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Borun Center Study Finds Low Activity Levels among
Restrained and Unrestrained Nursing Home Residents
Date: April, 2004
Contact: Anna Rahman, MSW (rahmananna@yahoo.com)
Phone: (818) 774-3347
Reseda, CA—Nursing homes with a high rate of physical restraint use employ more restrictive care processes, which limit their residents’ movements, than facilities that use restraints less often. But findings from the first study to independently evaluate the validity of a nursing home “prevalence of restraint” quality measure also suggest that most long-stay residents spend a potentially unhealthful amount of time in bed.
The authors contend that an assessment of residents’ physical activity might be a more meaningful measure of care quality than restraint use. The study was conducted by researchers at the Borun Center for Gerontological Research, a joint venture between the UCLA School of Medicine and the Jewish Home for the Aging of Greater Los Angeles.
The restraint rate in nursing homes has dropped dramatically since the implementation in 1990 of federal regulations that severely limit the use of restraining devices. Today an estimated 12% of nursing home residents are physically restrained, down from 40% in 1990. But there is scant evidence that freedom from physical restraints has lead to increases in residents’ activity levels or in rehabilitation programs that improve the gait and balance problems which can result in restraint use. Although the danger of being injured by a restraining device has diminished, the clinical significance of restraint reduction is still questionable.
The Borun Center study examined whether minimal restraint use in a nursing home reflects better care practices. The researchers compared two groups of nursing homes: eight with scores among the lowest (0-5%) on a quality indicator that measures prevalence of restraint use and six with scores among the highest on this measure (28-48%).
The researchers found residents in bed more often in the high-restraint homes, yet there was no obvious clinical difference between these residents and those in the low-restraint homes.
On all other care process measures, including those related to the management of restraints, exercise, and gait and mobility problems, the study found no differences between the two nursing home groups. In general, all facilities provided care to residents, restrained or unrestrained, less than once every two hours.
“Based on our observations, we estimate that the typical resident in a high-restraint home spends between 19 and 20 hours in bed each day. That estimate drops in low-restraint homes, but by only an hour a day,” said lead author Dr. John F. Schnelle, director of the Borun Center. “The conclusion we draw is that all residents seem to be spending too much time in bed and not enough time engaged in activities that enhance mobility, gait, and balance.”
The study appears in the April issue of The Gerontologist. The authors interviewed 413 long-stay residents and conducted physical performance evaluations as well as direct observations of these residents on three consecutive days. They gathered additional data through reviews of medical charts and federally mandated resident assessments.
Based on their findings, Schnelle and his colleagues question the usefulness of reporting restraint rates on the Nursing Home Compare Website maintained by the federal Centers for Medicare and Medicaid Services (CMS). This website publishes “report cards” for the nation’s nursing homes in an attempt to help long-term-care consumers make informed choices and to motivate nursing homes to improve the quality of their care. The report cards include restraint prevalence along with 13 additional quality measures.
Notes Schnelle: “Federal regulations to achieve restraint reduction were conceived largely as a means toward an end—the end being increased movement and physical activity among residents. Although we’ve made significant progress on the means, it doesn’t seem to have gotten us much closer to the end. Perhaps we would reach that goal faster if we directly measured residents’ physical activity levels.”
The authors recommend interviewing residents to determine whether they are receiving the amount of help they want to be physically active. In the Borun Center study, the residents interviewed said they weren’t. The authors also say that nursing home managers—and family members—can quickly determine whether residents are spending an inordinate amount of time in bed by noting resident locations at both 10 a.m. and 4 p.m. on the same day. Given that many residents are put to bed early—all were observed in bed by 7 p.m. in the Borun Center study—any resident found in bed at both times is highly likely to be spending more than 16 hours a day in bed.
The Borun Center for Gerontological Research, established in 1989 and housed at the Jewish Home for the Aging in Reseda, California, is an interdisciplinary center for applied research that focuses on creating, testing, and promoting the adoption of behavioral interventions to improve daily care and quality of life in nursing homes. It currently is developing web-based training modules that will help nursing homes prevent mobility decline among their residents and improve other, related daily care processes.
For more information, contact Dr. Schnelle at (818) 774-3347 or JSchnell@ucla.edu.
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