It is widely believed that physical restraint use causes mental and physical health decline in nursing home residents. Yet few studies exist showing an association between restraint initiation and health decline. In this research, we examined whether physical restraint initiation is associated with subsequent lower physical or mental health.
We used all nursing homes (N = 740) in Pennsylvania in 2001, with 12,820 residents. We used the Minimum Data Set data; Online Survey, Certification and Reporting data; and the Area Resource File as data sources. We restricted our sample to newly admitted nursing home residents who were not restrained in the first two quarters of their residency. We examined which facility and individual characteristics during those first two quarters were associated with restraint initiation during the third quarter. We then examined the association of third-quarter restraint initiation with fourth-quarter health outcomes, using regressions that controlled for first- and second-quarter health status as well as other resident, facility, and market characteristics. The physical health outcomes examined consisted of falls, walking dependence, activities of daily living (ADLs), pressure ulcers, and contractures. Mental health outcomes examined consisted of cognitive performance, depression, and behavior problems.
The initiation of restraint use was associated with a previous fall (p <.01), psychoactive medication use (p <.05), low cognition (p <.01), ADL scores (p <.01), and the absence of pressure ulcers (p <.10), as well as a variety of facility characteristics. Subsequent to restraint initiation, we found an association with lower cognitive performance (p <.01), lower ADL performance (p <.01), and higher walking dependence (p <.01).
We found that an association between restraint initiation and subsequent adverse health consequences exists and is substantial. Moreover, these results would appear to have practical as well as statistical significance.
"Research into the use of restraint in elderly people has been conducted in general hospitals  and nursing home settings [9,10,29]. However, there has been little investigation of the use of these containment practices with elderly persons in old age psychiatry inpatient settings, and the rate and type of restraint use can vary, even within neighbouring units . "
[Show abstract][Hide abstract] ABSTRACT: In psychiatry, most of the focus on patient aggression has been in adolescent and adult inpatient settings. This behaviour is also common in elderly people with mental illness, but little research has been conducted into this problem in old age psychiatry settings. The attitudes of clinical staff toward aggression may affect the way they manage this behaviour. The purpose of this study was to examine the attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient settings.
A convenience sample of clinical staff were recruited from three locked acute old age psychiatry inpatient units in Melbourne, Australia. They completed the Management of Aggression and Violence Scale, which assessed the causes and managment of aggression in psychiatric settings.
Eighty-five staff completed the questionnaire, comprising registered nurses (61.1%, n = 52), enrolled nurses (27.1%, n = 23) and medical and allied health staff (11.8%, n = 10). A range of causative factors contributed to aggression. The respondents had a tendency to disagree that factors directly related to the patient contributed to this behaviour. They agreed patients were aggressive because of the environment they were in, other people contributed to them becoming aggressive, and patients from certain cultural groups were prone to these behaviours. However, there were mixed views about whether patient aggression could be prevented, and this type of behaviour took place because staff did not listen to patients. There was agreement medication was a valuable approach for the management of aggression, negotiation could be used more effectively in such challenging behaviour, and seclusion and physical restraint were sometimes used more than necessary. However, there was disagreement about whether the practice of secluding patients should be discontinued.
Aggression in acute old age psychiatry inpatient units occurs occasionally and is problematic. A range of causative factors contribute to the onset of this behaviour. Attitudes toward the management of aggression are complex and somewhat contradictory and can affect the way staff manage this behaviour; therefore, wide-ranging initiatives are needed to prevent and deal with this type of challenging behaviour.
"Barnett et al. (2012), in a literature review, pointed out the mortality related to PR use. Furthermore, restrained residents, when compared with the nonrestrained , had poorer muscle strength in their legs, significantly lower Barthel Index, lower MMSE scores and took longer time for the Get-Up & Go Test (Engberg et al. 2008). Minimum Data Set analysis showed that residents restrained in a RACF usually had a previous fall, a lower level of cognition, a lower Barthel Index score, pressure ulcers and greater walking dependence (Saarnio et al. 2009). "
[Show abstract][Hide abstract] ABSTRACT: AimTo identify the rate and risk factors of physical restraint in residential aged care facilities in Taiwan. Background
In Taiwan, physical restraint is commonly used in aged care facilities to prevent accidents. Many are unaware of the associated risks. Restrained residents cannot move freely, increasing the risk of atrophy and leading to reduced physical functioning. DesignA community-based epidemiological survey. Methods
Data were collected from June-December 2007 across 178 residential aged care facilities with 5,173 residential beds in the target city of Taiwan. Twenty facilities were sampled using probability proportional to size by beds and accreditation ranking. In all, 256 primary caregivers (78 nurses and 178 care aides) and 847 residents completed the study questionnaires and tests. A multilevel analysis approach was used to identify individual- and facility-level risk factors for physical restraint and assess the variation in physical restraint at the individual- and facility-level. ResultsOf 847 residents, 62% (527) were restrained during the study period. The main reasons for restraint use were fall prevention and prevention of tube removal. Resident level risk factors for physical restraint included lower Barthel Index scores (more dependent) and an agreement allowing the use of physical restraint to avoid injury signed by a family member or social worker. A facility-level risk factor for physical restraint was younger primary caregivers. Conclusion
To reduce the incidence of physical restraint in residential aged care facilities in Taiwan, educational programmes should target primary caregivers and families in facilities.
"According to prosecution, physical restraints such as bilateral bed rails, belts, and fixed tables in a chair should be always considered inadequate or wrong. Physical restraints are quite frequently used in geriatric division in Italy despite some evidences for their lack of effectiveness and safety [19-21]. In US a recent survey reported physical restraint rates of more than 20% in nursing homes . "
[Show abstract][Hide abstract] ABSTRACT: The case presented by the authors gives the opportunity to discuss the medico-legal issues related to lack of prevention of falls in elderly hospitalized patients.
A 101 year old Caucasian female was admitted to a surgery division for evaluation of abdominal pain of uncertain origin. During hospitalization, after bilateral bed rails were raised, she fell and reported a femoral fracture. Before surgical treatment of the fracture, scheduled for the day after injury, the patient reported a slight reduction in hemoglobin. She received blood transfusion but her general condition suddenly worsened; heart failure was observed and pulseless electrical activity was documented. The patient died 1 day after the fall. Patient relatives requested a judicial evaluation of the case.The case was studied with a methodological approach based on the following steps: 1) examination of clinical records; 2) autopsy; 3) evaluation of clinicians' behavior, in the light of necroscopic findings and a review of the literature.
The case shows that an accurate evaluation of clinical and environmental risk factors should be always performed at the moment of admission also in surgery divisions. A multidisciplinary approach is always recommended also with the involvement of the family members. In some cases, as in this one a fall of the patient is expectable but not always avoidable. Physical restraint use should be avoided when not necessary and used only if there are no practical alternatives.
Sanju P Joy, Sanjib Sinha, Pramod Kumar Pal, Samhita Panda, M Philip, Arun B Taly
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