Factors associated with use of restraints on older adults with home care: A secondary analysis of a cross-sectional survey study

Patterns of Physical Restraints and Their Associated Factors Among Personal Care Assistants Working at Daycare Centers in Korea

In South Korea, the use of physical restraints (PR) in long-term care for older adults are generally prohibited due to their link to elder abuse. This study analyzed data from the 2017 National Survey on Human Rights for Older Adults (N = 4,447), focusing on personal care assistants (PCAs) in daycare settings. The study explored the prevalence and patterns of PR use among PCAs, using Latent Class Analysis (LCA) to identify four distinct groups based on attitudes and behaviors toward PR: High-risk Group, Semi-aware Low Usage Group, Unaware Low Usage Group, Desired Group. The study revealed a significant gap between PCAs' attitudes toward PR and their actual practices. Notably, High-risk Group tended to attribute elder abuse to personality disorders in older adults. In contrast, the desired group linked elder abuse to caregivers' personality disorders. These findings highlight the need for standardized, human rights-focused education.

Factors related to the use of physical restraints and hand restraints among older adults receiving home care services

OBJECTIVES

Physical restraints and hand restraints are used in medical settings to provide protection and control. However, few studies have investigated their use among community-dwelling older adults. The study explored variables associated with the use of physical restraints and hand restraints among older adults receiving home care services and the reasons behind their use.

METHODS

This cross-sectional study recruited 128 older adults receiving home care services and with catheters. Data were collected regarding demographic characteristics; activities of daily living (ADLs); muscle strength; family function; the use of nasogastric tubes, urinary catheters, and tracheal tubes; and the type and duration of restraint use and the reasons behind such use.

RESULTS

Among the participants, 76% experienced the use of physical restraints, and 34% experienced the use of hand restraints. The variables related to physical restraints were ADLs (adjusted odds ratio [AOR] = 0.95, p = .02) and the presence of a paid caregiver (AOR = 3.33, p = .02). The variables related to hand restraints were ADLs (AOR = 0.93, p = .03), use of a nasogastric tube (AOR = 13.46, p = .03) and the presence of a paid caregiver (AOR = 6.38, p = .02). The primary reasons behind restraint use were to prevent fall and extubation events.

CONCLUSIONS

The use of physical restraints among older adults with catheters may be affected by their functioning in ADLs and the presence of paid caregivers to ensure their safety. Thus, implementing interventions that target functional capabilities and caregiving skills may help reduce the use of restraints.

Prevalence of involuntary treatment among community-living older persons with dementia: A systematic review

OBJECTIVE

This systematic review and meta-analysis aimed to ascertain the prevalence of involuntary treatment among community-living older persons with dementia and explore associated factors.

METHODS

We comprehensively searched seven electronic databases (PubMed, Embase, Cochrane Library, Web of Science, CINAHL, PsycINFO, and Scopus) from their inception to October 17, 2023, with an update conducted on April 1, 2024. Meta-analysis synthesized prevalence estimates of involuntary treatment and its three subcategories, with 95% confidence intervals.

RESULTS

This study included 11 research papers involving 12,136 community-dwelling individuals with cognitive impairment and dementia from 19 countries. The pooled prevalence of involuntary treatment among community-dwelling older persons with dementia was 45.2% (95% CI: 33.7-60.5%). Subcategories included physical restraints (9.8%, 95% CI: 5.1-18.8%), psychotropic medication (19.1%, 95% CI: 13.6-26.9%), and non-consensual care (34.3%, 27.6-42.7%). Factors influencing involuntary treatment were categorized as caregiver-related and care recipient-related.

CONCLUSION

This study underscores the prevalent use of involuntary treatment among community-dwelling older persons with dementia, emphasizing its association with specific caregiver and care recipient factors. Addressing these findings underscores the importance of proactive measures and targeted interventions to improve the quality of care for this vulnerable population.

[Use of physical restraints in the elderly in an emergency department. Analysis of clinical, environmental and health care team organization factors associated with decision making]

OBJETIVE

To determine the influence of different factors involved in the decision to apply physical restraints (PR) in the management the elderly people with conduct disorders in an emergency department (ED) METHODS: A prospective observational study was conducted in the ED of the Hospital Universitario Severo Ochoa (Leganés, Madrid). We included 125 elderly people with disruptive behaviors and collected clinical, patient handling, organizational and environmental variables. Individuals who had undergone PR were analyzed to learn what factors were related to the final decision to restrain.

RESULTS

32.8% of the participants underwent PR. The aspects that most influenced the decision to restrain were those related to the organization and environment: specific staff training decreased the probability of restraint by 50% (P<.05) and good support from the whole team reduced the risk of using SF by up to 75% (P<.0005). Related patient handling factors such as verbal restraint, pain relief, family accompaniment and early mobilization significantly reduced the use of PR (P<.05). The only patient-dependent clinical aspect that increased the risk of SF was male sex (P<.05). Other factors unrelated to the probability of applying PR were, among others, nurse-patient ratio, type of behavior, age, or functional/cognitive status.

CONCLUSIONS

Exclusively clinical factors of the patient had little influence on the decision to restrain the elderly in an ED. However, environmental, organizational, and behavioral handling variables could favor more respectful alternatives and thus reduce the use of PR in the elderly with disruptive behaviors in the ED.

Physical restraint in older people: an opinion from the Early Career Network of the International Psychogeriatric Association

The International Psychogeriatric Association (IPA) has expressed significant concerns over the use of physical restraints in older people across diverse aged care settings. Following an extensive analysis of the available literature, the IPA's Early Career Network (ECN) has formulated a collection of evidence-based recommendations aimed at guiding the use of physical restraints within various care contexts and demographic groups. Physical restraints not only infringe upon human rights but also raise significant safety concerns that adversely impact the physical, psychological, social, and functional well-being of older adults. Furthermore, their effectiveness in geriatric settings remains inadequate. Given these considerations, the IPA and its ECN firmly assert that the use of physical restraints should only be considered as a final recourse in the care of older people.

Caregiver-reported use of physical restraints among community-dwelling older adults with severe dementia in Singapore

BACKGROUND

Older adults with severe dementia are at increased risk of being physically restrained in nursing homes and acute care settings, but little is known about restraint use among those cared for at home. This study explores caregiver-reported use of restraints among community-dwelling older adults with severe dementia.

METHODS

Using cross-sectional data from 215 family caregivers, we describe restraint use among older adults with severe dementia living at home. We then use multivariable logistic regression to identify factors associated with restraint use.

RESULTS

Nearly half (47%) of caregivers reported on older adults who had been subject to restraints. Most caregivers reporting restraint use suggested safety reasons, such as prevention of falls (68%), wandering (30%), and removal of catheters or feeding tubes (29%); and 44% indicated doctors or other health care providers were involved in the decision to restrain. Feeding tubes (OR = 4.16, 95% CI: 1.27-13.59) and physically aggressive agitation behaviors (OR = 1.93, 95% CI: 1.09-3.40) were associated with higher odds of restraint use among older adults with severe dementia. Caregivers who received strong emotional support from friends (OR = 0.45, 95% CI: 0.21-0.95) were less likely to report restraint use while serving as a caregiver to others (OR = 2.77, 95% CI: 1.36-5.63) increased the odds of restraint use.

CONCLUSIONS

The pervasiveness of restraint use is concerning and suggests a lack of evidence-based guidance and support for both caregivers and healthcare providers to prevent restraint use among older adults with severe dementia cared for at home.

Trust-building interventions to home-dwelling persons with dementia who resist care

BACKGROUND

Providing care for a home-dwelling person with dementia who resists care is an ethical and practical complex and challenging task. Faced with a growing number of persons with dementia, the healthcare professional's understanding of how to best care for and prevent unnecessary use of coercion with persons with dementia is of key importance.

RESEARCH AIM

The aim of this study was to explore the use of trust-building interventions in home-dwelling persons with dementia resisting care, as described by health professionals in documents of decisions of forced treatment and care.

RESEARCH DESIGN

A qualitative thematic document analysis inspired by critical realism was conducted.

PARTICIPANTS AND RESEARCH CONTEXT

Descriptions of trust-building interventions were extracted from 88 documents of forced treatment and care for home-dwelling persons with dementia, receiving home healthcare, in 2015 and 2016.

ETHICAL CONSIDERATIONS

Approved by the Regional Committee for Medical and Health Research Ethics, reference number 2017/788, and controlled by the Norwegian Centre for Research Data, reference number 54897. The study adhered to the guidelines of the Declaration of Helsinki.

FINDINGS

We found that "balancing safe care with the person's integrity" was an overarching theme that permeated the descriptions of trust-building interventions in the study. Three main themes were identified when the data were analyzed: safeguarding care, protecting integrity, and optimizing the environment.

DISCUSSION AND CONCLUSION

Health professionals balanced on a thin line between care and integrity when met with resistance from person with dementia. However, the trust-building interventions used in the most challenging situations did not differ from the interventions used in general in dementia care. Two knowledge gaps were identified: how to perform appropriate assessments of situations of home-dwelling persons with dementia when met with resistance to care, and whether environmental initiatives may also benefit home-dwelling persons with dementia who are not easily cared for.

Risks and risk mitigation in homecare for people with dementia-A two-sided matter: A systematic review

Policy guidance promotes supporting people to live in their own homes for as long as possible with support from homecare services. People living with dementia who need such support can experience a range of physical and cognitive difficulties, which can increase the risks associated with homecare for this group. We aimed to examine risk and safety issues for people with dementia and their homecare workers and risk mitigation practices adopted by homecare workers to address identified risks. We searched MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, ASSIA and Cochrane Central Register of Controlled Trials databases 5 March 2021. Included studies focussed on homecare for people with dementia and had a risk or safety feature reported. Risk of bias was assessed with the Joanna Briggs Institute Critical Appraisal tools. Two authors assessed articles for potential eligibility and quality. A narrative synthesis combines the findings. The search identified 2259 records; 27 articles, relating to 21 studies, met the eligibility criteria. The review identified first-order risks that homecare workers in the studies sought to address. Two types of risk mitigation actions were reported: harmful interventions and beneficial interventions. Actions adopted to reduce risks produced intended benefits but also unintended consequences, creating second-order risks to both clients with dementia and homecare workers, placing them at greater risk. Risk mitigation interventions should be person-centred, the responsibility of all relevant professions, and planned to minimise the creation of unintended risks.

The multi-subject cooperation mechanism of home care for the disabled elderly in Beijing: a qualitative research

BACKGROUND

Currently, population aging has been an obstacle and the spotlight for all countries. Compared with developed countries, problems caused by China's aging population are more prominent. Beijing, as a typical example, is characterized by advanced age and high disability rate, making this capital city scramble to take control of this severe problem. The main types of care for the disabled elderly are classified as home care, institutional care, and community care. With the obvious shortage of senior care institutions, most disabled elderly people are prone to choose home care. This kind of elderly care model is in line with the traditional Chinese concept and it can save the social cost of the disabled elderly to the greatest extent. However, home care for the disabled elderly is facing bumps from the whole society, such as lack of professional medical care, social support and humanistic care, and the care resources provided by a single subject cannot meet the needs of the disabled elderly.

OBJECTIVE

Based on the demands of the disabled elderly and their families, this study aims to explore the current status of home care service, look for what kind of care is more suitable for the disabled elderly, and try to find an appropriate elderly care mechanism which could meet the diverse needs of the disabled elderly.

METHODS

A total of 118 disabled elderly people and their primary caregivers were selected from four districts of Beijing by using multi-stage stratified proportional sampling method. A one-to-one and semi-structured in-depth qualitative interview were conducted in the study to find out the health status of the disabled elderly, the relationship between the disabled elderly and their primary caregivers, and utilization of elderly care resources, etc. The views of the interviewees were analyzed through the thematic framework method. All the methods were carried out in accordance with relevant guidelines and regulations.

RESULTS

The results showed that the average age of 118 disabled elderly is 81.38 ± 9.82 years; 86 (72.9%) are severe disability; 105 (89.0%)are plagued by chronic diseases; the average duration of disability is 5.63 ± 5.25 years; most of disabled elderly have 2 children, but the primary caregiver are their own partner (42, 35.6%), and there is an uneven sharing of responsibilities among the disabled elderly's offspring in the process of home care. The disabled elderly enjoy medical care services, rehabilitation training, daily health care, psychological and other demands. However, the disabled elderly and their families in Beijing face a significant financial burden, as well as physical and psychological issues. The care services provided by the government, family doctors, family members and social organizations fall far short of satisfying the diverse care needs of the disabled elderly.

CONCLUSIONS

In order to effectively provide home care services for the disabled elderly, it is therefore necessary to establish a coordination mechanism of multiple subjects and give full play to the responsibilities of each subject. This study proposes a strengthening path for the common cooperation of multiple subjects, which taking specific responsibilities and participating in the home care for the disabled elderly: (1) The government should give full play to the top-level leading responsibilities and effectively implement people-oriented measures to the disabled elderly. (2) Family doctors strengthen their responsibilities as health gatekeepers and promote continuous health management of the disabled elderly. (3) Family members assume the main responsibility and provide a full range of basic care services. (4) Social forces promote supplementary responsibilities of public welfare and expand the connotation of personalized care services. (5) The disabled elderly should shoulder appropriate personal responsibility and actively cooperate with other subjects.

Autonomy conquers all: a thematic analysis of nurses’ professional judgement encountering resistance to care from home-dwelling persons with dementia

Background

Adequate care support from home health care nurses is needed to meet the needs of an increasing number of home-dwelling persons with dementia and those who resist care. The decisions nurses make in home health care when encountering resistance from persons with dementia have an extensive impact on the quality of care and access to care. There is little research on what influences nurse’s encounters with resistance to care from home-dwelling persons with dementia.

Research aim

To get insight into how nurses experience resistance to care from home-dwelling persons with dementia.

Methods

A qualitative research design using a thematic analysis was conducted following the six steps by Braun and Clarke. Data was gathered from three focus group and three individual interviews, and a total of 18 nurses from home health care participated. The interviews took place over a period of 5 months, from December 2020 to April 2021.

Ethical considerations

Approved by the Norwegian Centre for Research, reference number 515138 and by the research advisers and home care managers in each section of the municipality.

Results

Two main themes were identified: 1) Challenged by complex and inadequate care structures and 2) Adapting care according to circumstances. There were three subthemes within the first main theme: lack of systematic collaboration and understanding, insufficient flexibility to care, and the challenge of privacy. In the second main theme, there were three subthemes: avoid forced treatment and care to protect autonomy, gray-areas of coercive care and reduced care. The two main themes seemed to be interdependent, as challenges and changes in organizational structures influenced how nurses could conduct their care practices.

Conclusion

Our findings indicate that nurses’ responsibility to decide how to conduct care is downplayed when facing resistance. Further, their professional judgement is influenced by contextual factors and characterized by a strong commitment to avoid forced treatment and care.

A continuous challenge is to safeguard shared decision-making at the same time as it is balanced against risks of severe health damage in home-dwelling persons with dementia. A fundamental question to ask is whether autonomy does conquer all, even when severe health damage is at stake.

Physical restraint in elderly in home care: a cross-sectional study

OBJECTIVE

To estimate the prevalence of mechanical restraint and factors associated with its practice in elderly in Home Care.

METHODS

This was a cross-sectional study with 162 elderly randomly assigned to a home care program in Rio de Janeiro, from March 2018 to July 2018. Used as a technique for data collection and direct observation and structured interview of elderly clinical data. Data were analyzed descriptively and inferentially.

RESULTS

There was a 13% prevalence of mechanical restraint in elderly in home care. The most frequent restraints were the use of bandage, tissues and sheets in the arms/legs and chests of the elderly, and the justification for their use were control of aggressive behavior (28.6%), prevention of falls (19%) and protection (19%). Of the total elderly participants, 42.9% remained contained for more than 24 hours, and in 85.7% of the cases, the individuals were confined to a room.

CONCLUSION

It is necessary to expand the training of formal and informal caregivers, recommending the rehabilitation of care practices that preserve the elderly's autonomy, giving them dignity, respecting gerontological and home care principles.

An Application of the Theory of Planned Behavior to Predict the Intention and Practice of Nursing Staff Toward Physical Restraint Use in Long-Term Care Facilities: Structural Equation Modeling

PURPOSE

Understanding the factors that affect nursing staffs' intention and practice of physical restraint (PR) on older adults help develop restraint-reduction programs. This study aimed to identify the relationship between the Theory of Planned Behavior (TPB) constructs and nursing staffs' practice to use PR in long-term care (LTC) facilities.

PATIENTS AND METHODS

A cross-sectional survey was conducted via convenience sampling among 316 nursing staff in six Chinese LTC facilities. PR-TPB questionnaire and the practice subscale of the Chinese version of the Staff Knowledge, Attitudes and Practices Questionnaire regarding PR were used to collect the data. Structural equation modeling (SEM) was used to examine the relationship between variables.

RESULTS

The SEM fit well with the data (χ2/df =1.639, RMSEA = 0.045, CFI= 0.955, GFI=0.945). Attitude (β=0.536, P<0.001) and perceived behavioral control (PBC) (β=0.139, P<0.05) predicted intention (R2 =0.359). PBC was a significant predictor of practice, with R2 accounting for 0.151.

CONCLUSION

TPB provided useful insight into better understanding nursing staffs' PR practices, although it did not support all the TPB principles significantly. Prospective studies may be conducted to design and implement multi-component interventions based on TPB and explore the effectiveness of PR reduction in LTC facilities in-depth.

Reducing the use of physical restraints in home care: development and feasibility testing of a multicomponent program to support the implementation of a guideline

BACKGROUND

A validated evidence-based guideline was developed to reduce physical restraint use in home care. However, the implementation of guidelines in home care is challenging. Therefore, this study aims to systematically develop and evaluate a multicomponent program for the implementation of the guideline for reducing the use of physical restraints in home care.

METHODS

Intervention Mapping was used to develop a multicomponent program. This method contains six steps. Each step comprises several tasks towards the design, implementation and evaluation of an intervention; which is theory and evidence informed, as well as practical. To ensure that the multicomponent program would support the implementation of the guideline in home care, a feasibility study of 8 months was organized in one primary care district in Flanders, Belgium. A concurrent triangulation mixed methods design was used to evaluate the multicomponent program consisting of a knowledge test, focus groups and an online survey.

RESULTS

The Social Cognitive Theory and the Theory of Planned Behavior are the foundations of the multicomponent program. Based on modeling, active learning, guided practice, belief selection and resistance to social pressure, eight practical applications were developed to operationalize these methods. The key components of the program are: the ambassadors for restraint-free home care (n = 15), the tutorials, the physical restraint checklist and the flyer. The results of the feasibility study show the necessity to select uniform terminology and definition for physical restraints, to involve all stakeholders from the beginning of the process, to take time for the implementation process, to select competent ambassadors and to collaborate with other home care providers.

CONCLUSIONS

The multicomponent program shows promising results. Prior to future use, further research needs to focus on the last two steps of Intervention Mapping (program implementation plan and developing an evaluation plan), to guide implementation on a larger scale and to formally evaluate the effectiveness of the multicomponent program.

Patient safety and bedrail use as a global phenomenon: A prevalence study

Background: Although bedrail use may increase the risk of accidents among patients, bedrails are still extensively used in healthcare facilities. Therefore, the field calls for a review of bedrail use in practice. Objective: This report examined the prevalence and implications of bedrail use in rehabilitation facilities in Hong Kong. The findings are compared with the current state of bedrail use worldwide. Design and methods: This work is a cross-sectional, observational study. A secondary analysis was conducted on the database of a prospective trial. Bilateral bedrail use was observed in two Hong Kong rehabilitation hospitals. Logistic regression was performed to examine the factors associated with bedrail use. Results: A total of 3,384 restraint observations were made. The bedrail rate was 31.34%, which revealed that bedrail use was the second most commonly used physical restraint. The fall history (OR: 2.84), cognitive impairment (OR: 0.91) and functional dependency (OR: 0.79) of patients were significant predictors of bedrail use, p < .05. Conclusion: This study examines bedrail prevalence through direct observation, which is the preferred method for examining bedrail use in practice. We found that actual bedrail use is higher than the numbers reported in previous studies in Hong Kong. In addition, our research reveals that bedrails are commonly used for vulnerable patients. This finding highlights the need to change nurses' beliefs on bedrail use through education. The management of these health facilities should also aim to create an institutional environment that promotes the reduction of bedrail use. Implementation strategies on restraint reduction should also fit the culture of the organisation and local nursing practices, as well as the staff's values. Impact Statement: This study provides preliminary information about the widespread use of bedrails in Hong Kong and other countries. The research also introduces effective ways to achieve the reduction of bedrail use.

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.

Reducing physical restraints by older adults in home care: development of an evidence-based guideline

Background

Restraint use is a complex and challenging issue in home care. Due to socio-demographic trends, worldwide home healthcare providers are faced with an increasing demand for restraint use from informal caregivers, patients and healthcare providers, resulting in the use of various types of restraints in home care. Awareness and knowledge of restraint use in home care, its implications and the ethical challenges surrounding it are of crucial importance to its reduction. This research aimed to describe the development process of an evidence-based practice guideline to support caregivers to optimize home care.

Method

The practice guideline was developed according to the framework of the Belgian Centre for Evidence-Based Medicine and AGREE II. The guideline was developed over several stages: (1) determination of the target population and scope, (2) literature search, (3) drafting and (4) validation. A multidisciplinary working group determined the proposed purpose, target group, and six clinical questions for the guideline. A consensus procedure and consultation by experts were used to develop the guideline.

Results

The guideline provides an answer to six clinical questions and contains ten key recommendations based on the classification of GRADE, with the objective of increasing healthcare providers’ awareness, knowledge and competence to adequately deal with situations or questions related to restraint use. The guideline also includes a flowchart for dealing with complex situations where the use of restraints is requested, already present or considered.

Conclusions

The guideline was validated by the Belgian Centre for Evidence-Based Medicine. Increasing competence, awareness and knowledge related to restraint use are key objectives of the guideline for reducing restraint use in home care. A multicomponent intervention to support healthcare workers in implementing the guideline in clinical practice needs to be developed.