Factors relating to the use of physical restraints in psychogeriatric care: A paradigm for elder abuse

Programa Hospital Seguro para a Pessoa Idosa: estudo observacional do impacto na redução de declínio funcional

Ao ser hospitalizado, o idoso apresenta maior risco de complicações e declínio funcional. O presente estudo avaliou os resultados do Programa Hospital Seguro para a Pessoa Idosa. A intervenção foi realizada em um hospital filantrópico da cidade de São Paulo, Brasil, por meio de uma estratégia de implantação estruturada em 10 passos, incluindo rastreio de fragilidade, avaliação multidimensional, plano terapêutico singular, implementação de protocolos e estratégias de gestão de alta. Foram analisadas ao longo de dois anos 865 internações de idosos frágeis. Indicadores de processo e de resultado foram comparados entre o primeiro ano (período de implementação) e o segundo ano (período de consolidação). A comparação dos indicadores entre os dois períodos revelou que o programa melhorou os processos assistenciais fundamentais na qualidade do cuidado para essa população, incluindo reabilitação motora iniciada nas primeiras 72 horas (74,1 vs. 84,3%; p < 0,001), triagem de risco de broncoaspiração (38,5 vs. 82,8%; p < 0,001) e suplementação nutricional oral (55,6 vs. 76,4%; p < 0,001). A taxa de declínio funcional, que era 17,2% no ano de implantação, caiu para 11,7% no ano de consolidação, com diferença significativa após ajuste em modelo multivariável (p = 0,009). Em conclusão, desenvolvemos um programa factível para a realidade dos hospitais brasileiros e que pode ser reproduzido em outros centros usando-se uma metodologia sistematizada de implantação. Os resultados relativos aos indicadores de processos assistenciais e desfechos clínicos parecem promissores. A disseminação dessa iniciativa deve ser considerada no planejamento das políticas de saúde pública para a rede hospitalar.

Prevalence and risk factors for seclusion and restraint in old-age psychiatry inpatient units

BACKGROUND AND OBJECTIVES

Coercion in psychiatry is legally tolerated as a last resort. The reduction of the use of coercion is a shared goal of hospital administrators, medical and nursing staff and representatives of patients and families but requires the identification of risk factors for coercion. These risk factors in geriatric psychiatric inpatient settings are not well known, especially regarding seclusion. Through examining the prevalence of coercion and patients' characteristics, this study aims to identify risk factors for coercion in elderly people.

METHODS

The use of coercion in the geriatric psychiatry division of Geneva University Hospital in 2017 was retrospectively analyzed. The incidence rate ratios were estimated with multivariable Poisson regressions to assess risk factors for coercion.

RESULTS

Eighty-one of 494 patients (16.4%) experienced at least one coercive measure during their stay (mainly seclusion). The risk factors for coercion were younger age, male gender, being divorced or married, cognitive disorders, high item 1 of the Health of the Nation Outcome Scales (HoNOS) score (overactive, aggressive, disruptive or agitated behavior) at admission, previous psychiatric hospitalizations and involuntary referrals from the emergency department. Other disorders and global HoNOS scores were not associated with the use of coercion.

CONCLUSION

Higher risks of coercion were outlined in men with cognitive disorders, agitated behaviors, and previous psychiatric hospitalizations. They differed from those observed in younger adults in terms of age, civil status, disorders, global HoNOS scores and referrals. Therefore, geriatric psychiatric populations should be specifically investigated for the development of interventions aiming coercion reduction.

Determinants of Non-emergency Use of Control Interventions in Older Canadian Psychiatric Inpatients: Analysizing the InterRAI Mental Health Electronic Health Records

Background: The use of control interventions (CIs; acute control medications, physical/mechanical restraint) is associated with negative physical and psychological outcomes, particularly in older adults who are physically vulnerable. The aims of this study were to: (i) report the rates of CI use in older psychiatric inpatients (age 65 - 84 and age 85+), and compare them with younger age groups (18 - 44, age 45 - 64); and (ii) identify the factors associated with non-emergency CI use in older psychiatric inpatients. Methods: Routinely collected interRAI Mental Health assessments from 2005 - 2018 in Ontario, Canada, were analyzed to determine the rates of CI use. Logistic regression models were used to examine the sociodemographic and clinical determinants of non-emergency and any CI use. Results: There were 226,119 (female: 48.6%) interRAI assessments, and 85% of those assessed were under 65 years of age. The rates of non-emergency CI use in the four age groups were: 18 - 44 = 9.4%, 45 - 64 = 8.3%, 65 - 84 = 9.9%, 85+ = 13.2%. The most significant determinants of non-emergency CI use in older adults were highest impairments in activities of daily living (ADL Short Form score 8-16: OR = 2.72, 95% CI = 2.42 - 3.06), highest levels of aggression (Aggressive Behavior Scale score 4 - 6: OR = 1.76, 95% CI = 1.57 - 1.98), and highest levels of positive psychotic symptoms (Positive Symptoms Scale score 9+: OR = 1.65, 95% CI = 1.43 - 1.90). Delirium, cognitive disorder diagnosis, cognitive impairment, and falls were also associated with increased CI use odds, as were having the reasons for admission be danger to self, danger to others or inability to care for self. Females were less likely to have non-emergency CI use (OR = 0.84, 95% CI = 0.73 - 0.95). Patients admitted from long-term care homes had significantly greater odds of non-emergency CI use compared with community admissions (OR = 1.18; 95% CI = 1.07 - 1.29). Conclusion: The higher rates of non-emergency CI use in older psychiatric inpatients is concerning. Alternative non-pharmacological and person-centered management strategies should be considered to support older psychiatric inpatients with functional impairment, positive symptoms, aggressive behavior, cognitive impairment and delirium. The use of CIs could be incorporated as a quality improvement activity to monitor changes at various service provision levels.

[Factors associated with physical restraint use in acute care hospitals: A comparison of patient characteristics between patients with and without restraints]

AIM

Physical restraints are defined as limitations on patients' freedom of movement, such as bed/chair belts and/or the use of mittens. Such restraints may be harmful, and the predictors of or factors reducing physical restraint use are unclear. This study investigated the factors determining physical restraint use in patients with stroke admitted to an acute care hospital.

METHODS

This retrospective study analyzed patients' data obtained between August 2014 and September 2015. The variables analyzed were age, sex, physical restraint use, operations performed, presence of tubes, stroke severity, psychotropic medication use, disturbance of consciousness, motor paralysis, cognitive status, independence in activities of daily living, and presence of behavioral disorders. Patient characteristics associated with physical restraints were analyzed using the t-test, Fisher's exact test, and a logistic regression analysis.

RESULTS

The analysis included 253 patients (179 in the non-restraint group and 74 in the restraint group). The prevalence of physical restraint use was 29.2%. The age, cognitive status, stroke severity, operations performed, presence of tubes, disturbance of consciousness, motor paralysis, independence in the activities of daily living, presence of behavioral disorders, and psychotropic medication use significantly differed between the two groups. A logistic regression analysis showed that the age, cognitive status, stroke severity, and presence of behavioral disorders were risk factors.

CONCLUSION

Physical restraint use is more likely in elderly patients and those with cognitive impairment, behavioral disorders, or serious strokes. Physical restraints are also more likely to be applied in patients with cognitive impairment than in those with merely physical impairment.

Physical Harm and Death in the Context of Coercive Measures in Psychiatric Patients: A Systematic Review

Background: For centuries coercive measures in psychiatry have been means of averting acute danger. It has been known for almost as long that these measures can lead to harm or even death to those affected. Over the past two decades the topic has increasingly been the subject of scientific discussion and research. While the legal and ethical preconditions for coercive measures in psychiatry as well as epidemiological studies on their incidence and patients' subjective experiences have increasingly come into focus, research on possible adverse events has lagged behind. To our knowledge there is no systematic review on the harmful or even fatal physical adverse effects of coercive interventions in psychiatry. Methods: We searched the databases PubMed and CINAHL for primary literature with a search string based on the PICO framework including key words describing different psychiatric diagnoses, coercive measures, and harms. Results: In total, 67 eligible studies (mainly case reports and case series) of very heterogeneous quality were included. Two RCTs were found reporting position-dependent cardiac deterioration, but were, however, carried out with healthy people and were characterized by a small number of cases. Death was the most frequently reported harm: cardiac arrest by chest compression in 14 studies, cardiac arrest by strangulation in 9, and pulmonary embolism in 8 studies. Further harms were, among others, venous thromboembolism and injuries. Injuries during physical restraint were reported in 0.8-4% of cases. For other kinds of coercive interventions, there are no sufficient data. Venous thromboembolism occurred in a considerable percentage of cases during mechanical restraint, also under prophylaxis. The most commonly reported coercive measure was restraint, distinguishing in mechanical restraint (43 studies), physical restraint (22 studies), bedrails (eight studies), vest restraint (7 studies), and chair restraint (6 studies). Forced medication was explicitly mentioned only in two, but seems to have occurred in nine studies. Six studies included seclusion. Conclusion: Coercive measures can lead to physical harm or even death. However, there is a significant lack of data on the incidence of such adverse events related to coercive interventions. Though reported anecdotally, physical adverse events during seclusion appear to be highly underresearched.

Physical restraints and associations with neuropsychiatric symptoms and personal characteristics in residential care: a cross-sectional study

BACKGROUND

Physical restraints are widely used in residential care. The objective was to investigate restraint use and its associations with neuropsychiatric symptoms and personal characteristics in residential care.

METHODS

Data were collected in the South Savo Hospital District from 66 of 68 public or private institutions providing long-term residential care. Nurses assessed the use of physical restraints and neuropsychiatric symptoms (NPS) included in the symptom list of the Neuropsychiatric Inventory (NPI). Drug use was obtained from medical records, and activities of daily living (ADL) were assessed by the nurses according to the Barthel Index.

RESULTS

The total number of persons in residential care was 1386. Any restraint was used for 721 patients (52%) in the preceding 24 h. Bedrails were the most common restraints. In the multivariate analysis, psychotic symptoms (OR 1.94, 95% CI 1.14-3.31) and use of benzodiazepines (OR 1.69, 95% CI 1.18-2.41) were positively associated with restraint use, whereas antipsychotic (OR 0.62, 95% CI 0.44-0.87) and antidepressant drug use (OR 0.64, 95% CI 0.45-0.90) and higher ADL score (OR 0.9, 95% CI 0.92-0.93) were negatively associated. Concomitant use of at least two restraints was associated with high prevalence of hyperactivity NPS symptoms.

CONCLUSIONS

More than half of the residents were exposed to some physical restraint, most frequently bedrails, within the last 24 h. Psychotic symptoms and benzodiazepine use increased while good ADL and antipsychotic or antidepressant use decreased the risk of restraint use. Bedridden persons were the most frequently restrained which may pose an ethical problem. Copyright © 2016 John Wiley & Sons, Ltd.

Restraint use among selected hospitalized elderly patients in Cairo, Egypt

Objective

This study’s primary objective was to investigate the prevalence of physical and chemical restraint use in selected elderly hospitalized patients.

Results

This study was conducted in April 2014 in four major acute care hospitals. Trained data collectors assessed the use of physical and chemical restraint among all admitted elderly patients. There were 287 elderly patients (median age 64 years, 46% women). 32 patients were restrained. The overall prevalence of restraints was 11.1%, with physical restraint use alone at 3.2% and chemical restraints use alone at 7.3%. Restraint use varied by hospital type, with the highest at the private hospital (22.9%) and the lowest at the two university hospitals (< 6%). In conclusion the prevalence of physical and chemical restraint use among admitted elderly patients in Egypt is comparable to that seen in developed countries. However, the use appears to vary widely by hospital type. The use of restraints in the elderly remains an important question considering the increasing number of elderly.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-2978-x) contains supplementary material, which is available to authorized users.

Effectiveness of bedrails in preventing falls among hospitalized older adults: a systematic review

BACKGROUND

Falls are a major problem today affecting adults of any age, but the elderly are a population that is more susceptible to falls. Falls are the leading cause of injury or death among older adults. Hospitalized older people are particularly vulnerable to falls. Falls cause direct injuries (minor injuries, severe wounds of the soft tissues and bone fractures) to patients and increased length of stay. The prevention of falls is commonly considered an indicator of the quality of care. Therefore, health institutions and professionals treat the identification and implementation of strategies to prevent or minimize their effects as a high priority. Fall prevention interventions involving physical restraints are still common and considered a primary preventative measure, despite controversy in their use. One of the most frequently used restraint interventions is bedrails. The question of the effectiveness of bedrails in preventing falls cuts across all societies and cultures and has with significant implications for the clinical practice of nurses.

OBJECTIVES

The objective of this review was to identify the effectiveness of the use of bedrails in preventing falls among hospitalized older adults when compared with no use of bedrails or any type of physical restraints.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered studies that included hospitalized adults (female and male), 65 years and over with any clinical condition in a non-intensive care unit (ICU).

TYPES OF INTERVENTION(S)

The current review considered studies that evaluated the use of bedrails as a restraint to prevent falls among older adults in non-ICUs compared to no use of bedrails or any type of physical restraints, for example, bedrails versus no bedrails, and bedrails versus no wrist or ankle ties.

TYPES OF STUDIES

The current review considered any randomized controlled trials (RCTs). In the absence of RCTs, other research designs such as non-RCTs, before and after studies, cohort studies, case-control studies, descriptive studies, case series/reports and expert-opinion were considered.

OUTCOMES

The current review considered studies that included primary outcomes (number of patients who fell or the number of falls per patient) and secondary outcomes (number of head trauma, bone fractures or soft tissue injuries).

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished articles. A three-step search strategy was utilized in 13 databases. Articles published in Portuguese, English and Spanish beginning from 1980 were considered for inclusion.

METHODOLOGICAL QUALITY

Assessment of methodological quality was not conducted as no articles were identified that met the inclusion criteria.

DATA EXTRACTION AND DATA SYNTHESIS

Data extraction and synthesis was not performed, because no articles were included in this systematic review.

RESULTS

The search identified a total of 875 potentially relevant articles. Sixteen articles were identified through the reference lists of all identified articles. One hundred and thirteen full-text papers were assessed by two independent reviewers to determine eligibility. However, 11 articles were not found (despite all the efforts), and 102 articles did not meet the inclusion criteria.

CONCLUSION

There is no scientific evidence comparing the use of bedrails in preventing falls among hospitalized older adults to no use of bedrails or any type of physical restraints.

A mixed method study of an education intervention to reduce use of restraint and implement person-centered dementia care in nursing homes

Background

People living with dementia in nursing homes are most likely to be restrained. The primary aim of this mixed-method education intervention study was to investigate which factors hindered or facilitated staff awareness related to confidence building initiatives based on person-centred care, as an alternative to restraint in residents with dementia in nursing homes. The education intervention, consisting of a two-day seminar and monthly coaching sessions for six months, targeted nursing staff in 24 nursing homes in Western Norway. The present article reports on staff-related data from the study.

Methods

We employed a mixed-method design combining quantitative and qualitative methods. The P-CAT (Person-centred Care Assessment Tool) and QPS-Nordic (The General Nordic questionnaire for psychological and social factors at work) instruments were used to measure staff effects in terms of person-centred care and perception of leadership. The qualitative data were collected through ethnographic fieldwork, qualitative interviews and analysis of 84 reflection notes from eight persons in the four teams who facilitated the intervention. The PARIHS (Promoting Action on Research Implementation in Health Services) theoretical framework informed the study design and the data analysis. Six nursing homes were selected for ethnographic study post-intervention.

Results

Qualitative data indicated increased staff awareness related to using restraint - or not- in the context of person-centered care. A slight increase in P-CAT supported these findings. Thirteen percent of the P-CAT variation was explained by institutional belonging. Qualitative data indicated that whether shared decisions of alternative measures to restraint were applied was a function of dynamic interplay between facilitation and contextual elements. In this connection, the role of the nursing home leaders appeared to be a pivotal element promoting or hindering person-centered care. However, leadership-staff relations varied substantially across individual institutions, as did staff awareness related to restraint and person-centeredness.

Conclusions

Leadership, in interplay with staff culture, turned out to be the most important factor hindering or promoting staff awareness related to confidence building initiatives, based on person-centered care. While quantitative data indicated variations across institutions and the extent of this variation, qualitative data offered insight into the local processes involved. A mixed method approach enabled understanding of dynamic contextual relationships.

Trial registration

The trial is registered at Clinical Trials gov. reg. 2012/304 NCT01715506.

Electronic supplementary material

The online version of this article (10.1186/s12912-017-0244-0) contains supplementary material, which is available to authorized users.

Incidence Rate and Patterns of Physical Restraint Use Among Adult Patients in Malaysia

Incidence rate and patterns of physical restraint use were examined based on a cross-sectional study in 22 wards of a large teaching hospital in Malaysia. Results indicated that the highest rate of physical restraint (19.7%) was reported from neurology-neurosurgery wards. "Un-cooperative for electroconvulsive therapy" and "trying to pull out catheters" were the most commonly reported reasons to use restraint in psychiatric and non-psychiatric wards, respectively. There were some relationships between patterns of physical restraint in this study. Exploring the incidence rate and patterns of physical restraint is important so that effective strategies can be formulated to minimize using restraint in hospitals.

Use of physical restraints in nursing homes: a multicentre cross-sectional study

Background

Although many countries have implemented strict legal rules, the prevalence of physical restraints in nursing homes seems to remain high. In Switzerland, data related to the frequency of physical restraints are scarce and little is known about associations with resident and nursing home characteristics. The aim of this study was to investigate the prevalence and types of physical restraints in nursing homes in two Swiss cantons and to explore whether resident-related and organisational factors are associated with the use of physical restraints.

Methods

We conducted a multicentre cross-sectional study. Twenty nursing homes with 1362 residents from two culturally different cantons were included. Data on physical restraints and residents’ characteristics were extracted from residents’ records (11/2013 to 2/2014). Organisational data were collected by questionnaires addressing nursing home directors or nursing managers. Sample size calculation and outcome analysis took cluster-adjustment into account. Descriptive statistics and multiple logistic regression analysis with nursing homes as random effect were used for investigation.

Results

The prevalence of residents with at least one physical restraint was 26.8 % (95 % confidence interval [CI] 19.8–33.8). Centre prevalence ranged from 2.6 to 61.2 %. Bilateral bedrails were most frequently used (20.3 %, 95 % CI 13.5–27.1). Length of residence, degrees of care dependency and mobility limitation were significantly positively associated with the use of physical restraint, but none of the organisational characteristics was significantly associated.

Conclusion

Approximately a quarter of the nursing home residents included in our study experienced physical restraints. Since variation between nursing homes was pronounced, it seems to be worthwhile to explore nursing homes with particularly low and high use of physical restraints in future research, especially by using qualitative methods. There is a need for effective interventions aiming at restraint-free nursing care. Development of interventional approaches should consider specific residents’ characteristics associated with restraint use.

Use of control interventions in adult in-patient mental health services

This study examined the prevalence of Control Intervention (CI) use in adult in-patient psychiatric units/hospitals in Ontario and developed a profile of those patients who had CI use during their admission between April 2006 and March 2010. Control intervention types included mechanical/physical, chair prevents rising, acute control medications, and seclusion. The profiles of patients with control intervention use included an examination of sociodemographic, mental health service use, and mental health clinical characteristics.

Predictors of Physical Restraint Use in Hospitalized Veterans at End of Life: An Analysis of Data from the BEACON Trial

BACKGROUND

The use of physical restraints in dying patients may be a source of suffering and loss of dignity. Little is known about the prevalence or predictors for restraint use at end of life in the hospital setting.

OBJECTIVE

The objective was to determine the prevalence and predictors of physical restraint use at the time of death in hospitalized adults.

METHODS

Secondary analysis was performed on data from the "Best Practices for End-of-Life Care for Our Nation's Veterans" (BEACON) trial conducted between 2005 and 2011. Medical record data were abstracted from six Veterans Administration Medical Centers (VAMCs). Data on processes of care in the last seven days of life were abstracted from the medical records of 5476 who died in the six VAMCs. We prospectively identified potential risk factors for restraint use at the time of death from among the variables measured in the parent trial, including location of death, medications administered, nasogastric tube, intravenous (IV) fluids, family presence, and receipt of a palliative care consultation.

RESULTS

Physical restraint use at time of death was documented in 890 decedents (16.3%). Restraint use varied by location of death, with patients in intensive settings being at higher risk. Restraint use was significantly more likely in patients with a nasogastric tube and those receiving IV fluids, benzodiazepines, or antipsychotics.

CONCLUSIONS

This is the first study to document that one in six hospitalized veterans were restrained at the time of death and to identify predictors of restraint use. Further research is needed to identify intervention opportunities.

Knowledge, perceptions, and experiences of family caregivers and home care providers of physical restraint use with home-dwelling elders: a cross-sectional study in Japan

BACKGROUND

The use of physical restraints by family caregivers with home-dwelling elders has not been extensively studied but it might be widespread. Furthermore, it is also not clear how home care providers who support family caregivers perceive the use of physical restraint in elders' homes. This study assessed family caregivers' and home care providers' knowledge and perceptions of physical restraint used with elders living at home in Japan, a country with the highest proportion of elders in the world and where family caregiving is common.

METHODS

We undertook a cross-sectional study of 494 family caregivers, 201 home helpers, 78 visiting nurses, 131 visiting physicians, and 158 care managers of home-dwelling frail elders needing some care and medical support in Japan, using questionnaires on knowledge of 11 physical restraint procedures prohibited in institutions and 10 harmful effects of physical restraints, perceptions of 17 reasons for requiring physical restraints, and experiences involving physical restraint use.

RESULTS

Family caregivers were aware of significantly fewer recognized prohibited physical restraint procedures and recognized harmful effects of physical restraint than home care providers, and differences among home care providers were significant. The average importance rating from 1 (least) to 5 (most) of the 17 reasons for requiring physical restraints was significantly higher among family caregivers than home care providers, and significantly different among the home care providers. Moreover, these differences depended in part on participation in physical restraint education classes. While 20.1% of family caregivers had wavered over using physical restraints, 40.5% of home care providers had seen physical restraints used in elders' homes and 16.7% had advised physical restraint use or used physical restraints themselves.

CONCLUSIONS

Knowledge and perceptions of physical restraints differed between family caregivers and home care providers and were also diverse among home care providers. Because both groups might be involved in physical restraint use with home-dwelling elders, home care providers should acquire standardized and appropriate knowledge and perceptions of physical restraints to help family caregivers minimize abusive physical restraint use.

Linguistic validation of the Alberta Context Tool and two measures of research use, for German residential long term care

Background

To study the association between organizational context and research utilization in German residential long term care (LTC), we translated three Canadian assessment instruments: the Alberta Context Tool (ACT), Estabrooks’ Kinds of Research Utilization (RU) items and the Conceptual Research Utilization Scale. Target groups for the tools were health care aides (HCAs), registered nurses (RNs), allied health professionals (AHPs), clinical specialists and care managers. Through a cognitive debriefing process, we assessed response processes validity–an initial stage of validity, necessary before more advanced validity assessment.

Methods

We included 39 participants (16 HCAs, 5 RNs, 7 AHPs, 5 specialists and 6 managers) from five residential LTC facilities. We created lists of questionnaire items containing problematic items plus items randomly selected from the pool of remaining items. After participants completed the questionnaires, we conducted individual semi-structured cognitive interviews using verbal probing. We asked participants to reflect on their answers for list items in detail. Participants’ answers were compared to concept maps defining the instrument concepts in detail. If at least two participants gave answers not matching concept map definitions, items were revised and re-tested with new target group participants.

Results

Cognitive debriefings started with HCAs. Based on the first round, we modified 4 of 58 ACT items, 1 ACT item stem and all 8 items of the RU tools. All items were understood by participants after another two rounds. We included revised HCA ACT items in the questionnaires for the other provider groups. In the RU tools for the other provider groups, we used different wording than the HCA version, as was done in the original English instruments. Only one cognitive debriefing round was needed with each of the other provider groups.

Conclusion

Cognitive debriefing is essential to detect and respond to problematic instrument items, particularly when translating instruments for heterogeneous, less well educated provider groups such as HCAs. Cognitive debriefing is an important step in research tool development and a vital component of establishing response process validity evidence. Publishing cognitive debriefing results helps researchers to determine potentially critical elements of the translated tools and assists with interpreting scores.

German translation of the Alberta Context Tool and two measures of research use: methods, challenges and lessons learned

Background

Understanding the relationship between organizational context and research utilization is key to reducing the research-practice gap in health care. This is particularly true in the residential long term care (LTC) setting where relatively little work has examined the influence of context on research implementation. Reliable, valid measures and tools are a prerequisite for studying organizational context and research utilization. Few such tools exist in German. We thus translated three such tools (the Alberta Context Tool and two measures of research use) into German for use in German residential LTC. We point out challenges and strategies for their solution unique to German residential LTC, and demonstrate how resolving specific challenges in the translation of the health care aide instrument version streamlined the translation process of versions for registered nurses, allied health providers, practice specialists, and managers.

Methods

Our translation methods were based on best practices and included two independent forward translations, reconciliation of the forward translations, expert panel discussions, two independent back translations, reconciliation of the back translations, back translation review, and cognitive debriefing.

Results

We categorized the challenges in this translation process into seven categories: (1) differing professional education of Canadian and German care providers, (2) risk that German translations would become grammatically complex, (3) wordings at risk of being misunderstood, (4) phrases/idioms non-existent in German, (5) lack of corresponding German words, (6) limited comprehensibility of corresponding German words, and (7) target persons’ unfamiliarity with activities detailed in survey items. Examples of each challenge are described with strategies that we used to manage the challenge.

Conclusion

Translating an existing instrument is complex and time-consuming, but a rigorous approach is necessary to obtain instrument equivalence. Essential components were (1) involvement of and co-operation with the instrument developers and (2) expert panel discussions, including both target group and content experts. Equivalent translated instruments help researchers from different cultures to find a common language and undertake comparative research. As acceptable psychometric properties are a prerequisite for that, we are currently carrying out a study with that focus.

Characteristics of nursing home residents and physical restraint: a systematic literature review

AIMS AND OBJECTIVES

To analyse and to summarise factors associated with nursing home residents' characteristics which could lead to physical restraint, and to investigate the consequences of physical restraint use for this population.

BACKGROUND

Even though the application of physical restraint is highly controversial, prevalence rates show that it is a common intervention in nursing homes. Residents' characteristics seem to be important to predict the use of physical restraint. Evidence suggests that restrained nursing home residents may have physical and psychological disadvantages as a consequence of being restrained.

METHODS

A systematic literature research involving the databases PubMed, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science and Cochrane Library was carried out for articles published from January 2005-November 2011. Nine Studies fulfilled the inclusion criteria and the quality assessment.

RESULTS

Restrained residents had low activities of daily living (ADL) scores and severe cognitive impairment. Residents with low cognitive status and serious mobility impairments were at high risk to be restrained, as well as residents with previous fall and/or fracture. Repeated verbal and physical agitation was found to be positively associated with restraint use. Possible consequences of physical restraint were as follows: lower cognitive and ADL performance, higher walking dependence, furthermore falls, pressure ulcers, urinary and faecal incontinence.

CONCLUSIONS

This systematic literature review reveals notable resident-related factors for physical restraint use. The consequences of restraint seem to negatively influence residents' physical and psychological well-being. Physical restraint seems to be an important risk factor for residents' further health problems.

RELEVANCE TO CLINICAL PRACTICE

Resident's characteristics appear to be decisive factors for the use of physical restraint. Nurses need a high level of expertise and competence in evaluating the individual residents' situation and deciding further steps, with respect for the autonomy and dignity of the person.

Which bed designs and patient characteristics increase bed rail use?

BACKGROUND

the design and use of bed rails has been contentious since the 1950s with benefits including safety, mobility support and access to bed controls and disadvantages associated with entrapment and restraint.

OBJECTIVE

to explore which bed designs and patient characteristics (mobility, cognitive status and age) influence the likelihood of rails being used on UK medical wards.

METHOD

the use of rails was surveyed overnight at 18 hospitals between July 2010 and February 2011.

RESULTS

data were collected on 2,219 beds with 1,799 included (occupied). Eighty-six percent had rails attached; 52% had raised rails (42% had all raised). Adjusted logistic regression results suggest a significantly increased likelihood of rail use for (i) electric profiling beds and ultra low beds; (ii) >80 years; (iii) described as having any level of confusion or mobility impairment. These variables together explained 55% of the variance in rail use. The most frequently mentioned reason for raising rails was 'to prevent falls from the bed' (61%) especially for patients described as confused (75%).

CONCLUSION

there were indications that rails were being used inappropriately (as a restraint) for both confused patients and those needing assistance to mobilise.

Institutional abuse of older adults: what we know, what we need to know

Although Canadian policies support "aging in place," there still will be a number of older adults who will require institutional care in the future. Most research on elder abuse, however, has focused on domestic abuse and has paid less attention to institutional abuse. The purpose of this article is to comprehensively review current research to identify gaps in knowledge and methodological issues in the study of institutional abuse. Overall, 49 studies in English and 20 studies in French were reviewed, and 11 key-informant interviews were conducted with methodological experts. Methodological challenges are addressed in light of the review and interviews.

Elder abuse

Five types of elder abuse (physical, psychological, sexual, neglect and financial) are recognized. They are not new, occur worldwide and are associated with persistent morbidity and mortality. The forensic clinician has responsibilities to: (i) the patient, with competent history taking and examination, (ii) interpret findings and recognize patterns of harm and (iii) promulgate this issue in wider professional and public forums. Research into elder abuse is relatively recent; standardized terminology remains unsettled, and small-scale, local studies are hard to generalize. Cross-sectional, population-based studies of elder abuse should be possible, and standardized endpoints will require forensic science contributions.

A national survey of the use of physical restraint in long-term care hospitals in Japan

AIMS AND OBJECTIVES

To investigate the prevalence of physical restraints in the long-term care hospitals in Japan and to examine the factors of physical restraint use, including the specific skills/techniques that the staff use to minimise the restraints. Background.  Despite the national efforts to nullify physical restraint, it is still prevalent in long-term care facilities in and out of Japan. More detailed information regarding what affects physical restraint is needed.

DESIGN

Cross-sectional mail survey.

METHOD

A questionnaire was sent to a nursing ward manager of the random sample of long-term care facilities in Japan.

RESULTS

The average rate of physical restraint was 25·5%. Altogether, 81·0% of the restrained clients were under restraint for more than one month. The most prevalent method of restraint was bilateral bedrails, followed by the use of coveralls and gloves. Factors of restraint were different depending on the type of restraint, suggesting specific approaches are needed for specific type of restraint.

CONCLUSIONS

Physical restraint is still prevalent in Japanese long-term care hospitals, and nurses need to develop effective intervention approach to redesigning practice related to physical restraints. Specialised intervention approach seems needed depending on the types of restraint.

RELEVANCE TO CLINICAL PRACTICE

Specific approach should be developed to minimise the physical restraint in long-term care hospitals in Japan.

Education on physical restraint reduction in dementia care: a review of the literature

Dementia is a priority area for all countries as populations age and dementia prevalence increases. The use of physical restraint is a possible clinical practice for persons with dementia across settings when behaviours indicate a perceived need. Indeed, this may be the first choice in practice, occurring in part because of lack of education, safety concerns, perceived costs and staffing issues. This article reviews the literature on the issues surrounding, and use of, physical restraint for people with dementia, highlighting the rationales for use and the benefits and barriers to physical restraint. Recommendations include the importance of education and policy to reduce or eliminate physical restraint of persons with dementia to overcome identified barriers at the individual, cultural and organizational levels. An educational programme from the literature review is proposed specific to the reduction or elimination of physical restraint.

Elder Abuse and Neglect in Canada: The Glass is Still Half Full

Cet article examine les développements dans le domaine de la maltraitance et de la négligence des aînés depuis la publication de Elder Abuse and Neglect in Canada (Butterworths, 1991). Les arguments présentés ici sont de deux ordres : d’abord, nous n’avons aucune idée de la taille ou de la nature du problèmes de la violence et de la négligence dans la communauté ou dans les institutions et, d’autre part, nous ne savons pas comment résoudre ces problèmes ou leurs questions connexes qui ont été masqués par la rhétorique et le recyclage de l’information pendant les 20 dernières années. C’est le temps d’avancer au-delà de la « phase de sensibilisation ». Ce à quoi nous devons nous attaquer à l’avenir est aussi évident aujourd’hui qu’il ne l’était il y a 20 ans. Notre connaissance est incomplète parce qu’il nous manque le type d’enquêtes dont le besoin se fait le plus urgent: les études de prévalence dans la communauté et les institutions, un développement théoriquement solide, et des essais cliniques randomisé pour tester à la fois nos interventions socialement et juridiquement.

Abuse of older Chinese with dementia by family caregivers: an inquiry into the role of caregiver burden

OBJECTIVE

This study examined the prevalence and risk factors for elder abuse in older Chinese with dementia by their family caregivers in Hong Kong.

METHODS

A sample of 122 family caregivers of older persons with dementia was conveniently recruited from local community centers for the elderly. Participants provided information on their demographic characteristics, care recipients' physical functioning and agitated behavior, caregiver burden, and whether they had directed any abusive behavior at the care recipients in the previous month.

RESULTS

Sixty-two and 18 per cent of the caregivers reported having verbally or physically abused the care recipients in the past month. Family caregivers who spent more days co-residing with the care recipients, lacked any assistance from a domestic helper, observed more agitated behaviors in the care recipients, and/or reported a higher level of caregiver stress, reported more abusive behaviors. The results of hierarchical regression analysis showed that the number of co-residing days (p < 0.001), lack of any assistance from a domestic helper (p < 0.05), and caregiver burden (p < 0.01) were significant predictors of verbal abuse. Care recipient agitated behavior (p < 0.01) also predicted verbal abuse, with its effect mediated by caregiver burden. For physical abuse, the number of co-residing days (p < 0.01) was the only significant predictor.

CONCLUSIONS

Verbal and physical abuse were highly prevalent among this population of older Chinese with dementia. A higher level of caregiver stress is related to a higher level of verbal, but not physical abuse inflicted by the caregivers of these older persons with dementia.

Variation in use of coercive measures in psychiatric hospitals

PURPOSE

The use of coercive measures in psychiatry is still poorly understood. Most empirical research has been limited to compulsory admission and to risk factors on an individual patient level. This study addresses three coercive measures and the role of predictive factors at both patient and institutional levels.

METHODS

Using the central psychiatric register that covers all psychiatric hospitals in Canton Zurich (1.3 million people), Switzerland, we traced all inpatients in 2007 aged 18-70 (n = 9698). We used GEE models to analyse variation in rates between psychiatric hospitals.

RESULTS

Overall, we found quotas of 24.8% involuntary admissions, 6.4% seclusion/restraint and 4.2% coerced medication. Results suggest that the kind and severity of mental illness are the most important risk factors for being subjected to any form of coercion. Variation across the six psychiatric hospitals was high, even after accounting for risk factors on the patient level suggesting that centre effects are an important source of variability. However, effects of the hospital characteristics 'size of the hospital', 'length of inpatient stay', and 'work load of the nursing staff' were only weak ('bed occupancy rate' was not statistically significant).

CONCLUSION

The significant variation in use of coercive measures across psychiatric hospitals needs further study.

Management and outcomes of delirious patients with hyperactive symptoms in a secured behavioral unit jointly used by geriatricians and pyschogeriatricians

To compare the clinical outcomes and length of stay (LOS) between delirious patients with hyperactive symptoms admitted directly and those admitted indirectly from Emergency Department into a secured, behavioral unit jointly used by geriatricians and pyschogeriatricians (the Unit). A retrospective study analyzing data from the medical records of 122 patients with an admission diagnosis of delirium with hyperactive symptoms and subsequently discharged from the Unit, including restraint, one-to-one nursing care, falls, absconding, duration of delirium, recovery from delirium, destination and LOS. Significantly fewer patients with direct admission (n=68) required physical restraint or chemical restraint compared with those transferred (n=54). Patients admitted directly showed a higher discharge rate back home, shorter LOS, shorter duration of delirium and a higher rate of recovery from delirium than transferred patients. Of the transferred patients, more received one-to-one nursing care before transfer than after transfer. Three (5.6%) absconded before transfer, but none absconded from the Unit. The falls rate reduced from 14.2 to 6.7 falls/1000 patient delirium days after transfer. Delirious patients with hyperactive symptoms admitted directly to the Unit fared better in clinical outcomes and LOS. They also required less restraint, less intensive nursing and were unlikely to abscond compared to those transferred.

[Delirium in the elderly]

Delirium is a common, serious medical and often life-threatening condition in elderly in-patients. Delirium can develop primarily or secondarily related to other medical conditions and lead to hospital admission. The pathogenesis is still not fully known and is usually addressed as multifactorial. Alterations in neurotransmitters have a key role in this process. The incidence varies by setting up to 90%. Delirium is associated with increased short- and long-term mortality, iatrogenic complications, functional decline, and future development of cognitive impairment or dementia. Delirium is also associated with longer hospital stays, higher hospital and total health system costs, and an increasing rate of nursing home admissions. A structured diagnostic and therapeutic process is recommended. Delirium should become a quality indicator for hospital medicine; however, many research questions still exist.

Factors related to potentially harmful behaviors towards disabled older people by family caregivers in Japan

OBJECTIVE

The purpose of the present study was to examine factors related to potentially harmful behaviors (PHB) by family caregivers towards their older family members.

METHODS

Four hundred and twelve pairs of disabled older adults and their family caregivers participated in the study. All of these disabled older adults were users of visiting nursing services under the public Long-Term Care insurance system, who resided in one of the eight catchment areas of visiting nursing services in Kyoto Prefecture, Japan. The caregivers were asked to complete questionnaires in relation to their PHB towards their older family members, caregiver burden, patient-caregiver kinship, behavioral disturbances of their older adult, age and sex. Visiting nurses obtained the following information regarding the older adults: the severity of dementia; the severity of physical impairment; age and sex.

RESULTS

More than 30% of the caregivers admitted PHB towards their older family members. The most frequently reported PHB included verbal aggression (16.8%) and ignoring (13.6%). A logistic regression analysis revealed that adult children (OR = 2.69, 95%CI = 1.23-5.89, p = 0.013) and caregivers of disabled older people with behavioral disturbances (OR = 3.61, 95%CI = 1.65-7.90, p < 0.01) were more likely to show PHB.

CONCLUSIONS

In the present study, PHB towards the older people by family caregivers was associated with patients' behavioral disturbances and patient-caregiver kinship, i.e. an adult child as a caregiver. These findings should be taken into account when planning strategies to prevent PHB by family members.