Ms Yeo

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This case concerns the director of nursing at a nursing home, who convenes a staff meeting to talk about a common problem. What should staff do, and refrain from doing, when a resident with dementia hits another person?

Ms Yeo

Cindy Yeo is the director of nursing at a nursing home. She has convened her facility’s nurse managers and several long-time aides for a staff meeting.

‘Thanks for coming today, everyone! Okay, let’s get started.

‘We’ve all faced this situation: a resident with dementia starts hitting staff. Don’t worry, this isn’t about a complaint and no one is in trouble. We all know that a person who would never have slapped or punched anyone before he or she developed dementia might start doing so because of the condition. We’ve explained this to families. But what should we do in response to these situations? What shouldn’t we do? That’s what I hope we can talk about today. I’ve asked Carla, a nursing assistant who has been here for a long time and has lots of experience, to help us get started. Carla?’

Carla moves forward to speak, ‘Ah, thank you, Mdm Yeo. What I always think, when a person with dementia hits me or another assistant, is that this person is bothered by something. Can I figure out what that is? Are they having trouble sleeping? Are they scared because of their hallucination? Did we make some change in their routine that is upsetting? Maybe there is a new assistant they can’t recognise or understand? The person often can’t tell me what the problem is. And once there’s an incident, you have to document it. You have to inform the family. Sometimes the staff members who get struck or shoved or punched feel upset. We have to calm them down. So, we are thinking about these other things, too. We may even feel annoyed at the resident for making extra work for us.’

‘Thank you, Carla,’ said Mdm Yeo. ‘Okay, so what seems to help in these situations?’ As people offer suggestions, she writes them on a white board:  ‘Speak calmly’; ‘Make eye contact’; ‘Distract the person with something they like’… .

‘So, say we try all these things, and they work for a while. But the behaviour gets worse. What do we do?’ asks Felicity, another long-time nursing assistant. ‘The person may still be quite strong. It’s hard to care for someone who is pushing you, slapping you, or shouting, especially at night, when there are just a few of us looking after so many residents. That’s when we think, “Can we just put him on something?”’

Nurse Jamila, gestures to speak, ‘You mean medication, right? When I worked in a care home in the UK, we learned that antipsychotics could be harmful to a person with dementia. They can cause stroke and other medical problems. But if you were understaffed, and a resident was hitting or shouting, I can see why you might think chemical restraint would be a solution, if it made the resident quiet and sleepy and didn’t seem to harm them.’

‘I’m glad you mentioned that, Jamila,’ said Mdm Yeo. ‘It’s a touchy subject. Is it right to chemically restrain a person who has dementia? Is it wrong? What do you think?’

Is chemical restraint appropriate?

Commentary by Michael C. Dunn

Restraint can be defined as the ‘intentional restriction of a person’s voluntary movement or behaviour’ (Counsel and Care UK, 2002). Restraints are most commonly used in dementia care settings as an attempt to manage what are called ‘behavioural and psychological symptoms of dementia’. Occasionally these symptoms mean that people with dementia are at risk of harming themselves or others. Chemical restraints refer to those restraints aimed at reducing the risk of these harms occurring using psychoactive medications (typically antipsychotic medicines) rather than physical forms of confinement.

Chemical restraint requires the medication to be used with the primary intention of sedating the person or controlling his/her behaviour. This is different from situations in which the same medication is prescribed to treat symptoms for a mental illness that the person with dementia is also experiencing. Whilst the latter situation might have similar effects on behaviour, the primary intention is to treat mental disorder. Up to 80% of people with dementia in residential care are believed to be receiving psychoactive medications of some kind, and there is evidence that some of these people are receiving these medications as chemical restraints.

What is ethically problematic about the use of chemical restraints?

There has been growing concern raised by policymakers and voluntary welfare organisations in Singapore and internationally that chemical restraints are problematic, and that their use should be reduced. The conversation involving Carla, Jamila, and Madam Yeo reveals some immediate ethical concerns. These include:

  • Calculating and balancing risks and harms correctly: As Jamila recognises in this case, certain antipsychotic drugs pose serious medical risks to people with specific kinds of dementia and can increase mortality risk. All psychotropic medicines have side effects that pose risks. The constraining effects of chemical restraints can also exacerbate the person’s challenging behaviours.
  • Negative impact on daily functioning and quality of life: In controlling a person’s behaviour, the medications impair functioning more generally, preventing the person from moving freely or engaging in activities that he/she enjoys, reducing the quality of his/her experiences. Antipsychotic medications can also lead to a state of apathy, where the person’s emotions are blunted, further reducing well-being.
  • Negative impact on autonomy and control: The impairment of functioning resulting from chemical restraint use can also strip the person of the ability to make choices for himself/herself or to act on these choices.
  • Whose interests? As both Carla and Jamila suggest, chemical restraints may not always be motivated by the desire to reduce harm. Instead they might be used to ease staff workloads, or to bring peace of mind to staff, family members, or other residents. Using restraints in ways that do not serve the direct and immediate interests of the person or other people is not justifiable.

Alternative approaches to managing challenging behaviour

Psycho-social interventions based on individualised assessments are appropriate alternatives to chemical restraints. Rather than labelling behaviour such as hitting a staff member as ‘challenging’, a psycho-social approach understands this behaviour as a non-verbal form of communication that reflects the person’s cognitive state, personality, life history, and environmental context. In line with Carla’s perspective, these interventions aim to identify and respond to unmet needs. Appropriate responses might include pain management interventions, psychological or group therapies involving art, music or animals, and/or modifications to the nursing home routine. Changing practice to reduce chemical restraints in nursing homes requires staff training and time to be allocated to these activities. Nursing home staff first need to think carefully about what kinds of behaviour are considered a ‘problem’, and how they should describe these behaviours.

It will, of course, remain entirely appropriate to prescribe antipsychotic medications in some circumstances. The onset of dementia can give rise to psychotic symptoms and Behavioural and Psychological Symptoms of Dementia (BPSD), and these medications can, alongside other therapeutic interventions, reduce these symptoms for a minority of patients. However, the simple fact that a person is engaged in behaviours that challenge staff does not provide a good reason to use chemical restraints. Alternative, less restrictive approaches should always be used first wherever possible.

Chemical restraint as a last resort?

Whilst using chemical restraints is unethical in most circumstances, there remain some very limited situations in nursing homes in which chemical restraints are justified. This will depend on determining whether the person’s best interests, or the interests of others, are maximised by the chemical restraint being used, when the person lacks the capacity to give consent to the use of the restraint.

Due to the range of ethical concerns identified above, it would only be appropriate to use chemical restraint when the person’s behaviour poses severe distress or immediate risk of harm to himself/herself or others. When these criteria are met, chemical restraint should be used as a very short-term measure, and the person should be supported in a dignified way when the restraint is used. Following the use of such restraint, and in all other circumstances, alternative and individualised psycho-social interventions should be adopted.


Commentary by Dunn, Michael C., ‘Is it ever appropriate to use chemical restraint?’ in in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics Casebook, vol. ii: Caring for Older People in an Ageing Society (Singapore: National University of Singapore, 2017),

The importance of involving the staff

Commentary by Michael K. Gusmano

In this case, Cindy Yeo provides an excellent example of how a nursing home administrator can create a working environment that promotes good care for patients and addresses a potential source of stress for her staff. When and under what circumstances should we implement restraints in nursing homes is a frequent question among staff. The use of restraints is often troubling to nursing home staff, but it may not always receive the attention it deserves and staff may benefit enormously from having more opportunities to discuss this issue. Although it is clearly important to give nursing home staff a chance to discuss ethical concerns related to end-of-life decision-making, it is also important to find time for staff to discuss routine issues like the use of physical or chemical restraints.

By giving her staff the platform for discussing this issue in an open way without trying to blame them for inappropriate behaviour, she is able to help them identify a number of potential problems associated with the use of restraints. Furthermore, the conversation among the staff may be helpful in identifying possible alternatives to the use of restraints, which might not have been shared. Most importantly, discussions of this sort are likely to make this nursing home a better, more supportive place for the staff to work. This is important because nursing home staff do a difficult job and often receive relatively low pay. Offering nursing home staff an opportunity to discuss the challenges they face is appropriate because these hard-working professionals deserve to be treated with respect. In addition, an enormous body of research demonstrates that improving the working environment of nursing home staff translates into higher quality care for the patients.

Nursing homes are stressful places to work

Nursing is a stressful profession and working in a nursing home is a particularly challenging workplace setting. Along with the physical burdens, including lifting and bathing patients, nursing home staff face a variety of emotionally and psychologically difficult situations. Studies have found that the vast majority of nursing home staff are encumbered by routine situations they face at work. For example, most nursing home staff report that they have been the victims of verbal and/or physical abuse by patients, and they often struggle with whether to use physical or chemical restraints on the patients they serve. In this case, Nurse Jamila recognised that she might harm patients with dementia if she administered antipsychotic medications to keep them calm, but she was also aware that doing so might help her cope if the nursing home did not have sufficient staff. Situations of this sort put staff in difficult situations because they are asked to balance the needs of other patients, and the short-term needs of the staff, with the well-being of the patient being restrained. Furthermore, many of the staff coping with these stressful work conditions receive relatively low pay, and high turnover among staff is a serious problem in nursing homes.

Improving the work environment will improve patient outcomes

One benefit of involving the staff and encouraging discussion of routine challenges, like the possibility of using restraints, is the opportunity to generate creative solutions by people with an intimate knowledge of the situation. Staff discussions like the one described in this case is an opportunity to provide ongoing professional education. Psycho-social interventions based on individualised assessments are often preferable to the use of chemical restraints, so it is important to provide nursing home staff with appropriate training in how to address the needs of patients with dementia. While more formal teaching and learning opportunities are important, creating time for sharing information during staff meetings can help reinforce and share lessons about alternative strategies.

Equally important is the opportunity to empower the nursing home staff and improve the workplace. We know that a better work environment is closely related to the quality of care provided at nursing homes. Studies have found that the quality of the nursing home environment is associated with a range of positive outcomes. Staff who are appropriately rewarded and who feel empowered by their supervisors are more likely to express job satisfaction and less inclined to leave their jobs. Furthermore, nursing homes with more satisfied staff experience better patient outcomes. For example, one study found a correlation between staff rewards and the incidence of pressure ulcers.

Providing staff with a constructive, non-judgemental environment in which to share their experiences and coping strategies is one way to overcome frustration and unhappiness in the workplace. Rather than lecture her staff about the right way to deal with patients who engage in violent behaviour, Ms Yeo invited them to think about these situations and asked them to reflect on how they might respond. By asking one of the home’s nursing assistants, Carla, to share her experiences, Ms Yeo was signalling to the other members of her staff that their experiences have value and their voices matter. Without an opportunity to discuss these situations together, each member of the staff may have assumed that they were the only ones troubled by the routine use of chemical restraints and they may have been reluctant to raise questions about a practice that appeared to be widely accepted. By encouraging her staff to work together and draw on their collective experience, Ms Yeo was demonstrating leadership and creating an environment that has the potential to improve the lives of her staff and the patients they serve.


Commentary by Gusmano, Michael K., ‘The importance of involving staff’, in in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics CasebookCaring for Older People in an Ageing Society (Singapore: National University of Singapore, 2017).

A person-centred approach in understanding aggression in persons with dementia

Practice Perspective by Philip Yap

It is important to know that persons with dementia (PWDs) become aggressive not without a reason, the same as how any person would. We must examine the circumstances under which the PWD became agitated as it would be unfair and inappropriate to attribute the behaviour to dementia per se. However, PWDs can have a lower threshold for stress and agitation, this can explain why they may be upset even if the trigger is seemingly minor. A brain that is ravaged by dementia pathology, especially in the frontal lobes, has diminished emotional control. As such, PWDs can be more irritable, emotionally labile and may fly into a rage in situations which mature adults usually have a handle on.

In caring for PWDs who become aggressive, we should first consider the possible precipitants of the behaviour as avoiding the trigger will avert the likelihood of future occurrences. Next, we need to review our reaction to the behaviour because changing our response may ameliorate the behaviour. For example, aggressive behaviours are not uncommon during custodial care when PWDs are disrobed or bathed against their will. If we forcibly persist, the PWD is likely to act out. Although PWDs have poor memory of events, the emotions associated with events may linger on. Feelings of fear, anxiety, insecurity, and animosity will thrive if PWDs are continually cared for in a manner that does not uphold their dignity and comprises their autonomy. Therefore, the PWD may always be resistive as attempts to render care may be perceived as threats.

To achieve a breakthrough, we have to re-think our priorities and approach to care. Although providing personal care in bathing and dressing are important, we may need to put them aside and focus on nurturing a trusting relationship with the PWD first before we attempt these custodial tasks. Drawing on our ability to empathise, we embrace the perspective of the PWD to experience and understand how he may be feeling, and let the experience guide our approach to care. A person-focused rather than task-oriented approach requires time and patience but surely procures better outcomes for both the caregiver and care recipient.

There is a tendency to look to drugs for a quick fix when we encounter behaviours that challenge. Today, the term ‘responsive behaviours’ is preferred because these behaviours call for a response to the unmet needs in PWDs. Responsive behaviours are also reactions in PWDs to the physical and social environment. For instance, aggressive behaviour seen in a nursing home resident who is stopped from getting out of the facility could be a response to a threat to his physical space and need for personal freedom. We should explore if the need can be met directly or by substituting with something else that could similarly meet the need before we resort to medication.

When PWDs attempt to leave the nursing home and demand to go home, it is useful to examine what home may mean for them. Metaphorically, ‘home’ could represent a yearning for comfort, love, security and identity, as well as meaningful and purposeful engagement given the duties and responsibilities at home. If going home physically is no longer a possibility, could these needs be met in the nursing home? The desire for comfort, love, and security could be fulfilled by nurturing new relationships with other residents and the care staff, and likewise one’s identity could be forged in meaningful relationships that enkindle a reason for living. Additionally, being engaged in work that harnesses the residual abilities in PWDs can enhance esteem and provide continued purpose in life. With time, the nursing home takes on the meaning of home for the PWD and he no longer pines for his old home because he has found a sense of belonging in his new home. Most importantly, the agitation and aggression he used to display whenever he was stopped from wanting to leave dissipates without the need for medication.

There are a variety of medications used to ameliorate behavioural symptoms in dementia and not all carry the same potential for harm. Antipsychotics convey the highest risk with serious adverse effects in sudden cardiac deaths, cerebrovascular events, falls, functional decline, and disability. Anti-depressants, particularly SSRIs (selective serotonin reuptake inhibitors), have a lower risk profile and have in recent studies been shown to be effective in decreasing symptoms such as anxiety, agitation, and aggression. In PWDs with agitated depression, antidepressants can improve emotional well-being and volition, thereby reducing frustration and the likelihood of violent outbursts. There are the rare occasions when PWDs can be combative to the extent of hurting care staff and other patients, or may threaten with sexual advances. Under these circumstances, chemical restraint may be considered to subdue the aggressor and defuse the situation.

Calling to mind the dictum ‘primum non nocere (first do no harm)’, discretion and caution should always guide the use of psychotropic medications in PWDs. These medications should not be the first line of treatment. Instead, a deep understanding of the PWD and his/her needs to tailor the appropriate care is germane to securing his well-being. If PWDs are to receive the best care, we need to look beyond diagnostic labels to know the person behind dementia. The words of William Osler, that ‘it is more important to know what type of person has the disease than what type of disease a person has’ cannot be more relevant.


Practice Perspective by Yap, Philip, ‘A person-centred approach in understanding aggression in persons with dementia’, in Chin, Jacqueline, Nancy Berlinger, Michael C. Dunn, Michael K. Gusmano (eds.), A Singapore Bioethics Casebook, vol. ii: Caring for Older People in an Ageing Society (Singapore: National University of Singapore, 2017),