Reducing and managing restraints in long-term-care facilities

Interventions for preventing and reducing the use of physical restraints for older people in all long-term care settings

BACKGROUND

Physical restraints (PR), such as bedrails and belts in chairs or beds, are commonly used for older people receiving long-term care, despite clear evidence for the lack of effectiveness and safety, and widespread recommendations that their use should be avoided. This systematic review of the efficacy and safety of interventions to prevent and reduce the use of physical restraints outside hospital settings, i.e. in care homes and the community, updates our previous review published in 2011.

OBJECTIVES

To evaluate the effects of interventions to prevent and reduce the use of physical restraints for older people who require long-term care (either at home or in residential care facilities) SEARCH METHODS: We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid Sp), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register, the International Clinical Trials Registry Portal, on 3 August 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that investigated the effects of interventions intended to prevent or reduce the use of physical restraints in older people who require long-term care. Studies conducted in residential care institutions or in the community, including patients' homes, were eligible for inclusion. We assigned all included interventions to categories based on their mechanisms and components.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the publications for inclusion, extracted study data, and assessed the risk of bias of all included studies. Primary outcomes were the number or proportion of people with at least one physical restraint, and serious adverse events related to PR use, such as death or serious injuries. We performed meta-analyses if necessary data were available. If meta-analyses were not feasible, we reported results narratively. We used GRADE methods to describe the certainty of the evidence.

MAIN RESULTS

We identified six new studies and included 11 studies with 19,003 participants in this review update. All studies were conducted in long-term residential care facilities. Ten studies were RCTs and one study a CCT. All studies included people with dementia. The mean age of the participants was approximately 85 years. Four studies investigated organisational interventions aiming to implement a least-restraint policy; six studies investigated simple educational interventions; and one study tested an intervention that provided staff with information about residents' fall risk. The control groups received usual care only in most studies although, in two studies, additional information materials about physical restraint reduction were provided. We judged the risk of selection bias to be high or unclear in eight studies. Risk of reporting bias was high in one study and unclear in eight studies. The organisational interventions intended to promote a least-restraint policy included a variety of components, such as education of staff, training of 'champions' of low-restraint practice, and components which aimed to facilitate a change in institutional policies and culture of care. We found moderate-certainty evidence that organisational interventions aimed at implementation of a least-restraint policy probably lead to a reduction in the number of residents with at least one use of PR (RR 0.86, 95% CI 0.78 to 0.94; 3849 participants, 4 studies) and a large reduction in the number of residents with at least one use of a belt for restraint (RR 0.54, 95% CI 0.40 to 0.73; 2711 participants, 3 studies). No adverse events occurred in the one study which reported this outcome. There was evidence from one study that organisational interventions probably reduce the duration of physical restraint use. We found that the interventions may have little or no effect on the number of falls or fall-related injuries (low-certainty evidence) and probably have little or no effect on the number of prescribed psychotropic medications (moderate-certainty evidence). One study found that organisational interventions result in little or no difference in quality of life (high-certainty evidence) and another study found that they may make little or no difference to agitation (low-certainty evidence). The simple educational interventions were intended to increase knowledge and change staff attitudes towards PR. As well as providing education, some interventions included further components to support change, such as ward-based guidance. We found pronounced between-group baseline imbalances in PR prevalence in some of the studies, which might have occurred because of the small number of clusters in the intervention and control groups. One study did not assess bedrails, which is the most commonly used method of restraint in nursing homes. Regarding the number of residents with at least one restraint, the results were inconsistent. We found very-low certainty evidence and we are uncertain about the effects of simple educational interventions on the number of residents with PR. None of the studies assessed or reported any serious adverse events. We found moderate-certainty evidence that simple educational interventions probably result in little or no difference in restraint intensity and may have little or no effect on falls, fall-related injuries, or agitation (low-certainty evidence each). Based on very low-certainty evidence we are uncertain about the effects of simple educational interventions on the number of participants with a prescription of at least one psychotropic medication. One study investigated an intervention that provided information about residents' fall risk to the nursing staff. We found low-certainty evidence that providing information about residents' fall risk may result in little or no difference in the mean number of PR or the number of falls. The study did not assess overall adverse events.

AUTHORS' CONCLUSIONS

Organisational interventions aimed to implement a least-restraint policy probably reduce the number of residents with at least one PR and probably largely reduce the number of residents with at least one belt. We are uncertain whether simple educational interventions reduce the use of physical restraints, and interventions providing information about residents' fall risk may result in little to no difference in the use of physical restraints. These results apply to long-term care institutions; we found no studies from community settings.

Evaluation of reporting quality of abstracts of randomized controlled trials regarding patients with COVID-19 using the CONSORT statement for abstracts

OBJECTIVE

To evaluate the reporting quality of randomized controlled trial (RCT) abstracts regarding patients with coronavirus disease 2019 (COVID-19) and to analyze the factors influencing the quality.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched to collect RCTs on patients with COVID-19. The retrieval time was from inception to December 1, 2020. The CONSORT statement for abstracts was used to evaluate the reporting quality of RCT abstracts.

RESULTS

A total of 53 RCT abstracts were included. The CONSORT statement for abstracts showed that the average reporting rate of all items was 50.2%. The items with a lower reporting quality were mainly the trial design and the details of randomization and blinding (<10%). The mean overall adherence score across all studies was 8.68 ± 2.69 (range 4-13.5). Multivariate linear regression analysis showed that the higher reporting scores were associated with higher journal impact factor (P < 0.01), international collaboration (P = 0.04), and structured abstract format (P < 0.01).

CONCLUSIONS

Although many RCTs on patients with COVID-19 have been published in different journals, the overall quality of reporting in the included RCT abstracts was suboptimal, thus diminishing their potential usefulness, and this may mislead clinical decision-making. In order to improve the reporting quality, it is necessary to promote and actively apply the CONSORT statement for abstracts.

Stepped wedge cluster randomised trials: a review of the statistical methodology used and available

BACKGROUND

Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials.

METHODS

Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design.

RESULTS

This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used.

CONCLUSIONS

Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.

The effect of work-based mentoring on patient outcome in musculoskeletal physiotherapy: study protocol for a randomised controlled trial

BACKGROUND

Despite persistent calls to measure the effectiveness of educational interventions on patient outcomes, few studies have been conducted. Within musculoskeletal physiotherapy, the effects of postgraduate clinical mentoring on physiotherapist performance have been assessed, but the impact of this mentoring on patient outcomes remains unknown. The objective of this trial is to assess the effectiveness of a work-based mentoring programme to facilitate physiotherapist clinical reasoning on patient outcomes in musculoskeletal physiotherapy.

METHODS/DESIGN

A stepped wedge cluster randomised controlled trial (CRCT) has been designed to recruit a minimum of 12 senior physiotherapists who work in musculoskeletal outpatient departments of a large National Health Service (NHS) organization. Participating physiotherapists will be randomised by cluster to receive the intervention at three time periods. Patients will be blinded to whether their physiotherapist has received the intervention. The primary outcome measure will be the Patient-Specific Functional Scale; secondary outcome measures will include the EQ-5D, patient activation, patient satisfaction and physiotherapist performance. Sample size considerations used published methods describing stepped wedge designs, conventional values of 0.80 for statistical power and 0.05 for statistical significance, and pragmatic groupings of 12 participating physiotherapists in three clusters. Based on an intergroup difference of 1.0 on the PSFS with a standard deviation of 2.0, 10 patients are required to complete outcome measures per physiotherapist, at time period 1 (prior to intervention roll-out) and at each of time periods 2, 3 and 4, giving a sample size of 480 patients. To account for the potential loss to follow-up of 33%, 720 sets of patient outcomes will be collected.All physiotherapist participants will receive 150 hours of mentored clinical practice as the intervention and usual in-service training as control. Consecutive, consenting patients attending treatment by the participating physiotherapists during data collection periods will complete outcome measures at baseline, discharge and 12 months post-baseline. The lead researcher will be blinded to the allocation of the physiotherapist when analyzing outcome data; statistical analysis will involve classical linear models incorporating both an intervention effect and a random intercept term to reflect systematic differences among clusters.

TRIAL REGISTRATION

Assigned 31 July 2012: ISRCTN79599220.

Interventions for preventing and reducing the use of physical restraints in long-term geriatric care

BACKGROUND

Physical restraints (PR) are commonly used in geriatric long-term care. Restraint-free care should be the aim of high quality nursing care.

OBJECTIVES

To evaluate the effectiveness of interventions to prevent and reduce the use of physical restraints in older people who require long-term nursing care (either in community nursing care or in residential care facilities).

SEARCH STRATEGY

The Cochrane Dementia and Cognitive Improvement Group's Specialized Register, MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, a number of trial registers and grey literature sources were searched on 7 September 2009. The following search terms were used: "physical restraint*", bedrail*, bedchair*, "containment measure*, elderly, "old people", geriatric*, aged, "nursing home*", "care home*", "geriatric care", "residential facilit*".

SELECTION CRITERIA

Individual or cluster-randomised controlled trials comparing an intervention aimed at reducing the use of physical restraints with usual care in long-term geriatric care settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the retrieved articles for relevance and methodological quality and extracted data. Critical appraisal of studies addressed risk of bias through selection bias, performance bias, attrition bias, and detection bias, as well as critera related to cluster designa. We contacted study authors for additional information where necessary. PR were defined heterogeneously throughout the studies. Not all studies offered sufficient data for aggregated data meta-analysis, and therefore study results are presented in a narrative form.

MAIN RESULTS

Five cluster-randomised controlled studies met the inclusion criteria. All of them investigated educational approaches. Two studies offered consultation in addition and two other studies offered guidance for nursing staff in addition. Four studies examined nursing home residents and one study residents in group dwelling units. No studies in community settings were included. Three studies included only one or two nursing homes per study condition. Overall, methodological quality of studies was low.The studies revealed inconsistent results. One study in the nursing home setting documented an increase of PR use in both groups after eight months, while the other three studies found reduced use of PR in the intervention groups after seven and 12 months of follow up respectively. The single study examining residents in group dwelling units found no change in PR use in the intervention group after six months whereas PR use increased significantly in the control group.

AUTHORS' CONCLUSIONS

There is insufficient evidence supporting the effectiveness of educational interventions targeting nursing staff for preventing or reducing the use of physical restraints in geriatric long-term care.

Sustaining a Best-Care Practice in a Nursing Home

This study tested whether an action research organizational intervention fostering participatory management practices would sustain a nursing best-care practice protocol in a nursing home. An experimental nursing home (EH) and a control nursing home (CH) with similar characteristics were studied over a 4-year period. A pretest/posttest quasi-experimental design was used. Baseline data were co[lected on residents, families, and the staffs at the EH and the CH. Staff turnover rates, demographics of participant groups, and surveys concerning job stress, nursing care, family involvement, and satisfaction of residents and family members served as proximal outcomes to indicate whether organizational changes had occurred in the EH. Sustaining best practices in a nursing home requires not only significant organizational change but also changes in regulatory support for quality care, sufficient staff resources to implement and monitor the practices, and a change coordinator with sufficient formal or informal influence.

Continuous quality improvement as an innovation: which nursing facilities adopt it?

PURPOSE

We identify environmental and organizational predictors that best discriminate between formal continuous quality improvement (CQI) adopters and nonadopters in nursing homes (NHs) and create a diagnostic profile for facility administrators and policy makers to promote CQI.

DESIGN AND METHODS

We performed a cross-sectional survey of licensed NH administrators in New Jersey in 1999, using The Nursing Care Quality Improvement Survey ( Zinn, Weech, & Brannon, 1998) and The New Jersey NH Profiles Chart. We also performed a discriminant analysis. Of 350 NHs, 46% returned completed questionnaires.

RESULTS

Using variance innovation, resource dependence, and institutional perspectives for our framework, we found that new requirements, environmental competition, organizational time and structural facilitators, and manager training made statistically significant contributions to discriminating between formal CQI adopters and nonadopters.

IMPLICATIONS

Regardless of size, NHs adopt formal CQI to meet external expectations of new regulations and accreditation criteria. CQI adoption is facilitated by information systems, flexible use of personnel, and team supports, as well as CQI training for managers. This profile of adopters can guide administrators and policy makers in promoting CQI for NHs, and it can help NHs already interested in CQI focus internal resources on key facilitators.

Perceptions regarding the use of physical restraints with elderly persons: comparison of Israeli health care nurses and social workers

In view of the difficulty involved in decision-making regarding the use or removal of physical restraints and the recent pattern encouraging the use of interdisciplinary teams for elder care issues, the present study compared the perceptions of Israeli nurses and social workers in health care settings regarding the use of physical restraints. Data were collected from a convenience sample of 50 nurses and 69 social workers working in long-term and acute care settings. The findings indicated that participants in all professions attributed moderate to low importance towards the use of physical restraints. Social workers' perceptions were similar to those of nurses in psychiatric hospitals and slightly more favourable to the use of physical restraints than those of nurses in nursing homes. Patients' safety (as reflected in the scores of the items related to protecting an older person from falling and protecting an older person from pulling out a catheter) was the most important reason for using physical restraints for both groups. Increased attention should be given to the role of social workers as team members in the process of decision-making regarding the use or removal of physical restraints, especially as mediators between the elderly person, family members and staff members.

Nursing staff members' intentions to use physical restraints with older people: testing the theory of reasoned action

AIM OF THE STUDY

To examine nursing staff members' attitudes, subjective norms, moral obligations and intentions to use physical restraints, using the Theory of Reasoned Action (TRA).

RATIONALE

During the last two decades an extensive body of research has examined nurses' attitudes as one of the main factors affecting the decision to use or not to use physical restraints with older persons. However, no studies have examined empirically the antecedents to nurses' intentions to use physical restraints within a theoretically based framework.

METHOD

A correlational design was used with 303 nursing staff members from an 800-bed elder care hospital in central Israel. Participants completed a questionnaire including questions based on the TRA as well as socio-demographic and professional characteristics.

RESULTS

Regression analyses found attitudes, subjective norms and moral considerations to be significantly associated to intention to use physical restraints with older people. The TRA explained 48% of the variance in nurses' intentions.

CONCLUSIONS

The TRA proved to be a useful framework for examining nurses' intentions to use physical restraints. Nurses' attitudes, beliefs and expectations of significant others should be examined before implementing educational programmes regarding the use of physical restraints.

Citations and compliance with the Nursing Home Reform Act of 1987

The purpose of this article is to show which Nursing Home Reform Act (NHRA) regulations nursing homes are, and are not, complying with. This is achieved by using deficiency citations that are issued by state and federal inspectors when a facility does not meet a NHRA standard. Structural and process characteristics of nursing homes associated with these deficiency citations are presented. The results of these analyses are discussed in terms of their policy issues.

Nutritional intake monitoring for nursing home residents: a comparison of staff documentation, direct observation, and photography methods

BACKGROUND

The current approach to assessing nutritional intake requires nursing home (NH) staff to document total percentage of food and fluid consumed at each meal. Because NH staff tend to significantly overestimate total food intake, methods need to be developed to improve the accuracy of food intake measurement.

OBJECTIVE

To compare three methods of assessing the nutritional intake of NH residents.

RESEARCH DESIGN

Validation Study.

SUBJECTS

Fifty-six NH residents in one facility.

MEASURES

Total percentage of food and fluid intake of each resident for each of nine meals, or all three meals for 3 consecutive days, was assessed by: (1) Nursing home staff chart documentation, (2) Research staff documentation according to direct observations, and (3) Research staff documentation according to photographs of residents' trays before and after each meal.

RESULTS

Research staff documentation of total intake and intake of all individual food and fluid items was similar for the direct observation and photography methods. In comparison with these two methods, NH staff documentation reflected a significant overestimate (22%) of residents' total intake levels. In addition, NH staff failed to identify the more than half (53%) of those residents whose intake levels were equal to or below 75% for most meals.

CONCLUSIONS

The photography method of nutritional assessment yielded the same information as direct observations by research staff, and both of these methods showed the intake levels of NH residents to be significantly lower than the intake levels documented by NH staff. The photography method also has several advantages over a documentation system that relies on an observer to be present to record food and fluid intake levels.

Seclusion and restraint for people with serious mental illnesses

BACKGROUND

Seclusion and restraint are interventions used in the treatment and management of disruptive and violent behaviours in psychiatry. The use of seclusion varies widely across institutions. The literature does offer numerous suggestions for interventions to reduce or prevent aggression.

OBJECTIVES

1. To estimate the effects of seclusion and restraint compared to the alternatives for those with serious mental illnesses. 2. To estimate the effects of strategies to prevent seclusion and restraint in those with serious mental illnesses.

SEARCH STRATEGY

Electronic searches of The Cochrane Controlled Trials Register (Issue 1, 1999) and The Cochrane Schizophrenia Group's Register (January 1999) were supplemented with additional searches of Biological Abstracts (1989-1999), CINAHL (1982-1999), EMbase (1980-1999), MEDLINE (1966-1999), MEDIC (1979-1999), PsycLIT (1974-1999), Sociofile (1974-1999), SPRI & SWEMED (1982-1999), Social Sciences Citation Index (1996-1999), and WILP (1983-1999). In addition, trials were sought by hand searching the reference lists of all identified studies and conference abstracts and contacting the first author of each relevant study.

SELECTION CRITERIA

Randomised controlled trials were included if they focused on the use (i) of restraint or seclusion; or (ii) of strategies designed to reduce the need for restraint or seclusion in the treatment of serious mental illness.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data relative risks (RR) with 95% confidence intervals (CI) were estimated. Normal continuous data were summated using the weighted mean difference (WMD).

MAIN RESULTS

1. Effect of seclusion and restraint The search strategy yielded 2155 citations. Of these, the full articles for 35 studies were obtained. No studies met minimum inclusion criteria and no data were synthesised. Most of the 24 excluded studies focused upon the restraint of elderly, confused people and preventing them from wandering or falling. 2. Prevention of seclusion and restraint Work ongoing.

REVIEWER'S CONCLUSIONS

No controlled studies exist that evaluate the value of seclusion or restraint in those with serious mental illness. There are reports of serious adverse effects for these techniques in qualitative reviews. Alternative ways of dealing with unwanted or harmful behaviours need to be developed. Continuing use of seclusion or restraint must therefore be questioned from within well-designed and reported randomised trials that are generalisable to routine practice.

What is the quality of the reporting of research ethics in publications of nursing home research?

OBJECTIVE

To assess the quality of reporting of research ethics in published clinical research that involves a particularly vulnerable population: nursing home residents.

DESIGN

A structured review of publications researched from 1992 to 1996 that involve nursing home residents. The review instrument assessed each publication's compliance with four common standards for research that involves nursing home residents or the cognitively impaired: justification of the use of nursing home residents, Institutional Review Board (IRB) review, nursing home committee review, and informed consent. For each publication, these results were summed into a quality score. The research ethics requirements contained in the journals' instructions for authors that corresponded with each publication were categorized in order to compare whether an association exists between the average quality score for each category and the detail of its research ethics instructions.

RESULTS

Forty-five publications were identified. The four quality measures of research ethics showed that (1) all 45 publications reported justification of use of nursing home residents, (2) 36 publications reported that informed consent was obtained or waived, (3) 18 publications reported IRB review, and (4) six publications reported nursing home committee review. Of the 35 publications reporting informed consent was obtained, 16 reported assessing subjects' decisional capacity, and 24 reported whether cognitively impaired subjects were included (19) or excluded (5). The research ethics requirements of each publication's instructions for authors ranked it in one of four categories: (A) None (9); (B) Less than "Uniform Requirements (UR) for Manuscripts Submitted to Biomedical Journals" (7); (C) UR (24); (D) UR plus Additional Instructions (5). A positive association exists between the detail of a research ethics instructions category and the average research ethics quality score for each category (Kruskal-Wallis chi2 = 11.2, P = .01). That is, the more detailed the instructions, the greater the quality score.

CONCLUSION

In publications of research that involves nursing home residents, basic standards of research ethics are not typically reported. However, the positive association between research ethics instructions category and research ethics quality score suggests that a journal's instructions for authors or other features of peer review and editing can affect the quality of reporting research ethics.

Physical restraints in nursing homes: a review of the literature since the Nursing Home Reform Act of 1987

The use of physical restraints is one of the most negative features of nursing home care. Their use significantly affects the quality of life of residents. In an attempt to limit the use of restraints, the Nursing Home Reform Act (NHRA) of 1987 contained provisions regulating their use. In this article, the authors review the literature on the use and consequences of physical restraints in nursing homes since the passage of the NHRA. First, they describe the history behind the use of restraints and define what is considered to be a physical restraint. Second, they examine the four most common justifications for restraint use. Third, they describe the incidence and prevalence of restraint use. Fourth, they address demographic and clinical characteristics of residents that have been found to be associated with restraint use. Fifth, they examine negative outcomes of restraining residents. Finally, they describe alternatives to using restraints.

Developing rehabilitative behavioral interventions for long-term care: technology transfer, acceptance, and maintenance issues

Rehabilitative behavioral interventions that are documented in clinical trials to improve nursing home resident outcomes and are recommended by practice guidelines are often not adapted for daily use in nursing homes and other long-term care (LTC) facilities. Failure to evaluate issues other than clinical efficacy when developing interventions contributes to this gap between efficacy and effectiveness in practice. A potential solution is a research model that supplements traditional clinical intervention research with methodology designed specifically to evaluate the ability of LTC facilities to implement the interventions. This paper discusses several critical issues of intervention and implementation that should be addressed, including targeting interventions, advocacy, cost-effectiveness, training, and quality control. We also describe how clinical trials could be designed and staged to increase the probability that effective interventions will be implemented in the day-to-day care of frail older patients in LTC facilities.

Lessons from geriatric psychiatry in the long-term care setting

Of all long-term care settings, the nursing home has served as the most productive laboratory for the study of the mental health problems of late life. Lessons from geriatric psychiatry research and practice in the nursing home have relevance to general psychiatry and to other health care settings, informing us about (a) psychiatric disorders in medically ill and disabled populations; (b) subsyndromes and subtypes of depression; (c) behavioral disturbances in patients with brain injury; (d) the effects of government regulation and education on mental health care; and (e) essential roles for psychiatrists in changing health care systems. Selected areas of knowledge based on geriatric psychiatry research and experience in long term care are reviewed in this paper, and their applications for the field of psychiatry in general are explored.

Facility and area variation affecting the use of physical restraints in nursing homes

OBJECTIVES

Various individual characteristics increase a nursing home resident's likelihood of being mechanically restrained. However, there is not good information on the role played by facility characteristics and geographic area in determining the likelihood of physical restraint use. This study investigates the importance of individual, facility, and area indicators in determining the likelihood of restraint use.

METHODS

This research uses data on 2,000 nursing home residents receiving care in more than 250 nursing homes in 10 different areas. Resident-level data were collected in 1990 by research nurses using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening. Facility-level data were gathered by telephone interviews with facility staff. The relations among the variables were investigated using contingency tables and multivariate logistic regression models.

RESULTS

Controlling for residents' physical and cognitive function, facility characteristics and location had a significant impact on restraint practices. Those facilities with low nurse staffing were more likely to restrain residents. Furthermore, controlling for these factors, restraint practices varied significantly across the geographic areas in the study.

CONCLUSIONS

Like hospitals, nursing homes exhibit significant interfacility and regional variation in their clinical practices. Future analyses of nursing home care might benefit from considering both factors in much finer detail.

Use of the Minimum Data Set to rate incontinence severity

OBJECTIVES

To assess the relationship of the MDS incontinence severity ratings to direct measures of incontinence frequency.

DESIGN

Two methods of measuring incontinence were compared: the MDS rating as recorded by nursing home (NH) staff and physical checks for wetness performed by research staff.

SETTING AND PARTICIPANTS

A total sample of 293 older residents from nine nursing homes located in Iowa, the State of Washington, and the Los Angeles area were assessed once. A subsample of 49 incontinent residents were assessed twice, before and after the implementation of a prompted voiding program.

INTERVENTION

This study is a part of a larger study evaluating the use of a computer-aided incontinence management system (IMS). Incontinent residents were assessed, and, if they met predefined criteria, they were treated with prompted voiding.

MEASUREMENTS

Three measures of incontinence were used: the MDS rating recorded by NH staff, physical checks for wetness performed by NH staff while assessing residents for and treating them with prompted voiding, and physical checks for wetness performed independently by research staff.

RESULTS

There was a statistically significant correlation (r = .49; P < or = .001) between research staff wet checks and the MDS ratings, but wetness checks performed by NH staff had an insignificant correlation with MDS ratings (r = .003; P < 0.914). There was wide variability within and between NHs in the correlation. For residents who were placed on the prompted voiding program, the pre to post wet rate, as measured by research staff, improved significantly (from 28 to 14%; t = 6.73; df = 48; P < .001), whereas the pre to post MDS ratings did not change significantly (from 1.7 to 2.0; t = -1.42; df = 48; P < .075).

CONCLUSIONS

Although the MDS appears to identify incontinent NH residents accurately, its clinical utility may be limited by disagreements between actual wet check data and MDS categorical severity rankings for residents known to be incontinent. The wide variability between direct observational measures of wetness and the MDS scores denoting incontinence severity we observed may limit the potential usefulness of the MDS for detecting changes in incontinence severity. It is possible that more information and instructions are needed for staff completing the MDS if the goal is to discriminate between different levels of incontinence severity and measure changes over time in response to therapeutic interventions.

Does physical activity improve sleep in impaired nursing home residents?

OBJECTIVES

To determine if two physical activity programs of varying intensity would result in improved sleep among incontinent and physically restrained nursing home residents.

DESIGN

Controlled trials of two physical activity programs.

SETTING

Seven community nursing homes in the Los Angeles area.

PARTICIPANTS

Residents were included if they had urinary incontinence or were physically restrained. Sixty-five subjects were studied. Mean age was 84.8 years, 85% were female, mean length of residency in the nursing home was 19.9 months, and mean Mean Mini-Mental State Exam score was 13.1.

INTERVENTION

The first physical activity program involved sit-to-stand repetitions and/or transferring and walking or wheelchair propulsion. These activities were performed every 2 hours during the daytime, 5 days per week for 9 weeks. The second, less frequent physical activity program involved rowing in a wheelchair-accessible rowing machine plus walking or wheelchair propulsion once per day three times per week for 9 weeks.

MEASUREMENTS

The physical function measures reported here include mobility endurance (maximum time walking or wheeling) and physical activity as measured by motion sensors (Caltrac). Nighttime sleep was estimated by wrist activity monitors. Nighttime sleep measures included total time asleep, percent sleep, average duration of sleep, and peak duration of sleep. Daytime sleep was measured by timed behavioral observations of sleep versus wakefulness performed every 15 minutes during the day.

RESULTS

Nighttime sleep was markedly disrupted in both groups at baseline. Across all subjects at baseline, the average total sleep time was 6.2 hours and the percent sleep was 72.0%, but the average duration of sleep episodes was only 21.2 minutes and the peak duration of sleep episode averaged only 83.8 minutes. During the daytime, subjects were observed asleep during 14.5% of observations. Although there was improvement in mobility endurance in the intervention subjects compared with controls (MANOVA F = 4.36, P = .042), there were no differences in the night and day sleep measures at follow-up testing. Even among a subgroup of intervention subjects who showed a 30% or greater improvement in mobility endurance, sleep did not improve at follow-up compared with baseline.

CONCLUSION

This study supports our previous findings of marked sleep disruption in impaired nursing home residents. In addition, despite documented improvements in physical function with activity, we did not find improvements in sleep in the intervention versus control groups. These results suggest that increasing daytime physical activity alone is not adequate to improve sleep in impaired NH residents. Future efforts to improve sleep in this population should take into account the multifactorial nature of sleep disruption, including individual health problems that effect sleep and the disruptive nature of the nighttime NH environment.

Reducing the use of physical restraints in long-term care facilities

1. There has been increasing recognition of the role of education as a catalyst for changing restraint use practices and policies of long-term care facilities in Canada and other Western countries. 2. Findings of this longitudinal study documented the positive outcome of a structured restraint education program in reducing the use of physical restraints and promoting non-restrictive alternatives. 3. With continuing education and inservice programs, restraint-free elderly care can be attained in a cost-effective manner and without an increase in resident falls and injuries.

Federal regulations and the care of patients with dementia in the nursing home

More than half of the people residing in nursing homes in the United States have dementia. A long history of basic contradictions in the conceptualization of nursing home care in the United States has resulted in a serious mismatch between the needs of residents with dementia and the resources of nursing homes to care for these residents. Concern for this discrepancy, and the resultant inadequate and inappropriate care, provided a major impetus for nursing home reform. OBRA 87 was a broad public policy initiative intended to improve the quality of life of nursing home residents. The spirit of the legislation is embodied in federal regulations that explicitly recognize the importance of psychological and social domains of the lives of nursing home residents; restrict the use of psychotropic drugs and physical restraints; and advocate for activities and services to attain or maintain patients' highest practicable physical, mental, and psychosocial well-being. Although the impact of OBRA 87 on the quality of life of residents with dementia is unknown, the federal regulations constitute a major step in the movement for nursing home reform and toward improved quality of care.

Safety assessment for the frail elderly: a comparison of restrained and unrestrained nursing home residents

OBJECTIVE

To facilitate clinicians' judgement concerning physical restraint decisions by identifying potentially reversible injury risk factors that differentiate representative samples of restrained and unrestrained nursing home residents.

DESIGN

Comparison of restrained and unrestrained nursing home residents on a safety assessment for the frail elderly (SAFE) protocol.

SETTING

Long-term care facilities in the Greater Los Angeles Area.

PARTICIPANTS

One hundred eight physically restrained and 111 unrestrained nursing home residents.

INTERVENTION

None.

MAIN OUTCOME MEASURES

(1) Internal, Interrater, and test/retest reliability of the overall SAFE protocol and of the four major factors measured by SAFE; (2) The relationship of SAFE scores to expert judgment of resident injury risk; (3) Differences between large samples of restrained and unrestrained residents on specific SAFE score factors.

RESULTS

Two walking, one transition, and one judgment factor are reliably measured by the SAFE protocol. SAFE scores were significantly correlated with expert judgment of risk for injury and showed large differences between restrained and unrestrained residents, even after differences in ambulation ability between the two groups were accounted for.

CONCLUSION

The SAFE is a reliable protocol that measures behavioral factors related to falls and risk for injury among nursing home residents with a broad range of cognitive impairment. Factors that significantly differentiate restrained and unrestrained groups should be targeted for rehabilitation and remediation in physical restraint reduction efforts. Removing or changing restraints for the large sample (50%) of restrained residents who were not ambulatory will not significantly increase their mobility, since the majority of this group could not independently propel their wheelchairs. Increased mobility for the large group of both restrained and unrestrained residents will likely be realized only if restraint reduction programs are combined with interventions to improve both mobility and the specific behavioral performance factors measured by SAFE.