Introduction

The use of restraints in elderly care, whether physical or chemical, remains one of the most debated ethical issues in healthcare. Restraints are implemented to limit an individual's mobility or behavior, often as a response to safety concerns such as fall prevention, agitation management, or the protection of both patients and caregivers. However, the application of restraints among the elderly raises significant ethical and clinical concerns, primarily due to the associated physical and psychological harms. Research has shown that restraints can lead to injuries such as pressure ulcers, fractures, and soft tissue damage, as well as psychological consequences like anxiety, depression, and diminished dignity (1). These outcomes challenge the ethical principles of beneficence and non-maleficence, which require healthcare providers to prioritize the well-being of patients and minimize harm. The principle of autonomy is particularly important in conversations about the elderly, as cognitive impairments such as dementia may limit their ability to provide informed consent for restraint use. In these cases, healthcare providers and family members often make decisions on behalf of the patient, which can lead to ethical dilemmas when there is a lack of consensus or understanding about the necessity of restraints (2). Furthermore, cultural and institutional factors often shape how restraints are perceived and applied in various settings, highlighting disparities in practice and the need for universally accepted ethical guidelines.

Legal and professional frameworks play a critical role in shaping restraint practices. In some jurisdictions, the use of restraints is strictly regulated, with guidelines emphasizing the importance of documenting necessity, seeking alternative measures, and conducting frequent reassessments to ensure that restraints are used only as a last resort (3). However, compliance with these standards varies across institutions, and in some cases, restraints are used as a matter of convenience rather than necessity. This misuse not only violates ethical principles but also undermines the trust of elderly patients and their families in the healthcare system. The prevalence of restraint use in elderly care is likely to increase unless proactive measures are taken to address these ethical challenges. The development and adoption of alternative interventions, such as environmental modifications, behavioral therapies, and caregiver training, can significantly reduce reliance on restraints while enhancing the quality of care (4). Addressing these issues requires a multidisciplinary approach that combines ethical reflection, evidence-based practices, and compassionate care for the elderly.

Review

The use of restraints among the elderly presents complex ethical challenges, often balancing the need for safety against the risks of physical and psychological harm. Restraints can lead to significant negative outcomes, including physical injuries such as fractures and skin breakdown, as well as emotional distress, loss of dignity, and increased dependency. These consequences highlight the need for careful ethical consideration before implementing restraints in elderly care (5). Furthermore, studies have shown that restraints may not always achieve the intended safety outcomes, with some evidence suggesting they can increase agitation and the risk of falls due to reduced mobility and strength. One of the core ethical dilemmas revolves around respecting autonomy while ensuring safety. For elderly patients with cognitive impairments, such as dementia, obtaining informed consent for restraint use can be difficult. Family members and healthcare providers often face conflicting views on what constitutes the best interest of the patient. This underscores the importance of exploring alternatives, such as improved staff training, environmental modifications, and individualized care plans, to reduce reliance on restraints while preserving the patient’s dignity and well-being (6). Addressing these challenges requires a collaborative, patient-centered approach rooted in ethical principles and evidence-based practices.

Physical and Psychological Impact of Restraints on Elderly Patients

The use of physical and chemical restraints in elderly care has been associated with significant physical and psychological consequences that often outweigh their intended benefits. Physical restraints, such as belts, bedrails, or wrist restraints, may restrict mobility but can also cause harm. Prolonged use can result in muscle atrophy, pressure ulcers, joint stiffness, and circulatory issues, leaving the patient more vulnerable to further physical decline (7). These adverse outcomes highlight the risks inherent in restraint use, particularly when employed for extended periods without proper oversight or alternative interventions.

Psychologically, restraints can evoke a sense of powerlessness and fear in elderly patients. Many report feelings of humiliation, frustration, and anxiety when restrained, which may exacerbate conditions such as depression and cognitive decline (8). For individuals with dementia, restraints can be particularly distressing, as they may misinterpret the restraint as punishment or an act of aggression. This can trigger agitation, aggressive behaviors, or a refusal to cooperate with caregivers, complicating the provision of care. Such outcomes not only diminish the patient’s quality of life but also create challenges for healthcare providers tasked with their well-being. The physical and psychological impacts of chemical restraints, often in the form of sedatives or antipsychotic medications, also deserve attention. These drugs, while sometimes necessary for managing acute agitation or aggression, can lead to serious side effects, including sedation, reduced cognitive function, and increased risk of falls. Research has shown that inappropriate or excessive use of chemical restraints is a contributing factor to the over-sedation and social withdrawal often observed in institutionalized elderly patients (9). Moreover, long-term use of these medications has been linked to adverse health outcomes, such as an increased risk of cardiovascular events and mortality.

Healthcare settings that rely heavily on restraints may inadvertently foster an environment that normalizes their use, further compounding the issue. This can lead to overreliance on restraints as a means of managing staff workload or addressing behavioral challenges, rather than implementing less restrictive and more patient-centered approaches. Studies indicate that restraint use is often influenced by institutional culture and staffing levels, with undertrained or overstretched caregivers more likely to resort to restraints as a quick solution (10). This underscores the need for better staff training and adequate resources to reduce dependence on such measures. Addressing the physical and psychological consequences of restraints in elderly care requires a shift in focus toward understanding and mitigating the underlying causes of behaviors that lead to their use. Alternatives such as environmental adjustments, personalized care strategies, and non-pharmacological interventions can effectively manage many of the challenges that restraints are intended to address. For instance, strategies like increasing patient engagement, optimizing pain management, and improving communication between caregivers and patients have been shown to reduce the need for restraints and improve overall patient outcomes (11).

Consent and Decision-Making in the Use of Restraints

The process of obtaining consent and navigating decision-making for the use of restraints in elderly patients presents unique ethical and practical challenges. Consent is a cornerstone of ethical medical practice, yet it becomes particularly complex when dealing with elderly individuals who may have cognitive impairments or other conditions limiting their ability to make informed decisions. When autonomy is compromised, caregivers and healthcare professionals must often rely on surrogate decision-makers or advanced directives, but these alternatives can introduce conflicting perspectives and ethical tensions (12).

Elderly patients with conditions such as dementia or delirium are frequently unable to comprehend the implications of restraint use. In such cases, informed consent may need to be obtained from family members or legal guardians. However, this process is not always straightforward. Families may have differing opinions on whether restraints should be used, influenced by cultural attitudes, personal experiences, or the perceived urgency of the situation. Studies indicate that family members often struggle with guilt or uncertainty when deciding on the use of restraints, as they may feel torn between protecting their loved ones and respecting their dignity (13). This emotional burden can complicate discussions with healthcare providers, particularly if there is a lack of clear communication or inadequate explanation of alternative options. Healthcare professionals also face significant challenges in the decision-making process. Institutional policies and resource limitations may pressure staff to resort to restraints for safety or operational reasons, even when alternative approaches are more ethically sound. The decision to use restraints is often made in high-stress situations, where immediate action is required to prevent harm to the patient or others. In such cases, consent may be bypassed or inadequately obtained, raising concerns about the ethical legitimacy of the practice. Moreover, a lack of standardized guidelines across institutions can result in inconsistencies in how consent is handled, further complicating the ethical landscape (14).

The role of advanced care planning in restraint decisions cannot be understated. Documented preferences for or against restraint use, outlined in advance directives, provide a framework for decision-making that aligns with the patient’s values and wishes. However, not all elderly individuals have access to or awareness of these planning tools. Even when advanced directives exist, they may not address the specific circumstances under which restraints are considered, leaving room for interpretation and potential conflict among caregivers and medical teams. This gap highlights the need for proactive discussions with elderly patients and their families about restraint policies and their potential implications, ideally before such decisions become urgent (15). Cultural factors also play a significant role in shaping consent and decision-making practices. In some societies, family members are deeply involved in medical decisions for elderly relatives, often prioritizing communal well-being over individual autonomy. In contrast, other cultures emphasize individual rights, advocating for elderly patients to retain as much control as possible over their care, even when their decision-making capacity is impaired. These cultural differences underscore the importance of culturally sensitive approaches to consent and communication, ensuring that all parties involved feel respected and understood (16).

Ethical Guidelines and Alternatives to Restraints in Elderly Care

The ethical management of elderly patients requiring care interventions often involves avoiding the use of physical or chemical restraints whenever possible. This approach is supported by numerous ethical guidelines that emphasize autonomy, dignity, and the minimization of harm. International healthcare organizations, including the World Health Organization (WHO), advocate for the least restrictive measures in managing elderly patients, aligning with ethical principles of beneficence and non-maleficence. These principles dictate that every effort should be made to implement care strategies that do not infringe upon the patient’s rights and well-being, even in challenging clinical scenarios (16).

One of the primary ethical guidelines involves comprehensive risk assessments before deciding to use restraints. Such assessments should include a thorough evaluation of the patient’s physical and psychological health, environmental factors, and the underlying causes of behaviors that might prompt restraint use. Evidence suggests that behaviors such as agitation or wandering are often mismanaged with restraints when alternative interventions, like addressing unmet needs or modifying the environment, could yield better results (17). Healthcare professionals are ethically obligated to explore these alternatives, ensuring that restraints are only employed as a last resort after less invasive methods have been attempted and documented. Education and training for healthcare staff are pivotal in reducing reliance on restraints and promoting ethical care. Training programs that focus on non-restrictive behavioral management strategies, communication skills, and patient-centered care have shown significant success in minimizing restraint use. For example, redirecting agitation through meaningful activities, creating safer environments, and using technology such as sensor alarms can effectively manage risks without compromising patient freedom (18). Such interventions not only align with ethical guidelines but also enhance the quality of care and the overall patient experience. Alternatives to physical restraints also extend to non-pharmacological interventions. These may include person-centered approaches such as reminiscence therapy, sensory stimulation, and social engagement, which have been shown to reduce agitation and improve mood in elderly patients with cognitive impairments. In cases where behavioral symptoms are present, strategies like consistent routines and improved caregiver-patient communication can mitigate risks while preserving patient dignity. These approaches reflect the ethical imperative to treat elderly patients as individuals with unique needs and preferences, rather than relying on one-size-fits-all solutions (19).

Policy initiatives and institutional reforms are equally critical in ensuring ethical practices. Healthcare facilities are encouraged to adopt restraint-free care models, supported by regulatory frameworks that mandate stringent documentation and accountability for restraint use. For example, some jurisdictions require mandatory review boards to oversee and approve restraint applications, ensuring they meet ethical and clinical criteria. Such policies create an environment where the use of restraints is scrutinized, and alternatives are prioritized. In addition, family involvement in care planning has been emphasized in many ethical guidelines, recognizing that families play a vital role in advocating patient-centered and humane care (20).

Conclusion

The ethical use of restraints in elderly care demands a balance between ensuring safety and respecting patient autonomy and dignity. By prioritizing individualized care, comprehensive assessments, and non-restrictive alternatives, healthcare providers can minimize the negative impacts of restraints. Adhering to ethical guidelines and fostering a culture of restraint-free care promotes better outcomes for elderly patients. Collaborative efforts between caregivers, families, and institutions are essential in addressing these challenges compassionately and responsibly.

Disclosure

Conflict of interest

There is no conflict of interest.

Funding

No funding.

Ethical consideration

Non applicable.

Data availability

Data that support the findings of this study are embedded within the manuscript.

Author contribution

All authors contributed to conceptualizing, data drafting, collection and final writing of the manuscript