There are many good reasons for recommending geriatric chairs for individuals in Assisted Living Facilities (ALFs), particularly those with Alzheimer’s and other forms of dementia. And yet the federal government and most state governments have classified the chairs as restraining devices and restricted their use. Good intentions notwithstanding, that action did a great disservice to our most vulnerable citizens.
Geriatric chairs, also known as geri-chairs, are mobile recliners, with ergonomically designed seats and backs of polyurethane-covered foam, and three different positions—in other words, the perfect chairs for non-ambulatory residents of assisted living facilities, allowing them to leave their beds and sit comfortably in the living room, on the porch, or at the dining room table. An attachable tray allows for eating meals outside the dining room or, for those who are able, playing cards or doing crafts.
Before geri-chairs were invented, non-ambulatory residents had to sit upright in wheelchairs with sling seats and backs as they were transported to immovable recliners. Wheelchairs, of course, are not very comfortable and pose the danger of falling forward.
What would cause government bureaucrats to restrict (or in some cases ban) a device so obviously beneficial to the elderly and infirm as the geri-chair? Careless use of language, overgeneralization, and fallacious thinking. Let’s examine each in turn.
Careless use of language
The principal document concerning restraints is the Centers for Medicare and Medicaid Services State Operations Manual, Appendix PP, a document written for skilled nursing facilities and nursing homes. Section 483: 13 (a) states: the resident has the right to be free from any physical or chemical restraints imposed for discipline or convenience, and not required to treat the resident’s medical symptom.” The clear meaning is that only a certain class of restraints is objectionable—those that are “imposed for discipline or convenience.” This is a very reasonable qualification.
A few lines later, however, the regulation defines “physical restraints” as “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which [sic] restricts freedom of movement or normal access to one’s body.” This passage omits the reasonable qualification “imposed for discipline or convenience” and adds the stipulation that the individual must be able to remove it easily. This stipulation ignores the fact that many individuals with advanced Alzheimer’s—or for matter, with serious arthritis—can no longer use their hands for any such purpose!
A few paragraphs later, examples of “restraints” are offered, including this one referring to geriatric chairs: “Using devices in conjunction with a chair, such as trays, tables, bars or belts, that the resident can not remove easily, that prevent the resident from rising.” This wording specifies that it is not the chair that prevents rising but the devices attached to it, a valid distinction. But more careful wording would have retained the original qualification and removed the unreasonable ease-of-removal stipulation. In other words, it would have banned “using, for discipline or convenience, devices in conjunction with a chair, such as trays, tables, bars or belts.”
This carelessness with language in the principal document invited widespread misinterpretation both in the states and in private health care agencies. Here are two notable examples of such misinterpretation:
1 The Hartford Institute for Geriatric Nursing says this about physical restraint: “The Centers for Medicare and Medicaid Services (CMS) defines [sic] physical restraint as ‘any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely’ (Ref 4, HHS, 2007). Examples include wrist or leg restraints, hand mitts, Geri-chairs, and, in certain situations, full side rails and reclining chairs.”
This statement not only ignores the qualification in the principal document—“imposed for discipline or convenience” and ignores the distinction in the original between the chairs themselves and the devices attached to them. It also adds geri-chairs themselves to the definition of physical restraints.
2 The Florida Agency for Health Care Administration (ACHA) declares, “Restraints are prohibited” and cites as one (of several) examples of such restraints, “Geriatric Chairs with lap trays.”
Recall that the federal regulation specified that not all restraints are prohibited but only “restraints imposed for discipline or convenience.” That regulation also distinguished between geri-chairs themselves and attachments such as trays. The Florida agency—which governs all assisted living facilities in the state—omits the qualification and ignores the distinction.
Overgeneralization
Overgeneralization occurs when a few persons or circumstances are falsely presumed to be typical of an entire group or class. A quick Internet search will reveal some dramatic stories of the misuse of geriatric chairs; for example, cases of people having trays locked in place to hold them in when they wanted desperately to get out. Bureaucrats who read those stories apparently leaped to the conclusion that all trays and all chairs are devices of torture and should be prohibited in assisted living facilities.
My experience shows that conclusion to be a serious overgeneralization. For the last 4 ½ years I have spent from two to three hours a day, five days a week, visiting my wife in an Alzheimer’s facility. Many of residents, including my wife, use geri-chairs. (A few use wheel chairs; no individuals are ambulatory.) Let me share a few of my observations:
- I have never seen a person struggle to get out of a geri-chair. That is because the people for whom doctors prescribe the chairs are non-ambulatory and beyond the stage of behaving in ways that harm themselves or others. The chairs provide the residents comfort and enable caregivers to move them safely from one place to another—e.g. the dining room or porch.
- I have never seen an ambulatory resident put into a geri-chair for discipline or convenience. The reason is not that all caregivers are saints—it is that geri-chairs are too expensive to keep on hand for people who don’t need them.
- To be sure, I have seen residents who are not in geri-chairs having anxiety attacks, becoming agitated, or lashing out at caregivers or fellow residents. In every such case, however, the problem was solved by having the person’s physician adjust his/her medications. (The same protocol should and surely would be followed in the unlikely event that someone in a geri-chair displayed such behavior.)
- I have seen people fall asleep watching TV in geri-chairs with head and shoulders tipped awkwardly to one side. The problem in such cases is their frailty and is easily solved by putting a pillow at each side for their arms to rest on. My wife also sits on a memory-foam cushion and uses a supportive neck pillow. (It would be absurd to classify these pillows and cushions, used solely to make people comfortable, as restraining devices.)
- Most geri-chairs come with a tray attachment that enables the person to eat a meal away from the dining room table or, if able, to play cards or do simple crafts. I attach my wife’s tray only when I feed her. (She can no longer feed herself.) I have never seen any other resident’s tray attached for any other purpose.
Fallacious Thinking
One of the most common errors in thinking is the failure to make careful distinctions. This failure is succinctly described in the ancient Yiddish proverb, “Send a fool to close the shutters and he’ll close them all over town.” Governmental failure to make distinctions is bountifully displayed in the regulations on geri-chairs. The most egregious examples include these:
Failure to distinguish between ALF residents who pose a danger to themselves and/or others, and those who do not. Alzheimer’s and other forms of dementia can make some people behave in unacceptable or dangerous ways. Other people, however, exhibit no such behavior. In my experience, people for whom geri-chairs are prescribed are almost always in the latter group.
Failure to distinguish between the need for an ALF and the need for a skilled nursing facility. Generally speaking, ALFs have nurses but emphasize caregiving, whereas skilled nursing facilities provide caregiving but emphasize nursing. Bureaucratic regulations for geri-chairs assume that all people who use geri-chairs need skilled nursing—that is, more administering of medicine, more monitoring of the individual’s physical condition, and more medical consultation than an ALF can provide. That notion greatly oversimplifies the reality.
Many people for whom geri-chairs are prescribed do not need extra nursing care. My wife, for example, takes NO medications other than baby aspirin and has no significant medical problems. Her need, and that of many others in her situation, is for more caregiving—that is, more personal attention at meals, more assistance in bathing, and more nurturing. Those needs are best met in an ALF with an Extended Congregate Care (ECC) license and a reasonable caregiver-to-resident ratio.
Failure to distinguish between making disabled people comfortable and restraining them. Is it “restraint” to use a geri-chair for a person unable to use her arms and legs because of Alzheimer’s or crippling arthritis? Only if the term “restraint” is tortured beyond all logic. By that reasoning, medication would also be banned—after all, the medications given for Alzheimer’s have a more “restraining” effect than any piece of furniture ever could.
Failure to distinguish between proper and improper use of a device. The geri-chair was designed to provide the comfort of a recliner and the mobility of a wheelchair for people with serious physical and/or mental disabilities. That use is proper and should not be restricted. In contrast, using a geri-chair to punish or discipline someone is improper and should be prohibited. The difference between the two uses is clear enough to be grasped by a moderately bright junior high student.
The fact that something may be misused does not justify banning it. No sane person would ban hammers or golf clubs because they might be used as weapons, children’s car seats because they could be used to restrain hyperactive children in their homes, or pillows because they could be used to suffocate people.
The ill-considered government regulations concerning geriatric chairs have their greatest negative impact on elderly citizens. But they also negatively affect the geriatric chair industry. I recently spoke with Tom Lorick, an executive with Winco Manufacturing of Ocala FL, one of the nation’s oldest and largest geri-chair makers. He explained that government regulations prohibit a number of design features and accessories that customers specifically request. In one instance, he noted, the regulations prevented the company from filling an order from Europe for several hundred geri-chairs with seat belts. In all likelihood that order went to a foreign chair manufacturer.
The aging of “baby boomers,” the largest generation in our history, is already swelling the number of residents in assisted living facilities and that number will continue to increase. That means that government regulations concerning geriatric chairs will deny more and more elderly Americans the comfort that will make their condition more bearable. It is time to end this abuse of the elderly by revising the restrictions on geriatric chairs.
Copyright © 2014 by Vincent Ryan Ruggiero. All rights reserved.
