Author: Nadia Chivers, Policy Intern, Health & Medicine Policy Research Group

Editor: Kristen Policy, Policy Analyst, Center for Long-Term Care Reform, Health & Medicine Policy Research Group

The Outlawing of Physical and Chemical Restraints

Since October 1990, nursing homes across the country have had to comply with a federal mandate, The Omnibus Budget Reconciliation Act of 1987, that restricts the use of inappropriate physical and chemical restraints on nursing home residents unless the restraint is necessary to treat their medical symptoms.

Physical restraints restrict a person’s movement and may include leg and arm restraints, hand mitts, vests, ties, and trays/tables/bars that cannot be removed from a chair or bed and limit the person’s mobility.

While the use of physical restraints in nursing homes serves some legitimate purpose, unnecessary use has drastically reduced in the past 20 years.  The same cannot be said for the use of chemical restraints.  While psychotropic drugs are often an essential form of treatment in nursing homes, they become chemical restraints when they are used to control a resident’s behavior rather than administered for medical purposes.

The misuse and overuse of psychotropic drugs on nursing home residents has been well documented and is now considered by some experts to be the newest form of nursing home abuse.  It is estimated that 1 in 4 patients in the U.S. receive anti-psychotic drugs and 15,000 nursing home patients are killed each year due to unnecessary anti-psychotics.  

As a response to the inappropriate use of psychotropic drugs in Illinois nursing homes, the Illinois Nursing Home Safety Task Force (The Task Force) has included in its Final Report a recommendation that a policy be developed to assure these drugs are used properly. 

Danger of Chemical Restraints and Lack of Regulation

The dangers associated with chemical restraint are just as severe as those associated with physical restraint.  Misuse and overuse of psychotropic drugs may result in overdose, malnutrition and dehydration, the inability to feel pain, brain injury, bed sores and other skin conditions, chemical dependence, choking, and death.

The lack of regulation surrounding the use of psychotropic drugs in nursing homes is one reason why these drugs are so frequently misused.  Currently, there is no policy prohibiting doctors from practicing off-label use of drugs.  For instance, an anti-psychotic drug to treat mental illness may also be prescribed for non-mentally ill patients, even though the FDA may not have approved the drug for such conditions.  The Task Force received complaints about inappropriate use of drugs – including that “psychotropic drugs were repeatedly used for unapproved indications,” (see Recommendation 28 and Highlights of Public Testimony in the Task Force Final Report).  There is also no oversight as to the doctors writing the prescriptions or the actual administration of the drugs.  The Task Force found that only a few physicians prescribe the majority of psychotropic drugs for people with mental illness, frequently doing so without even seeing the resident.  This could be a result of the practice of drug-makers paying doctors to promote their drug.

Additionally, the Task Force found that nursing home staff could administer the drugs “as needed” without first consulting a doctor.  As long as there is a valid prescription signed by an Illinois-licensed physician, the nursing home cannot be cited for improper use of the drugs. 

Lastly, Illinois does not require nursing homes to receive residents’ consent for each psychotropic drug administered.  According to a December 20, 2009 Chicago Tribune report, since 2001 hundreds of nursing home residents in Illinois have been given psychotropic drugs without their permission. 

Illinois Nursing Home Safety Task Force Recommendations on Use of Chemical Restraints

In its Final Report, the Task Force includes Recommendation 28 to “Develop a policy to assure proper use of psychotropic drugs for people with serious mental illness and dementia” as a result of the many complaints it received regarding inappropriate use of psychotropic drugs.

To achieve this, the Task Force offered “Next Steps,” which include implementation of policy changes that consist of standards for the appropriate use of psychotropic medications being developed in consultation with the Illinois State Medical Society, Illinois Psychiatric Society, University of Illinois College of Medicine, and other potential clinical and academic partners.  A workgroup devoted to this issue has convened and is currently preparing a rulemaking report for state agencies which is scheduled to be completed on April 23, 2010.  

While the use of physical restraints in nursing homes is no longer a widespread problem, the use of chemical restraints is.  With the deadline of the workgroup report nearing, we should all stay-tuned to see how it plans to address the inappropriate and dangerous use of psychotropic drugs in Illinois nursing homes. 

If you want to become more involved in this issue, please post your comments and ideas below or directly on the Nursing Home Safety Task Force website.  Finally, if you suspect your loved one is being chemically restrained in an Illinois nursing home facility, contact your regional ombudsman who will investigate your complaint.