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Watt JA, Porter J, Tavilsup P, Chowdhury M, Hatch S, Ismail Z, Kumar S, Kirkham J, Goodarzi Z, Seitz D. Guideline Recommendations on Behavioral and Psychological Symptoms of Dementia: A Systematic Review. J Am Med Dir Assoc 2024; 25:837-846.e21. [PMID: 38640961 DOI: 10.1016/j.jamda.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/20/2024] [Accepted: 03/12/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To synthesize recommendations on assessing and managing behavioral and psychological symptoms of dementia (BPSDs) in existing clinical practice guidelines on dementia care to learn from and adapt recommendations to a Canadian context and language for describing BPSDs. DESIGN Systematic review. SETTING AND PARTICIPANTS Moderate to high-quality clinical practice guidelines on dementia care that made 1 or more recommendations on BPSD assessment or management. METHODS We searched MEDLINE, Embase, JBI EBM, PsycINFO, AgeLine, and gray literature for clinical practice guidelines on dementia care making recommendations on BPSD, published between January 1, 2011, and October 13, 2022. Two independent reviewers conducted study screening and data abstraction. Four independent reviewers completed quality appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool; included guidelines had a mean overall AGREE II score ≥4. RESULTS Our systematic review identified 23 moderate to high-quality clinical practice guidelines (264 recommendations). The mean overall quality score on the AGREE II tool ranged from 4 to 6.5. Recommendations were clearly presented (mean clarity of presentation score 73.5%), but guideline applicability was not consistently addressed (mean applicability score 39.3%). BPSD was the most prevalent term describing neuropsychiatric symptoms (number of guidelines [n] = 14). People with lived experience contributed to 6 guidelines (26.1%). Ten guidelines (43.5%) described 1 or more health equity considerations. Guidelines made recommendations for assessing and managing agitation (n = 12), aggression (n = 10), psychosis (n = 11), depression (n = 9), anxiety (n = 5), apathy (n = 6), inappropriate sexual behavior (n = 3), nighttime behavior (n = 5), and eating disturbances (n = 3). There was substantial variability in recommendation statements, evidence quality assigned to each statement, and strength of recommendations. CONCLUSIONS AND IMPLICATIONS There are several moderate to high-quality clinical practice guidelines making recommendations on BPSD assessment and management, but variability in recommendation statements across guidelines and insufficient consideration of guideline applicability may hamper guideline dissemination and implementation in clinical practice.
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Affiliation(s)
- Jennifer A Watt
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Jennifer Porter
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pattara Tavilsup
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohammad Chowdhury
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stacey Hatch
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zahinoor Ismail
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjeev Kumar
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Julia Kirkham
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zahra Goodarzi
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dallas Seitz
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Weissflog M, Kim S, Rajack N, Kolla NJ. The impact of the COVID-19 pandemic on the use of restraint and seclusion interventions in Ontario emergency departments: A population-based study. PLoS One 2024; 19:e0302164. [PMID: 38626126 PMCID: PMC11020601 DOI: 10.1371/journal.pone.0302164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/27/2024] [Indexed: 04/18/2024] Open
Abstract
While COVID-19 impacted all aspects of health care and patient treatment, particularly for patients with mental health/substance use (MH/SU) concerns, research has suggested a concerning increase in the use of restraint and seclusion (R/S) interventions, although results vary depending on facility type and patient population. Thus, the present study sought to explore COVID-related changes in the use of R/S interventions among patients presenting to Ontario emergency departments (EDs) with MH/SU complaints. To determine whether temporal and clinical factors were associated with changes in R/S use during COVID, binary logistic regression models were computed using data from the National Ambulatory Care Reporting System database. We then compared both prevalence rates and probability of an R/S event occurring during an ED visit in Ontario before and after the onset of COVID. The number of ED visits during which an R/S event occurred for patients presenting with MH/SU concerns increased by 9.5%, while their odds of an R/S event occurring during an ED visit increased by 23% in Ontario after COVID onset. Similarly, R/S event probability increased for patients presenting with MH/SU concerns after COVID onset (0.7% - 21.3% increase), particularly during the first wave, with the greatest increases observed for concerns associated with increased restraint risk pre-COVID. R/S intervention use increased substantially for patients presenting to Ontario EDs with MH/SU concerns during the first wave of COVID when the strain on healthcare system and uncertainty about the virus was arguably greatest. Patients with concerns already associated with increased R/S risk also showed the largest increases in R/S probability, suggesting increased behavioural issues during treatment among this population after COVID onset. These results have the potential to inform existing policies to mitigate risks associated with R/S intervention use during future public health emergencies and in general practice.
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Affiliation(s)
- Meghan Weissflog
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
| | - Soyeon Kim
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Natalie Rajack
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
| | - Nathan J. Kolla
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
- Forensic Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Habbous S, Ford M, Bar-Ziv S, Donovan T, Hellsten E. The impact of the COVID-19 pandemic on longitudinal trends of surgical mortality and inpatient quality of care in Ontario, Canada. J Adv Nurs 2024. [PMID: 38491720 DOI: 10.1111/jan.16136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/27/2023] [Accepted: 02/18/2024] [Indexed: 03/18/2024]
Abstract
AIMS Previous studies have shown the COVID-19 pandemic was associated with reductions in volume across a spectrum of non-SARS-CoV-2 hospitalizations. In the present study, we examine the impact of the pandemic on patient safety and quality of care. DESIGN This is a retrospective population-based study of discharge abstracts. METHODS We applied a set of nationally validated indicators for measuring the quality of inpatient care to hospitalizations in Ontario, Canada between January 2010 and December 2022. We measured 90-day mortality after selected types of higher risk admissions (such as cancer surgery and cardiovascular emergency) and the rate of patient harm events (such as delirium, pressure injuries and hospital-acquired infections) occurring during the hospital stay. RESULTS A total 13,876,377 hospitalization episodes were captured. Compared with the pre-pandemic period, and independent of SARS-CoV-2 infection, the pandemic period was associated with higher rates of mortality after bladder cancer resection (adjusted risk ratio [aRR] 1.20 (1.07-1.34)) and open repair for abdominal aortic aneurysm (aRR 1.45 (1.06-1.99)). The pandemic was also associated with higher rates of delirium (adjusted odds ratio [aOR] 1.04 (1.02-1.06)), venous thromboembolism (aOR 1.10 (1.06-1.13)), pressure injuries (aOR 1.28 (1.24-1.33)), aspiration pneumonitis (aOR 1.15 (1.12-1.18)), urinary tract infections (aOR 1.02 (1.01-1.04)), Clostridiodes difficile infection (aOR 1.05 (1.02-1.09)), pneumothorax (aOR 1.08 (1.03-1.13)), and use of restraints (aOR 1.12 (1.10-1.14)), but was associated with lower rates of viral gastroenteritis (aOR 0.22 (0.18-0.28)). During the pandemic, SARS-CoV-2-positive admissions were associated with a higher likelihood of various harm events. CONCLUSION The COVID-19 pandemic was associated with higher rates of patient harm for a wide range of non-SARS-CoV-2 inpatient populations. IMPACT Understanding which quality measures are improving or deteriorating can help health systems prioritize quality improvement initiatives. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Steven Habbous
- Ontario Health (Strategic Analytics), Toronto, Ontario, Canada
- Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Maggie Ford
- Ontario Health (Clinical Institutes and Quality Programs), Toronto, Ontario, Canada
| | - Stacey Bar-Ziv
- Ontario Health (Clinical Institutes and Quality Programs), Toronto, Ontario, Canada
| | - Terri Donovan
- Ontario Health (Clinical Institutes and Quality Programs), Toronto, Ontario, Canada
| | - Erik Hellsten
- Ontario Health (Strategic Analytics), Toronto, Ontario, Canada
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Cortinhal VSJ, Correia ASC, Deodato Fernandes SJ. Nursing Ethical Decision Making on Adult Physical Restraint: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:75. [PMID: 38248539 PMCID: PMC10815796 DOI: 10.3390/ijerph21010075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/03/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE to map the existing knowledge on nursing ethical decision making in the physical restraint of hospitalised adults. (1) Background: physical restraint is a technique that conditions the free movement of the body, with risks and benefits. The prevalence of physical restraint in healthcare suffers a wide variation, considering the environment or pathology, and it raises ethical issues that hinders decision making. This article intends to analyse and discuss this problem, starting from a literature review that will provoke a grounded discussion on the ethical and legal aspects. Inclusion criteria are: studies on physical restraint (C) and ethical nursing decision making (C) in hospitalized adults (P); (2) methods: a three-step search strategy was used according to the JBI. The databases consulted were CINAHL Plus with Full Text (EBSCOhost), MEDLINE Full Text (EBSCOhost), Nursing and Allied Health Collection: Comprehensive and Cochrane Database of Systematic Reviews (by Cochrane Library, RCAAP and Google Scholar. All articles were analysed by two independent reviewers; (3) results: according to the inclusion criteria, 18 articles were included. The categories that influence ethical decision in nursing are: consequence of the decision, the context, the nature of the decision in terms of its complexity, the principles of the ethical decision in nursing, ethical issues and universal values; (4) conclusions: the findings of this review provide evidence that there is extensive knowledge regarding nursing ethical decision making in adult physical restriction, also, it is considered an ethical issue with many associated assumptions. In this article we aim to confront all these issues from a legal perspective.
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Affiliation(s)
- Vanessa Sofia Jorge Cortinhal
- Centro Hospitalar Barreiro Montijo, EPE, Institute of Health Sciences, Universidade Católica Portuguesa, 1649-023 Lisboa, Portugal
| | - Ana Sofia Castro Correia
- Centro Hospitalar de Lisboa Ocidental, EPE, Institute of Health Sciences, Universidade Católica Portuguesa, 1649-023 Lisboa, Portugal
| | - Sérgio Joaquim Deodato Fernandes
- School of Nursing, Institute of Health Sciences, Universidade Católica Portuguesa,1649-023 Lisbon, Portugal
- Center for Interdisciplinary Research in Health (CIIS), Institute of Health Sciences, Universidade Católica Portuguesa, 1649-023 Lisboa, Portugal
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Hostiuc S, Drima E. Dignity as a Central Issue in Treating Patients with Dementia Associated with COVID-19 Infection. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1588. [PMID: 37763707 PMCID: PMC10537082 DOI: 10.3390/medicina59091588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023]
Abstract
COVID-19 was initially considered a primary respiratory disorder associated with various short- and long-term complications, affecting many patients and imposing a significant burden. Patients who have dementia are especially vulnerable to the SARS-CoV2 infection, which is associated with an increased risk for neuropsychiatric complications. These patients need a unique approach to managing ethical issues related to the COVID-19 pandemic, including autonomy, veracity, non-maleficence, justice, compassion, and dignity. The latter is one of the most elusive and misunderstood concepts in medical ethics and is extremely important in debates surrounding the proper management of patients with dementia. However, it is often left out of ethical analysis, as most clinicians, when debating issues associated with clinical practice, often evaluate only the "classical" principles of biomedical ethics. In this article, we aim to assess the unique features of dignity in treating this group of patients during the COVID-19 pandemic. We will briefly analyze dignity as a bioethical concept. We will further explore its principal axes, namely compassion, creating a humane and purposeful environment, employing persuasion to meet the person's essential needs, exerting a certain degree of mild restraint to meet the person's critical needs, minimizing harm in terminal care, and justice, through the lens of people who had dementia during the COVID-19 pandemic. Applying this principle in clinical practice requires significant commitment from all healthcare workers. New approaches to the analysis of dignity, such as through the Ring Theory of Personhood, may facilitate its understanding by practitioners and aid its implementation in populations with multiple vulnerabilities, such as dementia patients, during an infectious outbreak that generates significant social and medical changes.
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Affiliation(s)
- Sorin Hostiuc
- Department of Legal Medicine and Bioethics, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Eduard Drima
- Medical Clinical Department, Dunărea de Jos University, 800201 Galați, Romania;
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Reppas-Rindlisbacher C, Boblitz A, Fowler RA, Lapointe-Shaw L, Sheehan KA, Stukel TA, Rochon PA. Trends in Delirium and New Antipsychotic and Benzodiazepine Use Among Hospitalized Older Adults Before and After the Onset of the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e2327750. [PMID: 37548976 PMCID: PMC10407689 DOI: 10.1001/jamanetworkopen.2023.27750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/28/2023] [Indexed: 08/08/2023] Open
Abstract
IMPORTANCE The COVID-19 pandemic caused large disruptions to health care for hospitalized older adults. The incidence and management of delirium may have been affected by high rates of COVID-19 infection, staffing shortages, overwhelmed hospital capacity, and changes to visitor policies. OBJECTIVE To measure changes in rates of delirium and related medication prescribing during the COVID-19 pandemic among hospitalized older adults. DESIGN, SETTING, AND PARTICIPANTS This population-based, repeated cross-sectional study used linked databases to measure rates of delirium and related medication prescriptions among adults aged 66 years or older hospitalized before and during the COVID-19 pandemic (January 1, 2017, to March 31, 2022) in Ontario, Canada. EXPOSURE The first 2 years of the COVID-19 pandemic (March 1, 2020, to March 31, 2022). MAIN OUTCOMES AND MEASURES The main outcomes were weekly rates of delirium per 1000 admitted population and monthly rates of new antipsychotic and benzodiazepine prescriptions per 1000 discharged population. Observed rates were compared with projected rates based on modeling from 3 years before pandemic onset. RESULTS Among 2 128 411 hospitalizations of older adults over the 5-year study period (50.7% female; mean [SD] age, 78.9 [8.3] years), absolute rates of delirium increased from 35.9 per 1000 admitted population during the prepandemic period to 41.5 per 1000 admitted population throughout the pandemic. The adjusted rate ratio (ARR) of delirium during the pandemic compared with the projected rate was 1.15 (95% CI, 1.11-1.19). Monthly rates of new antipsychotic prescriptions increased from 6.9 to 8.8 per 1000 discharged population and new benzodiazepine prescriptions from 4.4 to 6.0 per 1000 discharged population and were significantly higher during the pandemic compared with projected rates (antipsychotics: ARR, 1.28; 95% CI, 1.19-1.38; benzodiazepines: ARR, 1.37; 95% CI, 1.20-1.57). Rates were highest during pandemic waves 1 (March to June 2020), 3 (March to June 2021), and 5 (December 2021 to February 2022) and remained elevated above projected levels throughout the first 2 years of the pandemic. CONCLUSIONS AND RELEVANCE In this repeated cross-sectional study of hospitalized older adults, there was a temporal association between COVID-19 pandemic onset and significant increases in rates of delirium in the hospital and new antipsychotic and benzodiazepine prescriptions after hospital discharge. Rates remained elevated over 2 years. Pandemic-related changes such as visitor restrictions, staff shortages, isolation practices, and reduced staff time at the bedside may have contributed to these trends.
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Affiliation(s)
- Christina Reppas-Rindlisbacher
- Women’s Age Lab and Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System and the University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Robert A. Fowler
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Division of General Internal Medicine and Geriatrics, Sinai Health System and the University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen A. Sheehan
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Therese A. Stukel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Paula A. Rochon
- Women’s Age Lab and Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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