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

'Becoming restrained': Conceptualising restrictive practices in the care of people living with dementia in acute hospital settings

The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze's concepts of 'assemblage' and 'event' to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio-political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas 'events' and 'assemblages' have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.

Discussing physical restrictions in care plan meetings between family members of residents with dementia and nursing home staff

In long-term dementia care, caregivers face a dilemma. On the one hand, they need to respect the residents' right to self-determination, but on the other hand, they sometimes rely on physical restraints to deal with potential violence and self-destructive behavior. The issue of self determination is further complicated by residents often depending on family members as advocates in decision-making. In this article, we examine 15 care plan meetings to identify the professional practices of discussing the physical restrictions posed to residents with severe dementia. Our method is conversation analysis. Our analysis demonstrates that staff members' practices involve informing, accounting, and agreeing on the goals rather than on the methods of physical restraining. Staff members tend to first inform family members about the principles of restraining and then account for the use of restraints. Accounts highlight the problems that can be avoided and the benefits that can be achieved by limiting residents' actions. Consequently, the family members' role in the discussion is to accept the decision that has already been approved by authorities. As the staff members highlight the aim of protecting the well-being of the resident, the family members tend to respond with overt agreement and even promote the use of restraints. Current negotiation practices provide insufficient opportunities for family members to advocate for residents. Therefore, we recommend involving family members in decision-making about restraining at an earlier stage, adjusting the protocol in care plan meetings, and engaging the family in minimizing and preventing restraints. In general, staff members should pay more attention to the residents' experiences and the family members' lifeworld knowledge of the residents.

The optimal intervention for preventing physical restraints among older adults living in the nursing home: A systematic review

AIM

This study aimed to evaluate the effectiveness of restraint reduction programs for nursing home care providers in enforcing physical restraint on residents and identify the best strategies for such programs.

DESIGN

Systematic Review.

METHODS

We searched for randomized controlled trials published until February 2021 for systematic review. The systematic review captured multifactorial interventions, education and consultation measures, including nursing home residents' and care providers' results. Study quality was assessed using the Cochrane Collaboration criteria.

RESULTS

In all seven trials, the interventions were led by a nurse specialist or unit leader and targeted at care providers. Five of the restraint reduction programs effectively reduced the rate of physical restraint use; two increased knowledge of restraint reduction for care providers; and one each promoted positive attitudes and behaviours. Duration of at least 6 weeks significantly improved the knowledge of care providers.

Pad cultures: An ethnography of continence care and its consequences for people living with dementia during a hospital admission

BACKGROUND

There is little research examining how continence care is organised and delivered to people living with dementia across an acute hospital admission, despite the prevalence of this patient population and their vulnerability within these settings.

OBJECTIVE

To explore how continence care is delivered to people living with dementia during an acute hospital admission.

DESIGN

Ethnographic.

SETTING(S)

Acute medical units and wards within three hospitals across England and Wales.

PARTICIPANTS

People living with dementia and ward staff (registered nurses and care assistants) on participating wards.

METHODS

Ethnographic fieldwork collected over a period of 12 months (180 days of non-participant observation) focussing on the organisation and delivery of continence care to people living with dementia. Observations were supported with in situ ethnographic interviews (n = 562) with patients, visitors and staff within the six observed wards. Data collection and analysis drew on the theoretical sampling and constant comparison techniques of grounded theory.

RESULTS

The findings comprised of five overall themes: (1) visibility of continence; (2) rationales of continence care; (3) containment and contagion; (4) consequences of continence care and (5) supporting continence.

CONCLUSIONS

We introduce the term 'pad cultures' to refer to the established routine use of continence pads in the care of a wider group of people living with dementia (regardless of continence status and independence), with the rationale to provide safeguards, ensure containment and prevent 'accidents' or incontinent episodes. There was an expectation within acute wards that people living with dementia not only wear continence pads but that they also use them.

Knowledge and Attitudes towards Palliative Care: Validation of the Spanish Version of Questionnaire on Palliative Care for Advanced Dementia

Background: Palliative care is essential in the care of people with advanced dementia, due to the increasing number of patients requiring care in the final stages of life. Nurses need to acquire specific knowledge and skills to provide quality palliative care. The Questionnaire on Palliative Care for Advanced Dementia (qPAD) is useful for assessing knowledge and attitudes toward palliative care, but its adaptation to the Spanish language and analysis of its effectiveness and usefulness for the Spanish culture is lacking. Objective: To report on the Spanish language adaptation and psychometric analysis of the qPAD. Methods: The Questionnaire on Palliative Care for Advanced Dementia Spanish version (qPAD-SV) was obtained from a process that included translation, back-translation, comparison with other language versions, expert review, and pilot study. Content validity, criterion validity, and reliability of the questionnaire were analyzed. The difficulty and discrimination indices of items composing the knowledge subscale were also calculated. Results: Adequate content validity index obtained after the analysis of qPAD-SV by a heterogeneous group of experts was found (overall CVI = 0.96; 0.95 for the Knowledge subscale and 0.99 for the Attitudes subscale). Significant correlations with the Palliative Care Knowledge test (rho = 0.368, p < 0.001) and Self-Efficacy in Palliative Care Scale (rho = 0.621, p < 0.001) show an adequate criterion validity. Cronbach’s alpha coefficients for the Knowledge subscale (0.60) and the Attitudes subscale (0.91) supported the reliability of the qPAD-SV. The questionnaire had an overall difficulty index of 0.71, with three items that could be considered difficult or very difficult, and eleven items that could be considered very easy. Discussion: Although it shows internal consistency, validity, and difficulty indices similar to those obtained by qPAD versions in other languages, a reformulation of the items with lower content validity or discrimination indices and those that show difficulties in their comprehension is an aspect to be taken into account to improve this tool. Conclusions: The qPAD-SV is a useful instrument in Spanish to measure the knowledge of Spanish nurses in palliative care and is suitable for international comparisons.

Approach to Management of Wandering in Dementia: Ethical and Legal Issue

Wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. Ethical and legal issues especially in the light of the new Indian Mental Healthcare Act of 2017, related to confinement by family members in their homes by family caregivers, seclusion, physical or chemical restraints, other pharmacological and behavioral treatment, highlighting their effectiveness as well as adverse consequences are discussed. This article attempts to address an approach in managing wandering behavior in PwD in light of MHCA, 2017.

Variation in restraint use between hospitals: a multilevel analysis of multicentre prevalence measurements in Switzerland and Austria

BACKGROUND

In restraint use in the somatic acute-care hospital setting, routine and institutional culture seem to play an important role. This implies that similar patient situations would be managed with restraints in one hospital, while in another hospital the situation would be managed without restraints. This practice variation appears to be ethically and legally questionable. The influence of organisation-specific factors such as the availability of guidelines is discussed. However, the relevance of such factors at the hospital level has been rarely investigated to date. Therefore, the aims of this study were a) to determine how much variance in restraint use can be explained on the hospital level (hospital general effect) and b) to examine the impact of organisational factors on restraint use (specific contextual effects).

METHODS

A secondary data analysis of cross-sectional multicentre data was performed. Data were collected during three quality measurements (2016-2018) in acute-care hospitals in Switzerland and Austria. Hospitalised patients from different medical specialties aged 18+ with informed consent were included. Descriptive analysis and multilevel logistic regression analysis were performed.

RESULTS

The study included 29,477 patients from a total of 140 hospitals. The 30-day prevalence rate of patients with at least one restraint was 8.7% (n = 2577). The availability of guidelines regarding restraint use and refresher courses for nursing staff were associated with less restraint use (odds ratios = 0.60 and 0.75). By adding the hospital as a random effect, the explained variance of the model increased from 24 to 55%.

CONCLUSIONS

The use of restraints varies widely between hospitals, even considering patient characteristics. The identification of situations in which restraints were used out of routine or institutional culture appears to be an important approach in restraint reduction. Investments in appropriate structures and employee knowledge can facilitate providing restraint-free care as much as possible.

A cross-sectional study on nurses' attitudes towards physical restraints use in nursing homes in Portugal

Aim

To explore nurses' opinions regarding restraint measures and attitudes towards physical restraints use in nursing homes.

Design

Cross‐sectional study.

Methods

Nursing staff of 33 Portuguese nursing homes was asked to complete the Portuguese version of the Maastricht Attitude Questionnaire (MAQ), an instrument on attitudes regarding physical restraints (reasons, consequences and appropriateness of restraint use) and opinions about restraint measures (restrictiveness and discomfort). Descriptive statistics and bivariate analysis were performed.

Results

Data from 186 nurses were included in the analysis. Overall, nurses expressed neutral to moderately positive attitudes towards physical restraints usage. Nurses with longer professional experience reported a more positive attitude regarding the appropriateness of restraint use in their clinical practice. Wrist and ankle restraints were the measures that nurses reported feeling most uncomfortable using, and the most restrictive. Bilateral bedrails were globally assessed as a slightly restrictive measure and nurses reported not feeling uncomfortable using them.

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.

Restraint use in the acute-care hospital setting: A cross-sectional multi-centre study

BACKGROUND

Restraints are likely to negatively affect patients' health and therefore a reduction in their usage is recommended for all health-care settings. To date, research on restrictive practices has concentrated on mental health and long-term care settings. In the acute-care hospital setting few studies have been published and these studies mainly focus on physical/mechanical restraints in specific subpopulations and/or on intensive care units. However, to ensure restraints are used as little as possible in the acute-care hospital setting, it seems important to investigate more comprehensively the use of restraints, to include all types of restraints irrespective of ward type or subpopulations and to identify factors associated with restraint use.

OBJECTIVE

The aim of this study was to investigate restraint use regardless of ward type in the acute-care hospital setting, including restraint type, reasons for restraint use, process indicators when using restraints and restraint use-associated patient characteristics.

METHODS

Using a cross-sectional multi-centre design, data were collected by means of an annual international prevalence measurement in acute-care hospitals in Switzerland and Austria. All hospitalised patients aged 18+ who gave informed consent were included. Data were collected at three measurement points between 2016 and 2018. Descriptive and multivariate logistic regression analyses were performed.

RESULTS

A total of 29,477 patients hospitalised in 140 hospitals were included in this study. The prevalence rate for the use of at least one restraint over a 30-day period was 8.7% (n = 2577), with mechanical restraints representing the highest proportion of restraint type used (55.0%, n = 1417). The main reason for restraint use was fall prevention (43.8%, n = 1129), followed by confusion or delirious behaviour (20.4%, n = 525). In 64.3% of the cases (n = 1657), restraint use was documented in the patient file. Regular evaluation occurred in 42.9% of the cases (n = 1105). Care dependency had the strongest association with restraint use (odds ratio [OR] 25.00, 95% confidence interval [CI] 21.01-29.78 for completely dependant patients in comparison to completely independent patients), followed by mental and behavioural disorders (OR 2.36, 95% CI 2.15-2.59).

CONCLUSIONS

Restraints are often utilised in hospitals in complex care situations such as with patients at risk of falling or with delirium. When using restraints the consideration of processes like documentation and evaluation shows great potential for improvement. Standardisation of these processes and education of the interprofessional team could be beneficial for raising awareness and for the sustainable reduction of restraint use. Tweetable abstract: In hospitals restraints are often used in complex care situations. However, their use seems to be insufficiently documented and evaluated.

Forced treatment and care in home-dwelling persons with dementia

BACKGROUND

The use of forced treatment and care of home-dwelling persons with dementia is a universally important topic. These patients are completely dependent on care from others to continue living at home.

AIM

This study aimed to gain insights into formal decisions related to the forced treatment and care of home-dwelling persons with dementia.

DESIGN AND SAMPLE

This is a cross-sectional study, based on formal decisions of forced treatment and care of home-dwelling persons with dementia in Norway between 1 January 2015 and 31 December 2016.

METHODS

Descriptive statistical analysis. Statistically significant associations suitable for binary logistic regression were presented as odds ratios with 95% confidence intervals.

ETHICAL CONSIDERATIONS

Approved by The Regional Committee for Medical and Health Research Ethics, and by the Norwegian Center for Research.

RESULTS

We found 108 formal decisions of forced treatment and care of persons with dementia. Decisions of admission represented 57% of the data, other medical and safety decisions 27%, and assistance with activities of daily living 16%. In most cases, physicians were responsible for the decisions (77%), but nurses and family members were often involved.

DISCUSSION AND CONCLUSION

This study demonstrated a prevalence rate of formally documented decisions of forced treatment and care much lower than findings in previous studies. Poor documentation may constitute a risk for the safety and wellbeing of persons with dementia. Although physicians were usually responsible for the decisions, nurses and family members were often involved in the process. Family participation in forced treatment and care raises ethical dilemmas. More research on the experiences of nurses, persons with dementia and family members with forced treatment and care is needed to aid ethical, legal, and clinically challenging decision-making processes.

Nursing home care for people with dementia: Update of the design of the Living Arrangements for people with Dementia (LAD)-study

AIM

The aim of the current study is to describe the extended design of the Living Arrangements for people with Dementia (LAD)-study.

BACKGROUND

The demand for long-term care in care homes increases with the growing number of people with dementia. However, quality of care in care homes needs improvement. It is important to monitor quality of care in care homes for the purposes of conducting scientific research, providing input for policy, and promoting practice improvement.

DESIGN

The Living Arrangements for people with Dementia -study monitors changes in - quality of - care in care homes since 2008. With its extended design, the Living Arrangements for people with Dementia -study now also focuses on additional topics that are considered to improve quality of care: implementation of person-centred care, involvement of family carers and volunteers and reducing psychotropic drugs and physical restraints using a multidisciplinary approach.

METHODS

The data collection of the Living Arrangements for people with Dementia -study entails an interview with the manager and questionnaires are completed by care staff, family carers, volunteers, and multidisciplinary team members. This study is partly funded by the Dutch Ministry of Health, Welfare and Sports, grant number 323,088 and partly funded by the participating care homes.

DISCUSSION

Results of the Living Arrangements for people with Dementia -study will shed more light on variables related to quality of care in care homes for people with dementia.

IMPACT

Based on the obtained information, appropriate efforts to improve quality of care can be discussed and implemented. Furthermore, the results of this study guide policy making, because it expands knowledge about the effects of changing policies and exposes topics that need further attention.

TRIAL REGISTRATION

Not applicable. This article does not report the results of a healthcare intervention on human participants.

Use of physical restraint in nursing homes in Spain and relation with resident characteristics: a retrospective multi-centre cohort study with a self-organised maps approach

This is a retrospective cohort study based on data from five nursing homes which aims to appraise how physical and cognitive characteristics of nursing home residents were associated with the use of restraints, and to provide information on their prevalence in Spain. The goal was to assess, in a visual way, the possible interactions between the nursing homes residents’ characteristics and their association with the use of restraints. Motivation, risk factors, characteristics of the residents analysed by validated rating systems that assess mobility, level of dependence, cognitive condition and nutritional status, and their association with the use of restraints, were described by means of linear and non-linear multivariate approaches in the form of self-organised maps. Findings showed that the prevalence of restraints was high when compared to other developed countries. The visual analysis reinforced the knowledge that a greater impairment was associated with the use of restraints and vice versa. However, the residents’ characteristics were not always associated with the use of restraints. Subjective factors seem to play a relevant role in decision-making, so it is important to assess risk factors continuously and determine the actual need for the use of restraints from an individual perspective by basing the criteria on specific objectives, and on consistent, reproducible and reliable methods. Initiatives to minimise these subjective factors should be promoted. Likewise, a clear definition of physical restraints should be offered at each centre. In addition, effective legislation that clearly states the need, alternatives and motivation for the use of restraints is needed.

The Conditions for Ethical Application of Restraints

Despite the lack of evidence for the effectiveness of physical restraints, their use in patients is widespread. The best ethical justification for restraining patients is that it prevents them from harming themselves. We argue that even if the empirical evidence supported their effectiveness in achieving this aim, the use of restraints would nevertheless be unethical, so long as well-known exceptions to informed consent fail to apply. Specifically, we argue that ethically justifiable restraint use demands certain necessary and sufficient conditions. These conditions are that the physician obtained informed consent for their application, that their application be medically appropriate, and that restraints be the least liberty-restricting way of achieving the intended benefit. It is a further question whether their application is ever medically appropriate, given the dearth of evidence for their effectiveness.

The inter-play between facilitation and context in the promoting action on research implementation in health services framework: A qualitative exploratory implementation study embedded in a cluster randomized controlled trial to reduce restraint in nursing homes

AIM

To explore the inter-play between external facilitation and nursing home contexts relative to intervention outcomes.

BACKGROUND

The Promoting Action on Research Implementation in Health Services framework is frequently used to theoretically inform implementation and research in nursing and recent reviews indicate high face validity for health services. However, the inter-play and relationship between framework sub-elements of evidence, context and facilitation and the prospective utility in non-English speaking contexts warrant further illumination.

DESIGN

In an overarching single-blind cluster-randomized controlled trial, we applied participatory action research and ethnography from August 2011-June 2015 to evaluate a standardized education intervention to reduce restraint and agitation in nursing home residents living with dementia. The trial results are published elsewhere.

METHODS

Prospectively informed by the PARIHS framework, a research team and eight facilitators participating in dual roles as action researchers designed, implemented, and evaluated the intervention. How contextual factors influenced the facilitation processes were explored in focus group interviews (1), reflection notes (84) written by the facilitators' after each education session, ethnographic field studies (6 homes), and co-analysis workshops (5). Directed content analysis was used to analyse data.

RESULTS

Clinical leaders taking roles of internal facilitator influenced the success of implementation, while complex and fluctuating context elements determined whether restraint use was reduced- or not. The PARIHS framework was found to be relevant in a non-English nursing home setting, albeit some elements merit further conceptualization.

CONCLUSIONS

Our findings confirm the prospective utility of the PARIHS framework for implementation in a non-English context, particularly the notion of implementation processes as dynamic and multifaceted.

Care practices of older people with dementia in the surgical ward: A questionnaire survey

OBJECTIVES

The objective of this study was to describe the care practices of nursing staff caring older people with dementia in a surgical ward.

METHODS

The data were collected from nursing staff (n = 191) working in surgical wards in one district area in Finland during October to November 2015. Data were collected using a structured questionnaire and analyzed statistically. The instrument consists of a total number of 141 items and four dimensions. The dimensions were as follows: background information (12 of items), specific characteristics of older people with dementia in a surgical ward (24 of items), specific characteristics of their care in a surgical ward (66 of items) and use of physical restraints and alternative models for use of restraints for people with dementia (39 of items).

RESULTS

The questions which measure the nursing staff's own assessment of care practices when caring for people with dementia in surgical wards were selected: counseling people with dementia, reaction when a surgical patient with dementia displays challenging behavior and use of alternative approach instead of physical restraints. Most commonly the nursing staff pay attention to patient's state of alertness before counseling older people with dementia. Instead of using restraints, nursing staff gave painkillers for the patient and tried to draw patients' attention elsewhere. The nursing staff with longer work experience estimate that they can handle the patients' challenging behavior. They react by doing nothing more often than others. They pretend not to hear, see or notice anything.

CONCLUSION

The findings of this study can be applied in nursing practice and in future studies focusing on the care practices among older people with dementia in acute care environment. The results can be used while developing patient treatments process in surgical ward to meet future needs.

Healthcare staffs' experiences and perceptions of caring for people with dementia in the acute setting: Qualitative evidence synthesis

BACKGROUND

Dementia is a global issue, with increasing prevalence rates impacting on health services internationally. People with dementia are frequently admitted to hospital, an environment that may not be suited to their needs. While many initiatives have been developed to improve their care in the acute setting, there is a lack of cohesive understanding of how staff experience and perceive the care they give to people with dementia in the acute setting.

OBJECTIVES

The aim of this qualitative synthesis was to explore health care staffs' experiences and perceptions of caring for people with dementia in the acute setting. Qualitative synthesis can bring together isolated findings in a meaningful way that can inform policy development.

SETTINGS

A screening process, using inclusion/exclusion criteria, identified qualitative studies that focused on health care staff caring for people with dementia in acute settings.

PARTICIPANTS

Twelve reports of nine studies were included for synthesis. Data extraction was conducted on each report by two researchers.

METHODS

Framework synthesis was employed using VIPS framework, using Values, Individualised, Perspective and Social and psychological as concepts to guide synthesis. The VIPS framework has previously been used for exploring approaches to caring for people with dementia. Quality appraisal was conducted using Critical Appraisal Skills Programme (CASP) and NVivo facilitated sensitivity analysis to ensure confidence in the findings.

RESULTS

Key themes, derived from VIPS, included a number of specific subthemes that examined: infrastructure and care pathways, person-centred approaches to care, how the person interacts with their environment and other patients, and family involvement in care decisions. The synthesis identified barriers to appropriate care for the person with dementia. These include ineffective pathways of care, unsuitable environments, inadequate resources and staffing levels and lack of emphasis on education and training for staff caring for people with dementia.

CONCLUSIONS

This review has identified key issues in the care of people with dementia in the acute setting: improving pathways of care, creating suitable environments, addressing resources and staffing levels and placing emphasis on the education for staff caring for people with dementia. Recommendations are made for practice consideration, policy development and future research. Leadership is required to instil the values needed to care for this client group in an effective and personcentred way. Qualitative evidence synthesis can inform policy and in this case, recommends VIPS as a suitable framework for guiding decisions around care for people with dementia in acute settings.

Behind Closed Doors: Involuntary Treatment in Care of Persons with Cognitive Impairment at Home in the Netherlands

OBJECTIVES

To explore the prevalence and associated factors of involuntary treatment (physical restraints, psychotropic medication, nonconsensual care) in persons with cognitive impairment receiving home care.

DESIGN

Cross-sectional survey using association analyses.

SETTING

Professional home care in the southern part of the Netherlands.

PARTICIPANTS

Data were collected on 837 persons with cognitive impairment (mean age 81.6; 60% female).

MEASUREMENTS

Involuntary treatment was measured using a tool to identify physical restraints, psychotropic medication, and nonconsensual care. Activities of daily living (ADLs) were measured using the ADL Hierarchy subscale of the Resident Assistant Instrument-Minimum Data Set and cognitive status using the Cognitive Performance Scale. Informal caregiver burden was assessed using the Self-Perceived Pressure from Informal Care Scale.

RESULTS

Involuntary treatment was used in 39% of the total sample. Most common were nonconsensual care (79%; e.g., concealing medication in food, forcing hygiene) and psychotropic medication (41%). In 7% of the sample, physical restraints (e.g., deep or overturned chair, bilateral full-enclosure bedrails) were used. Caregiver burden, ADL dependency, cognitive status, living alone, and a diagnosis of dementia were strongly associated with involuntary treatment. The family of the person with cognitive impairment most often requested the use of involuntary treatment.

CONCLUSION

Involuntary treatment is often used in persons with cognitive impairment receiving home care in the Netherlands. Future research should focus on understanding and preventing inappropriate involuntary treatment in home care.