Factors Associated With the Trend of Physical and Chemical Restraint Use Among Long-Term Care Facility Residents in Hong Kong: Data From an 11-Year Observational 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.

Design of a prototype of clothing for older persons with neurocognitive diseases with behavioural troubles interfering with the management of sphincter disorders

INTRODUCTION

The evolution of neurocognitive diseases is marked by increasingly disruptive behavioural disorders as well as sphincter troubles. To avoid being forced to use physical restraints or therapies that promote drowsiness to prevent older patients from removing their diapers, caregivers can use a onesie. However, this solution does not respect the dignity of these persons.

OBJECTIVES

To design a prototype of onesie that will be aesthetically pleasing as daytime clothing, with features that simplify its use by professional caregivers and respect the dignity of older adults with neurocognitive diseases.

METHODOLOGY

A randomized open trial was conducted comparing the prototype of onesie that was developed to a classic onesie. The degree of respect for the dignity of these older adults was rated as well acceptability and reliability of the two onesies and a satisfaction survey among caregivers was carried out using a derived questionnaire from the ITHACA project.

RESULTS

The final version of the prototype was a onesie resembling to a clothing adapted for day wear and allowing caregivers to quickly change persons with restricted participation. Forty subjects were included. No difference was found in the dignity ratings assigned by their relatives. The caregiver satisfaction survey showed that they thought the prototype respected the dignity of the subjects but that the use of the classic onesie made the work easier.

CONCLUSION

Our prototype of onesie allowed a better usability by caregivers, was better accepted than a classic model of onesie while respecting the dignity of older adults with neurocognitive diseases.

Instruments and Warning Signs for Identifying and Evaluating the Frequency of Adverse Events in Intermediate and Long-Term Care Centres: A Narrative Systematic Review

INTRODUCTION

There is a lack of data about adverse events (AE) in intermediate and long-term care centers (ILCC). We aimed to synthesize the available scientific evidence on instruments used to identify and characterize AEs. We also aimed to describe the most common adverse events in ILCCs.

MATERIAL AND METHODS

A narrative systematic review of the literature was conducted according to Prisma recommendations. The PubMed database was searched for articles published between 2000 and 2021. Two reviewers independently screened and reviewed the studies through blind and independent review. We evaluated bias risk with Cochrane's risk of bias tool. Disagreements were resolved by consensus. Discrepancies that were not resolved by discussion were discussed with a third reviewer. Descriptive data was extracted and qualitative content analysis was performed.

RESULTS

We found 2191 articles. Based on the inclusion and exclusion criteria, 272 papers were screened by title and abstract, and 66 studies were selected for full review. The instruments used to identify AEs were mostly tools to identify specific AEs or risks of AEs (94%), the remaining 6% were multidimensional. The most frequent categories detected medication-related AEs (n=26, 40%); falls (n=7, 11%); psychiatric AEs (6.9%); malnutrition (4.6%), and infections (4.6%). The studies that used multidimensional tools refer to frailty, dependency, or lack of energy as predictors of AEs. However, they do not take into account the importance of detecting AEs. We found 2-11 adverse drug events (ADE) per resident/month. We found a prevalence of falls (12.5%), delirium (9.6-89%), pain (68%), malnutrition (2-83%), and pressure ulcers (3-30%). Urinary tract infections, lower respiratory tract infections, skin and soft tissue infections, and gastroenteritis were the most common infections in this setting. Transitions between different care settings (from hospitals to ILCC and vice versa) expose AE risk.

CONCLUSION

There are many instruments to detect AEs in ILCC, and most have a specific approach. Adverse events affect a significant proportion of patients in ILCC, the nurse-sensitive outcomes, nosocomial infections, and adverse drug events are among the most common. The systematic review was registered with Prospero, ID: CRD42022348168.

Is elderspeak communication in simulated hospital dementia care congruent to communication in actual patient care? A mixed-methods pilot study

AIMS

Simulation offers a feasible modality to prepare nurses for challenges communicating with patients with dementia. Elderspeak communication is speech that sounds like baby talk and can lead to rejection of care by patients with dementia. However, it is unknown if simulation can be used to capture elderspeak communication in dementia care. The purpose of this mixed-methods study was to determine if simulation accurately captures elderspeak communication by nursing staff in hospital dementia care.

DESIGN

A 3-part mixed-methods design in which (1) three dementia care simulations were designed and validated by a panel of experts, (2) communication by nursing staff completing each simulation was quantitatively compared to communication during actual patient care, and (3) views on the realism were explored using within- and across-case coding.

METHODS

Three simulations using different modalities (manikin, role-play, and standardised patient) were designed and validated with eight experts using the Lynn Method. Ten nursing staff were audio-recorded and their communication was coded for elderspeak communication. Results for each simulation were compared using Wilcoxon signed-rank test to recordings taken during actual dementia care encounters. Debriefings were coded for realism and results were converged.

RESULTS

The average time using elderspeak during naturalistic care was 29.9% (SD = 20.9%) which did not differ from the average amount of elderspeak used across the three simulations modalities which ranged from 29.1% to 30.4%. Qualitative results suggested a lack of realism with the manikin condition and the nursing staff indicated preference for the simulation with the standardised patient.

CONCLUSIONS

Communication elicited in the dementia care simulations was congruent to communication produced in actual dementia care but preference was for the standardised patient.

IMPLICATIONS FOR PATIENT CARE

Elderspeak communication can be accurately produced in the simulated environment which indicates that simulation is a valid method for person-centred communication training in nursing staff.

IMPACT

Simulation offers a feasible modality to prepare nurses for challenges communicating with patients with dementia. Elderspeak communication is speech that sounds like baby talk and can lead to rejection of care by patients with dementia. However, it is unknown if simulation can be used to capture elderspeak communication in dementia care. Elderspeak communication captured in the simulated environment was congruent to communication nursing staff use during actual patient care to hospitalised persons living with dementia. This study empirically identifies that communication is elicited in similar patterns by nursing staff in the simulated environment compared to the naturalistic care environment which demonstrates that simulation can be used as a valid tool for education and research on person-centred communication.

REPORTING METHODS

STROBE.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Assessment of Nurses' Knowledge, Attitude and Practice Regarding Physical Restraint: A Scoping Review

The use of physical restraints (PR) in healthcare settings, especially in psychiatric units, is a controversial topic. The attitude, knowledge, and practices of nurses towards PR can influence its application, which raises concerns about the balance between patient safety and individual rights. With mental disorders being a leading cause of disability globally, understanding the complexities surrounding PR use becomes paramount. A comprehensive literature review was conducted using multiple databases, including PubMed, Medline, CINAHL, PsycINFO, ProQuest, The Cochrane Library, the Saudi Digital Library, and Google Scholar. The search spanned literature published up to December 2022, focusing on studies that explored the relationship between nurses' knowledge, attitudes, and practices regarding PR in psychiatric settings. Inclusion and exclusion criteria were applied to filter out relevant studies. From 220 records initially retrieved, 12 articles were identified for the final review. The reviewed studies highlighted a moderate knowledge and attitude among nurses concerning PR. Many nurses were found to be uncertain about the reasons for PR application and its alternatives. Educational interventions were emphasized in several studies as beneficial in improving nurses' knowledge, attitudes, and practices. However, inconsistencies were observed regarding the impact of these interventions on nurses' attitudes. Experience, higher education, and continuous training sessions were found to be correlated with better knowledge and more favourable attitudes towards PR. This review emphasizes the critical need for consistent training and education for nurses regarding PR, given the profound implications for patient care and safety. While educational interventions show promise in enhancing knowledge and practice, their impact on attitudes remains contested. Future research should consider the gaps identified in this review, including the exploration of alternatives to PR, larger sample sizes and longitudinal studies to understand the long-term effects of interventions.

The prevalence of non-pharmacological interventions in older homecare recipients: an overview from six European countries

PURPOSE

Non-pharmacological interventions (NPIs) play an important role in the management of older people receiving homecare. However, little is known about how often specific NPIs are being used and to what extent usage varies between countries. The aim of the current study was to investigate the prevalence of NPIs in older homecare recipients in six European countries.

METHODS

This is a cross-sectional study of older homecare recipients (65+) using baseline data from the longitudinal cohort study 'Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care' (IBenC). The analyzed NPIs are based on the interRAI Home Care instrument, a comprehensive geriatric assessment instrument. The prevalence of 24 NPIs was analyzed in Belgium, Germany, Finland, Iceland, Italy and the Netherlands. NPIs from seven groups were considered: psychosocial interventions, physical activity, regular care interventions, special therapies, preventive measures, special aids and environmental interventions.

RESULTS

A total of 2884 homecare recipients were included. The mean age at baseline was 82.9 years and of all participants, 66.9% were female. The intervention with the highest prevalence in the study sample was 'emergency assistance available' (74%). Two other highly prevalent interventions were 'physical activity' (69%) and 'home nurse' (62%). Large differences between countries in the use of NPIs were observed and included, for example, 'going outside' (range 7-82%), 'home health aids' (range 12-93%), and 'physician visit' (range 24-94%).

CONCLUSIONS

The use of NPIs varied considerably between homecare users in different European countries. It is important to better understand the barriers and facilitators of use of these potentially beneficial interventions in order to design successful uptake strategies.

Physical Restraint Use in Nursing Homes-Regional Variances and Ethical Considerations: A Scoping Review of Empirical Studies

BACKGROUND

Physical restraints are known to violate human rights, yet their use persists in long-term care facilities. This study aimed to explore the prevalence, methods, and interventions related to physical restraint use among the elderly in nursing homes.

METHODS

The method described by Joanna Briggs was followed to conduct a scoping review without a quality assessment of the selected studies. An electronic search was conducted to find eligible empirical articles using MEDLINE, PsycINFO, EMBASE, Web of Science, Scopus, Google Scholar, CINAHL, and grey literature. The database search was performed using EndNote software (version X9, Clarivate Analytics), and the data were imported into Excel for analysis.

RESULTS

The prevalence of physical restraint use was found to be highest in Spain (84.9%) and lowest in the USA (1.9%). The most common device reported was bed rails, with the highest prevalence in Singapore (98%) and the lowest (4.7%) in Germany, followed by chair restraint (57%). The largest number of studies reported the prevention and/or risk of falls to be the main reason for using physical restraints, followed by behavioral problems such as wandering, verbal or physical agitation, and cognitive impairment. Most studies reported guideline- and/or theory-based multicomponent interventions consisting of the training and education of nursing home staff.

CONCLUSIONS

This review provides valuable insights into the use of physical restraints among elderly residents in nursing homes. Despite efforts to minimize their use, physical restraints continue to be employed, particularly with elderly individuals who have cognitive impairments. Patient-related factors such as wandering, agitation, and cognitive impairment were identified as the second most common reasons for using physical restraints in this population. To address this issue, it is crucial to enhance the skills of nursing home staff, especially nurses, in providing safe and ethical care for elderly residents with cognitive and functional impairments, aggressive behaviors, and fall risks.

A Risk Prediction Model for Physical Restraints Among Older Chinese Adults in Long-term Care Facilities: Machine Learning Study

BACKGROUND

Numerous studies have identified risk factors for physical restraint (PR) use in older adults in long-term care facilities. Nevertheless, there is a lack of predictive tools to identify high-risk individuals.

OBJECTIVE

We aimed to develop machine learning (ML)-based models to predict the risk of PR in older adults.

METHODS

This study conducted a cross-sectional secondary data analysis based on 1026 older adults from 6 long-term care facilities in Chongqing, China, from July 2019 to November 2019. The primary outcome was the use of PR (yes or no), identified by 2 collectors' direct observation. A total of 15 candidate predictors (older adults' demographic and clinical factors) that could be commonly and easily collected from clinical practice were used to build 9 independent ML models: Gaussian Naïve Bayesian (GNB), k-nearest neighbor (KNN), decision tree (DT), logistic regression (LR), support vector machine (SVM), random forest (RF), multilayer perceptron (MLP), extreme gradient boosting (XGBoost), and light gradient boosting machine (Lightgbm), as well as stacking ensemble ML. Performance was evaluated using accuracy, precision, recall, an F score, a comprehensive evaluation indicator (CEI) weighed by the above indicators, and the area under the receiver operating characteristic curve (AUC). A net benefit approach using the decision curve analysis (DCA) was performed to evaluate the clinical utility of the best model. Models were tested via 10-fold cross-validation. Feature importance was interpreted using Shapley Additive Explanations (SHAP).

RESULTS

A total of 1026 older adults (mean 83.5, SD 7.6 years; n=586, 57.1% male older adults) and 265 restrained older adults were included in the study. All ML models performed well, with an AUC above 0.905 and an F score above 0.900. The 2 best independent models are RF (AUC 0.938, 95% CI 0.914-0.947) and SVM (AUC 0.949, 95% CI 0.911-0.953). The DCA demonstrated that the RF model displayed better clinical utility than other models. The stacking model combined with SVM, RF, and MLP performed best with AUC (0.950) and CEI (0.943) values, as well as the DCA curve indicated the best clinical utility. The SHAP plots demonstrated that the significant contributors to model performance were related to cognitive impairment, care dependency, mobility decline, physical agitation, and an indwelling tube.

CONCLUSIONS

The RF and stacking models had high performance and clinical utility. ML prediction models for predicting the probability of PR in older adults could offer clinical screening and decision support, which could help medical staff in the early identification and PR management of older adults.

Prevalence, Risk Factors and Outcomes Associated with Physical Restraint in Acute Medical Inpatients over 4 Years-A Retrospective Cohort Study

BACKGROUND

Physical restraints are frequently used in acute care hospitals. Their application is associated with negative outcomes, while their intended preventive effect is debated.

OBJECTIVES

To determine the prevalence of physical restraints and associated outcomes on medical wards in a tertiary care hospital.

METHODS

Retrospective cohort study (January 2018 to December 2021). We included all adult medical in-patients and excluded patients with admission to the intensive care unit, short stays (length of stay (LOS) < 48 h), and patients declining informed consent.

RESULTS

Of 11,979 admissions, the prevalence of patients with at least one restraint was 6.4% (n = 772). Sensor mats were used most frequently (73.0%, n = 666), followed by blanket restrictions (14.5%, n = 132), bedrails (8.8%, n = 80) and belts (3.7%, n = 34). On average, restraints were applied 19 h (standard deviation (SD) ± 161) before a fall. Average restraint duration was 42 h (SD ± 57). Patients with a restraint had longer LOS 8 days (IQR 5-14) vs. 5 days (IQR 3-9). Median nurses' time expenditure was 309 h (IQR 242-402) vs. 182 h (IQR 136-243) for non-restrained patients. Patients with restraints fell more often (22.5% vs. 2.7%) and were more likely to die (13.3% vs. 5.1%). These differences persisted after adjusting a regression model for important clinical confounders. We saw a decline in the duration of restraints over the years, but no variation between wards.

CONCLUSION

Approximately 6% of medical patients, mostly older and severely ill, were affected by restraint use. For the first time, we report data over 4 years up to ward-level granularity.

A cross-sectional study examining the factors affecting nurses' knowledge, attitude, and behavior toward physical restraint use

PURPOSE

This study aimed to investigate the factors associated with nurses' intent to use physical restraint.

DESIGN AND METHODS

This cross-sectional study used a questionnaire to survey 403 nurses from a hospital in northern Taiwan.

FINDINGS

Nurses who participated in a simulation training program had better knowledge and behavioral intent toward physical restraint use. Seniority and workplace significantly influenced the knowledge of physical restraint use, whereas workplace and clinical ladder level significantly shaped nurses' attitude toward it.

PRACTICE IMPLICATIONS

The results showed that the simulated physical restraint training program was effective. The impact of nurses' workplace, seniority, and clinical ladder level on an educational intervention should be considered before formulating a plan to reduce physical restraint use.

A Night-Time Monitoring System (eNightLog) to Prevent Elderly Wandering in Hostels: A Three-Month Field Study

Older people are increasingly dependent on others to support their daily activities due to geriatric symptoms such as dementia. Some of them stay in long-term care facilities. Elderly people with night wandering behaviour may lose their way, leading to a significant risk of injuries. The eNightLog system was developed to monitor the night-time bedside activities of older people in order to help them cope with this issue. It comprises a 3D time-of-flight near-infrared sensor and an ultra-wideband sensor for detecting human presence and to determine postures without a video camera. A threshold-based algorithm was developed to classify different activities, such as leaving the bed. The system is able to send alarm messages to caregivers if an elderly user performs undesirable activities. In this study, 17 sets of eNightLog systems were installed in an elderly hostel with 17 beds in 9 bedrooms. During the three-month field test, 26 older people with different periods of stay were included in the study. The accuracy, sensitivity and specificity of detecting non-assisted bed-leaving events was 99.8%, 100%, and 99.6%, respectively. There were only three false alarms out of 2762 bed-exiting events. Our results demonstrated that the eNightLog system is sufficiently accurate to be applied in the hostel environment. Machine learning with instance segmentation and online learning will enable the system to be used for widely different environments and people, with improvements to be made in future studies.

Difference of Physical Restraint Knowledge, Attitudes and Practice Between Nurses and Nursing Assistants in Long-Term Care Facilities: A Cross-Sectional Study

Background

Purpose

Methods

Results

Conclusion

Optimizing the InterRAI Assessment Tool in Care Planning Processes for Long-Term Residents: A Scoping Review

The aim of this review was to chart and report on existing literature that discusses how the interRAI assessment tool drives care-planning processes for residents in long-term-care settings. This scoping review was informed by the Joanna Briggs Institute guidelines for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guideline. Relevant studies were obtained from databases search of CINAHL (EBSCO), MEDLINE (Ovid), PsycINFO (EBSCO), Academic Search Premier (EBSCO), Embase (Elsevier), ProQuest Nursing and Allied Health Database (ProQuest), Sociological Abstracts (ProQuest), and Social Services Abstracts (ProQuest). Of the 17 included studies, five (29.4%) addressed interRAI's minimum dataset component as a clinical data-collection tool; five (29.4%) addressed interRAI's assessment scales and its clinical-assessment protocols as viable health-assessment tools; four (23.5%) considered interRAI's assessment scales in terms of whether this tool is capable of predicting residents' health risks; one (5.9%) addressed the effects of interRAI's care plans on residents' health outcomes; and the remaining two studies (11.8%) used interRAI's quality-indicator function for both the performance of and improvements in the quality of care. The scoping review finds that there is no substantial evidence that supports the implementation of interRAI care plans for consistent health outcomes.

Factors Associated with Development of New Joint Contractures in Long-Term Care Residents

OBJECTIVE

Limb contractures are associated with poor outcomes and quality of life in long-term care (LTC) residents. This study examined the rate of developing new joint contracture in the LTC residents and associated risk factors to formulate effective interventions in this critical but understudied area.

DESIGN

This is an observational study with data obtained from the Hong Kong Longitudinal Study on LTC Residents between 2005 and 2016.

SETTING AND PARTICIPANTS

Trained assessors (nurses, social workers, and therapists) used the Minimum Data Set Resident Assessment Instrument (MDS-RAI 2.0) to collect the data of the residents from 9 residential LTC facilities.

MEASURES

Limb contractures were defined as a functional limitation in the range of motion involving the upper or lower limbs. Primary outcomes included annual prevalence of joint contractures and factors that were associated with the development of new joint contractures.

RESULTS

We analyzed the data for 1914 older residents (674 males, mean age 83.4 years). During the first 5 years since admission, the annual prevalence of upper limb contractures increased from 29.8% to 36.5%, and lower limb contractures increased from 41.5% to 57.4%. Overall, the increment of the prevalence rate of joint contractures per year ranged from 0.7% to 3.2% for the upper limbs and 0.3% to 6.0% per year for the lower limbs. Impaired mobility, presence of neurologic diseases, and older age were the leading independent risk factors for the development of new joint contractures.

CONCLUSIONS AND IMPLICATIONS

Joint contractures are highly prevalent among residents admitted to the LTC facilities, and many residents develop new contractures during the first 5 years of their admission. Immobility appears to be the main modifiable risk factor. Further studies are needed to identify potential strategies to prevent new contractures in this vulnerable group.

Effects of a Web-Based Educational Program Regarding Physical Restraint Reduction in Long-Term Care Settings on Nursing Students: A Cluster Randomized Controlled Trial

Physical restraint is still frequently used in many countries. However, a lack of education hinders physical restraint reduction in long-term care facilities. No study has yet to examine the effects of physical restraint reduction education on nursing students. This study aimed to evaluate the effects of a web-based educational program of physical restraint reduction on nursing students’ knowledge and perceptions. A cluster randomized controlled and single-blind design was used. This study was conducted at four nursing schools in South Korea. A total of 169 undergraduate nursing students completed this study. Using random allocation, two nursing schools (85 students) were allocated as the experimental group and the other two schools (84 students) as the control group. The experimental group received the web-based educational program, and the control group did not receive the educational program. Data were collected immediately before and after the web-based educational program. The experimental group’s knowledge and perceptions significantly improved between pre-test and post-test. The analysis of covariance showed statistically significant differences between groups in knowledge (p < 0.001) and perceptions (p < 0.001) over time, revealing positive effects of the web-based educational program. The web-based educational program regarding physical restraint reduction positively affected nursing students’ knowledge and perceptions. Future studies are required to examine the educational program’s longitudinal effects with more rigorous measurements and research methods.

Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: A systematic review and meta-analysis

BACKGROUND

Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths.

OBJECTIVE

To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates.

METHODS

Six health science databases were searched from inception up to 21st January 2020. Quantitative studies investigating restraint use in residential aged care facilities that reported data from year 2000 onwards were included. Meta-analyses of binomial data using a random effect model were performed to pool proportions of physical or chemical restraints with 95% confidence intervals. Univariable meta-regression analyses were used to assess factors that may contribute to the variability in physical and chemical restraint prevalence. Multiple meta-regression analyses were performed where possible to construct models of factors contributing to these variations.

RESULTS

Eighty-five papers were included. The pooled proportion of physical and chemical restraint use in residential aged care facilities were 33% and 32% respectively. Bedrails (44%) and benzodiazepines (42%) were the most prevalent forms of physical and chemical restraint respectively. Studies from North America (lower prevalence) [coefficient (95% CI): -0.15 (-0.27, -0.03)], measurement approaches using direct observation (higher prevalence) [0.17 (0.02, 0.33)] and a combination of multiple measurement approaches (higher prevalence) [0.17 (0.05, 0.29)] explained 25.5% of variability in the prevalence of physical restraint. Multiple meta-regression analyses were not performed to identify factors that may explain the observed variability in chemical restraint prevalence due to the small number of studies with data available.

CONCLUSION

Variability in prevalence of physical restraint could be explained partly by different measurement approaches and geographical regions. Valid and reliable measurement approaches across different regions is required to understand cultural differences due to geographical region effects on the prevalence of physical restraint use.

Definition and Measurement of Physical and Chemical Restraint in Long-Term Care: A Systematic Review

This systematic review aimed to identify thematic elements within definitions of physical and chemical restraint, compare explicit and implicit definitions, and synthesize reliability and validity of studies examining physical and/or chemical restraint use in long-term care. Studies were included that measured prevalence of physical and/or chemical restraint use, or evaluated an intervention to reduce restraint use in long-term care. 86 papers were included in this review, all discussed physical restraint use and 20 also discussed chemical restraint use. Seven themes were generated from definitions including: restraint method, setting resident is restrained in, stated intent, resident capacity to remove/control, caveats and exclusions, duration, frequency or number, and consent and resistance. None of the studies reported validity of measurement approaches. Inter-rater reliability was reported in 27 studies examining physical restraint use, and only one study of chemical restraint. Results were compared to an existing consensus definition of physical restraint, which was found to encompass many of the thematic domains found within explicit definitions. However, studies rarely applied measurement approaches that reflected all of the identified themes of definitions. It is necessary for a consensus definition of chemical restraint to be established and for measurement approaches to reflect the elements of definitions.

The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study

OBJECTIVES

The current study aimed to conduct a systematic review and meta-analysis to explore the efficacy and safety of tube feeding in patients with advanced dementia.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

PubMed, Medline, Embase, and Cochrane Library were searched from inception until March 7, 2020, to obtain relevant studies.

INTERVENTION

Feeding with nasogastric tube or percutaneous endoscopic gastrostomy (PEG).

MEASURES

We evaluated the associations of tube feeding and the risk of mortality, period of survival days, tube-related complications, and nutritional status. Data from original studies were synthesized by using a random-effects model. Each selected article was assessed for bias using the Newcastle-Ottawa Scale. A narrative synthesis and pooled analyses are reported.

RESULTS

Twelve trials were eligible, involving 1805 patients with tube feeding (mean age: 82.8 years; 71.3% female) and 3861 without tube feeding (mean age: 82.7; 68.7% female). For mortality rate, patients with advanced dementia with tube feeding are associated with significantly higher mortality rate [k = 8; odds ratio (OR) 1.79; 95% confidence interval (CI) 1.04-3.07; P = .03]. Initially, no association was found for the risk of pneumonia and pressure sore between groups. However, sensitivity analysis showed patients with advanced dementia with PEG tube feeding have significantly higher risk of pneumonia (OR 3.56; 95% CI 2.32-5.44; P < .001) and pressure sore (OR 2.25; 95% CI 1.92-2.63; P < .001). Finally, no association was found for the survival period and nutritional status between groups.

CONCLUSIONS AND IMPLICATIONS

This meta-analysis indicates that tube feeding is associated with increased mortality rate and possible tube-related complications, but not improves with prolonging survival days and nutritional status. Shared decision-making routinely before insertion of a tube between caregivers and physicians is recommended.

The Homestead: Developing a Conceptual Framework through Co-Creation for Innovating Long-Term Dementia Care Environments

Alternative care environments for regular nursing homes are highly warranted to promote health and well-being of residents with dementia that are part of an age-friendly and dementia-friendly city and society. Insight is lacking on how to translate evidence-based knowledge from theory into a congruent conceptual model for innovation in current practice. This study reports on the co-creation of an alternative nursing home model in the Netherlands. A participatory research approach was used to co-create a conceptual framework with researchers, practitioners and older people following an iterative process. Results indicate that achieving positive outcomes for people with dementia, (in)formal caregivers, and the community is dependent on how well the physical, social and organizational environment are congruently designed. The theoretical underpinnings of the conceptual model have been translated into "the homestead," which is conceptualized around three main pillars: activation, freedom and relationships. The Homestead Care Model is an illustrative example of how residential care facilities can support the development of age-friendly communities that take into consideration the needs and requirements of older citizens. However, challenges remain to implement radical changes within residential care. More research is needed into the actual implementation of the Homestead Care Model.

The use of physical restraints in Chinese long-term care facilities and its risk factors: An observational and cross-sectional study

AIM

To investigate the use of physical restraints among Chinese long-term care facilities older adults and to identify its risk factors.

DESIGN

Observational and cross-sectional study.

METHODS

A total of 1,026 older adults from six long-term care facilities in Chongqing were recruited by cluster sampling method from July - November 2019. Data on physical restraint use and older adults' characteristics were collected using physical restraints observation forms and older adults' records. Organizational data were collected by questionnaires asking nursing managers. The independent risk factors for physical restraints use were assessed using chi-square test and binary logistic regression.

RESULTS

The study found that the prevalence of physical restraints in six long-term care facilities in China was 25.83%. Waist belt (55.47%) and wrist restraint (52.83%) were most frequently used. Only 61.51% of physical restraints were signed with informed consent. 71.70% of physical restraints were caused by the prevention of falls, 89.06% of physical restraints were without nursing documentation, and 13.58% restrained older adults were observed to have physical complications. According to the binary logistic regression analysis, facility type and ownership, older adults per nursing assistant, length of residence, cognitive impairment, care dependency, mobility restriction, fall risk, physical agitation, and indwelling tubes emerged as important risk factors for the use of physical restraints.

CONCLUSION

The use of physical restraints among Chinese long-term care facilities older adults was at a relatively high level and lack standardized and regulated practices. Moreover, Physical restraint use was associated with facility type and ownership, older adults per nursing assistant, length of residence, cognitive impairment, care dependency, mobility restriction, fall risks, physical agitation, and indwelling tube.

IMPACT

This study will provide an effective reference for nursing staff in long-term care facilities to assess high-risk older adults in their use of physical restraints, which can support them to implement effective minimized restraint approaches to targeted people.

Efficacy and Generalizability of Falls Prevention Interventions in Nursing Homes: A Systematic Review and Meta-analysis

OBJECTIVES

To determine the efficacy of fall intervention programs in nursing homes (NHs) and the generalizability of these interventions to people living with cognitive impairment and dementia.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

NH residents (n = 30,057) living in NHs defined as residential facilities that provide 24-hours-a-day surveillance, personal care, and some clinical care for persons who are typically aged ≥65 years with multiple complex chronic health conditions.

METHODS

Meta-analysis of falls prevention interventions on number of falls, fallers, and recurrent fallers.

RESULTS

Thirty-six studies met inclusion criteria for the systematic review. Overall, fall prevention interventions reduced the number of falls [risk ratio (RR) = 0.73, 95% confidence interval (CI) = 0.60-0.88], fallers (RR = 0.80, 95% CI = 0.72-0.89), and recurrent fallers (RR = 0.70, 95% CI = 0.60-0.81). Subanalyses revealed that single interventions have a significant effect on reducing fallers (RR = 0.78, 95% CI = 0.69-0.89) and recurrent fallers (RR = 0.60, 95% CI = 0.52-0.70), whereas multiple interventions reduce fallers (RR = 0.69, 95% CI = 0.39-0.97) and multifactorial interventions reduce number of falls (RR = 0.65, 95% CI = 0.45-0.94).

CONCLUSIONS AND IMPLICATIONS

Exercise as a single intervention reduced the number of fallers and recurrent fallers by 36% and 41%, respectively, in people living in NHs. Other effective interventions included staff education and multiple and multifactorial interventions. However, more research on exercise including people with cognitive impairment and dementia is needed to improve the generalizability of these interventions to the typical NH resident.

Frailty status and increased risk for falls: The role of anticholinergic burden

PURPOSE OF THE STUDY

Frailty leads to serious adverse outcomes including falls. The relationship between frailty and falls has not been evaluated in the context of the side effects of drugs with anticholinergic properties. The aim of this study was to examine the potential association of anticholinergic burden (ACB) with the risk of falls among frail older adults.

DESIGN AND METHODS

Community-dwelling older adults were consecutively selected from the geriatrics outpatient clinic. Based on a fall history in the last 12 months, the participants were grouped as fallers and non-fallers. Frailty status was assessed by Fried's phenotype method. Exposure to anticholinergic medications was estimated using the ACB scale, and the participants were classified into ACB_0 (none), ACB_1 (possible) and ACB_2+ (definite).

RESULTS

The study included 520 older adults (mean age 77.7 years, 62.7 % female), with a fall prevalence of 25.8 % 12 months past. The proportions of frailty and pre-frailty were 33.1 % and 57.4 %, respectively. After adjustment for study confounders, receiving at least 1 drug with either possible or definite anticholinergic properties was independently associated to falls in frail [OR = 3.84 (1.48-9.93), p = 0.006] and pre-frail participants [OR = 2.71 (1.25-5.89); p = 0.012], but not in robust subjects. Moreover, ACB was significantly associated with the frailty components on adjusted analysis (p's<0.05).

IMPLICATIONS

Current study showed that the use of any drugs with possible or definite anticholinergic properties was associated with an increased risk of falls in frail older adults. The results emphasize the importance of medication management with respect to fall prevention in these patients.

Neuropsychiatric Symptoms as Predictors of Falls in Long-Term Care Residents With Cognitive Impairment

OBJECTIVES

Falls and neuropsychiatric symptoms (NPS) are common among long-term care residents with cognitive impairment. Despite the high prevalence of falls and NPS, little is known about their association. The aim of our study was to explore how NPS, particularly the severity of NPS and specific NPS subgroups, are associated with falls and how psychotropics modify this association.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

In total, 532 long-term care residents aged 65 years or older in Helsinki, Finland.

METHODS

NPS were measured with Neuropsychiatric Inventory (NPI) at baseline. Participants were grouped into 3 groups: no significant NPS (NPI points 0‒3), low NPS burden (NPI 4‒12), and high NPS burden (NPI >12). The number of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment.

RESULTS

Altogether, 606 falls occurred during the follow-up year. The falls led to 121 injuries, 42 hospitalizations, and 20 fractures. Falls and injuries increased significantly with NPS burden (P < .001): 330 falls in the high NPS group (n = 184), 188 falls in the low NPS group (n = 181), and 88 falls in the no significant NPS group (n = 167). The risk of falling showed a curvilinear association with NPI total score. Of NPS subgroups, psychosis and hyperactivity were associated with a higher incidence rate ratio of falls, whereas apathy had a protective association even after adjustment for age, sex, and mobility. Affective symptoms were not associated with falls. Psychotropics did not modify the association between NPS burden and falls.

CONCLUSIONS AND IMPLICATIONS

The results of this study show that NPS, especially NPS severity, may predict falls and fall-related negative consequences. Severity of NPS should be taken into account when assessing fall risk in long-term care residents with cognitive impairment.

[Use of sedating medication and physical restraints for patients with dementia in acute care hospitals : A non-randomized case control study]

Hintergrund

Auf Menschen mit Demenz mit stationär behandlungsbedürftiger Akuterkrankung ist der Großteil der Akutkrankenhäuser kaum vorbereitet. Dies birgt die Gefahr der Überforderung für das Personal. Demenzerkrankungen sind der häufigste Grund dafür, dass Krankenhauspersonal sedierende Medikamente verabreicht und bewegungseinschränkende Maßnahmen einsetzt.

Zielsetzung

Die vorliegende Studie untersucht Faktoren, die den (unangemessenen) Einsatz von sedierenden Medikamenten und bewegungseinschränkenden Maßnahmen beeinflussen.

Methoden

Eine nichtrandomisierte Fall-Kontroll-Studie wurde in 2 internistischen Abteilungen in Hamburg durchgeführt. In der Interventionsgruppe wurde ein spezielles Versorgungskonzept für Menschen mit Demenz implementiert. Die Versorgungsart in der Kontrollgruppe entsprach der Regelversorgung. Mit logistischen Regressionen wurden Zusammenhänge zwischen Faktoren wie Alter, Demenzschweregrad, Verhaltensauffälligkeiten, Barthel-Index oder Versorgungsart und dem Einsatz sedierender Medikamente bzw. bewegungseinschränkender Maßnahmen untersucht.

Ergebnisse

Herausfordernde Verhaltensweisen (OR = 1,32) und die Zugehörigkeit zur Kontrollgruppe (OR = 1,94) sind signifikant mit dem Einsatz sedierender Medikamente assoziiert. Ein geringerer Barthel-Index, längere Aufenthaltsdauer und die eine Behandlung in der Kontrollgruppe sind signifikant mit einer höheren Wahrscheinlichkeit des Einsatzes bewegungseinschränkender Maßnahmen assoziiert.

Diskussion

Der Einsatz sedierender Medikamente als auch bewegungseinschränkender Maßnahmen variiert stark zwischen Interventions- und Kontrollgruppe. Andere Studien, die zu ähnlichen Ergebnissen kommen, sehen verschiedene Bausteine spezieller Versorgungskonzepte als Gründe für diese Unterschiede. Dazu zählen neben der baulichen Gestaltung und räumlichen Aspekten auch demenzspezifische Schulungsangebote und ein angemessener Personalschlüssel. Dies vermag auch Unruhe und herausfordernde Verhaltensweisen aufseiten der Patienten zu reduzieren. Der Verzicht auf Sedierung und bewegungseinschränkende Maßnahmen hat nicht zuletzt auch positive Auswirkungen auf die Lebensqualität von Menschen mit Demenz.

Quality of life of patients with dementia in acute hospitals in Germany: a non-randomised, case-control study comparing a regular ward with a special care ward with dementia care concept

OBJECTIVES

To identify factors that predict the quality of life (QoL) of patients with dementia in acute hospitals and to analyse if a special care concept can increase patients' QoL.

DESIGN

A non-randomised, case-control study including two internal medicine wards from hospitals in Hamburg, Germany.

SETTING AND PARTICIPANTS

In all, 526 patients with dementia from two hospitals were included in the study (intervention: n=333; control: n=193). The inclusion criterion was an at least mild cognitive impairment or dementia. The intervention group was a hospital with a special care ward for internal medicine focusing on patients with dementia. The control group was from a hospital with a regular care ward without special dementia care concept.

OUTCOME MEASURES

Our main outcome was the QoL (range 0-100) from patients with dementia in two different hospitals. A Bayesian multilevel analysis was conducted to identify predictors such as age, dementia, agitation, physical and chemical restraints, or functional limitations that affect QoL.

RESULTS

QoL differs significantly between the control (40.7) and the intervention (51.2) group (p<0.001). Regression analysis suggests that physical restraint (estimated effect: -4.9), psychotropic drug use (-4.4) and agitation (-2.9) are negatively associated with QoL. After controlling for confounders, the positive effect of the special care concept remained (5.7).

CONCLUSIONS

A special care ward will improve the quality of care and has a positive impact on the QoL of patients with dementia. Health policies should consider the benefits of special care concepts and develop incentives for hospitals to improve the QoL and quality of care for these patients.