American Academy of Nursing

View all recommendations from this society

April 19, 2018

Don’t use physical or chemical restraints, outside of emergency situations, when caring for long-term care residents with dementia who display behavioral and psychological symptoms of distress; instead assess for unmet needs or environmental triggers and intervene using non-pharmacological approaches as the first approach to care whenever possible.

Behavioral and psychological symptoms of distress (BPSD) include aggression, agitation, wandering, disruptive vocalizations, anxiety, apathy, hallucinations, and depression. The majority of people living with dementia will experience these symptoms. They result in poor quality of life, more rapid cognitive and functional decline, high risk for abuse, caregiver burden, and tremendous cost to the US healthcare system. In fact, dementia care is among the most costly of diseases including diabetes, cancer and heart disease; and BPSD account for a staggering 30% of total dementia costs. Despite the high human and dollar costs associated with these symptoms, their treatment continues to challenge practitioners and remains a top research priority in long-term care settings. Because BPSD are often triggered by a change in physical condition, an unmet need or an environment that exceeds the person’s stress threshold, it is important that these triggers be addressed as the first line of treatment rather than resorting to physical or chemical restraint, which carry a risk for adverse effects.

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

How The List Was Created

The American Academy of Nursing has convened a Task Force of member fellows who are leaders of professional nursing organizations representing a broad range of clinical expertise, practice settings and patient populations. The Task Force collaboratively identifies nursing/interdisciplinary interventions commonly used in clinical practice that do not contribute to improved patient outcomes or provide high value. An extensive literature search and review of practice guidelines is conducted for each new proposed recommendation for the list. The supporting evidence is then reviewed by the respective nursing organization(s) with the most relevant expertise to each recommendation. The Academy Task Force narrows the recommendations through consensus, based on established criteria. The final recommendations are presented to the American Academy of Nursing’s Board of Directors for approval to be added to the Choosing Wisely list created by the Academy. Once approved by the Academy’s Board of Directors, the recommended statements are sent to the ABIM Foundation for an external review by physician(s) and nurse(s) and final approval for consistency with the ABIM Foundation principles.

Recommendations were developed in partnership with the following organizations: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), recommendations 1, 11, 12, & 13; Academy’s Expert Panel on Aging, recommendations 2, 3, 14, 15, & 24; American Association of Critical- Care Nurses (AACN), recommendations 4 & 5; Oncology Nursing Society (ONS), recommendations 6, 7, 8, 9, & 10; American Association of Neuroscience Nurses (AANN), recommendations 16, 17, 18, 19, & 20; Academy’s Expert Panel on Acute & Critical Care, recommendation 21; Society of Pediatric Nurses (SPN), recommendation 22; American Pediatric Surgical Nurses Association, Inc. (APSNA), and the American Pediatric Surgical Association (APSA), recommendation 23; and the Association of periOperative Registered Nurses (AORN), American Association of Nurse Anesthetists (AANA), and the American Association of Neuroscience Nurses (AANN), recommendation 25.

The American Academy of Nursing’s conflict of interests and disclosures policy can be found at


Evans, L. K., & Strumpf, N. E. (1989). Tying down the elderly. A review of the literature on physical restraint. Journal of the American Geriatrics Society, 37(1), 65-74.

Kales, H. C., Gitlin, L. N., Lyketsos, C. G., & Detroit Expert Panel on Assessment and Management of Neuropsychiatric Symptoms of Dementia. (2014). Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society, 62(4), 762-769. doi:10.1111/jgs.12730.

Kolanowski, A. M., Litaker, M., Buettner, L., Moeller, J., & Costa, P. (2011). A Randomized Clinical Trial of Theory-based Activities for the Behavioral Symptoms of Dementia in Nursing Home Residents. Journal of The American Geriatrics Society, 59(6), 1032-1041.

Kovach, C. R., Logan, B. R., Joosse, L. L., & Noonan, P. E. (2012). Failure to identify behavioral symptoms of people with dementia and the need for follow-up physical assessment. Research in Gerontological Nursing, 5(2), 89-93. doi:10.3928/19404921-20110503-01.

Kovach, C. R., Logan, B. R., Noonan, P. E., Schlidt, A. M., Smerz, J., Simpson, M., & Wells, T. (2006). Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia. American Journal of Alzheimer’s Disease and Other Dementias, 21(3), 147-155. doi:10.1177/1533317506288949.

Maust, D. T., Kim, H. M., Seyfried, L. S., Chiang, C., Kavanagh, J., Schneider, L. S., & Kales, H. C. (2015). Antipsychotics, other psychotropics, and the risk of death in patients with dementia: Number needed to harm. JAMA Psychiatry, 72(5), 438-445. doi:10.1001/jamapsychiatry.