minor injuries and falls increased, restraint-free care is safe when a comprehensive assessment is done and restraint alternatives are used.
Individualized care, resident assessment by a multidisciplinary team, and rehabilitation enhance functional independence in nursing home residents. Creativity in choosing alternatives to restraints was important in successful restraint reduction. Residents free of restraints had higher ADL levels, were more continent, and sustained fewer serious injuries, all of which are important quality of life indicators.
The leadership and commitment of nursing administrators play a pivotal role in minimizing the use of restraints and maintaining a restraint-free environment. This article describes the role of nursing administrators in reducing the use of physical restraints as part of a 2-year, national nursing home restraint-reduction project. It reviews important information about restraint-free care the benefits of restraint-free care, and strategies to reduce the use of restraints in nursing homes, much of which is applicable to settings other than nursing homes.
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