American Geriatrics Society

View all recommendations from this society

Released February 27, 2014; revised April 23, 2015

Don’t use physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.

Persons with delirium may display behaviors that risk injury or interference with treatment. There is little evidence to support the effectiveness of physical restraints in these situations. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Effective alternatives include strategies to prevent and treat delirium, identification and management of conditions causing patient discomfort, environmental modifications to promote orientation and effective sleep-wake cycles, frequent family contact and supportive interaction with staff. Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraint-free approach to patients with delirium. This approach includes continuous observation; trying re-orientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions are occasionally utilized after evaluation by a medical provider at the bedside, if a patient presents harm to him or herself or others. If physical restraints are used, they should only be used as a last resort, in the least-restrictive manner, and for the shortest possible time.


These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

1-5: The American Geriatrics Society (AGS) established a work group chaired by the Vice Chair of Clinical Practice and Models of Care Committee (CPMC). Work group members were drawn from that committee, as well as the Ethics, Ethnogeriatrics and Quality and Performance Measurement (QPMC) committees. AGS members were invited to submit feedback and recommendations as to what they thought should be included in the list via an electronic survey. The workgroup first narrowed the list down to the top 10 potential tests or procedures. The workgroup then reviewed the evidence and sought expert advice to further refine the list to five recommendations, which were then reviewed and approved by the AGS Executive Committee and the Chairs/Vice Chairs of CPMC, Ethics and QPMC.

6-10: The American Geriatrics Society (AGS) used the same work group from its first list to develop its second list. The group was chaired by the Chair of Clinical Practice and Models of Care Committee (CPMC). Work group members were drawn from that committee, as well as the Ethics, Ethnogeriatrics and Quality and Performance Measurement (QPMC) committees. AGS members were invited to submit feedback and recommendations as to what they thought should be included in a Choosing Wisely® list via an electronic survey. The workgroup then narrowed the list down and reviewed the evidence, seeking expert advice to further refine the list to five recommendations, which were then reviewed and approved by the AGS Executive Committee and the Chairs/Vice Chairs of CPMC, Ethics and QPMC.

On April 23, 2015, AGS revised items 2,3,6,7,8 and 10. Read more about these changes and rationale.

Sources

Bray K, Hill K, Robson W, Leaver G, Walker N, O’Leary M, Delaney T, Walsh D, Gager M, Waterhouse C; British Association of Critical Care Nurses. British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units. Nurs Crit Care. 2004 Sep-Oct;9(5):199–212.

Center for Medicare & Medicaid Services. Electronic Code of Federal Regulations. Condition of participation: patient’s rights. 42 C.F.R. § 482.13.

Cotter VT, Evans LK. Avoiding restraints in hospitalized older adults with dementia. Best practices in nursing care to older adults with dementia. 2012;D1.

Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157–65.

Minnick AF, Mion LC, Johnson ME, Catrambone C, Leipzig R. Prevalence and variation of physical restraint use in acute care settings in the U.S. J Nurs Scholarsh. 2007;39(1):30–7.

Maccioli GA, Dorman T, Brown BR, Mazuski JE, McLean BA, Kuszaj JM, Rosenbaum SH, Frankel LR, Devlin JW, Govert JA, Smith B, Peruzzi WT; American College of Critical Care Medicine, Society of Critical Care Medicine. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies – American College of Critical Care Medicine Task Force 2001-2002. Crit Care Med. 2003;31(11): 2665–767.

Mott S, Poole J, Kenrick M. Physical and chemical restraints in acute care: their potential impact on rehabilitation of older people. Int J Nurs Pract. 2005 Jun;11(3):95–101.

Flaherty JH, Little MO. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. J Am Geriatr Soc. 2011 Nov;59Suppl 2:S295–300.

McPherson JA, Wagner CE, Boehm LM, Hall JD, Johnson DC, Miller LR, Burns KM, Thompson JL, Shintani AK, Ely EW, Pandharipande PP. Delirium in the cardiovascular ICU: exploring modifiable risk factors. Crit Care Med. 2013 Feb; 41(2): 405-13.