Physical restraints in geriatric care in Sweden: prevalence and patient characteristics

OBJECTIVE: Physical restraints are used frequently in geriatric care to promote the safety of frail older patients. This study investigated the prevalence of the use of physical restraints in geriatric care and the way in which patient characteristics are related to the use of physical restraints. DESIGN: A point prevalence study of patients cared for in various types of geriatric settings. SETTING: Eight nursing homes, 15 old people's homes, a somatic geriatric clinic, and a psychogeriatric clinic in a health care district in northern Sweden. PARTICIPANTS: A total of 1325 patients, mean age 82 years, 64% of whom were women. MEASUREMENTS: The Multi-Dimensional Dementia Assessment Scale (MDDAS) was used to measure motor function, vision, hearing, speech, ADLs, behavioral symptoms, psychiatric symptoms, use of psychoactive drugs, and the physical and psychological workload of the staff. In addition, questions concerning the use of physical restraints were added to the instrument. RESULTS: Twenty-four percent of the patients were physically restrained. The highest prevalence was found in nursing homes and psychogeriatric care. Physical restraints were found to relate most strongly to cognitive impairment, impaired ADLs, and speech and walking ability. Ninety-four percent of the restrained patients were cognitively impaired. Other variables relating to the use of physical restraints were psychiatric symptoms and behavioral disturbances. CONCLUSIONS: This study has shown that physical restraints are used frequently in geriatric care in Sweden and that cognitive and physical impairments relate very closely to the use of physical restraints.     

Clinical decision making in the prediction of falls.

Objective: Examine rehabilitation professionals' capacity to identify risk factors for patient falls. Design: Survey study. Setting: Three academic medical center rehabilitation departments. Participants: Fifty-six rehabilitation specialists representing disciplines typically involved in patient care, including physiatry and occupational, physical, recreation, and speech therapy. Measures: A 2-part, self-report questionnaire with spontaneous and cued rank-order listing of factors related to fall risk. Results: Clinicians did not consider advanced age and history of falling when spontaneously delineating risks for falls. The importance of fall history, but not of advanced age, was recognized through cueing. Conclusions: Clinicians appear aware of strong predictors of fall risk but require cueing to consistently use them. Cueing increased hypothetical predictive accuracy, although clinicians still downplayed some of the most salient predictive factors. Staff education regarding validated fall risk factors and potential errors in clinical decision making can improve patient care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Risk factors for falls of hospitalized stroke patients

BACKGROUND AND PURPOSE: Patients with stroke are at a high risk for falling. We assessed the fall incidence and risk factors for patients hospitalized as the result of an acute stroke. METHODS: We studied a cohort of 720 stroke patients from 23 hospitals in The Netherlands. The data were abstracted from the medical and nursing records. RESULTS: We studied 346 women and 374 men with a median age of 75 years; 77% of the patients had had a cerebral infarct, 17% had had a hemorrhage, and 6% had had an undefined stroke. We recorded 104 patients (14%) who fell at least once; there were a total of 173 falls. The incidence of falls was 8.9/1000 patients per day. The daily incidence was 6.2/1000 patients for first falls and 17.9/1000 patients for second falls. Heart disease (relative risk [RR], 1.6; 95% confidence interval [CI], 1.0 to 2.4), mental decline (RR, 1.6; 95% CI, 1.0 to 2.4), and urinary incontinence (RR, 2.3; 95% CI, 1.3 to 4.1) were incremental risk factors for first falls, whereas the use of major psychotropic drugs lowered the fall risk (RR, 0.5; 95% CI, 0.3 to 0.8). The fall RR for patients with one previous fall was 2.2 (95% CI, 1.5 to 3.2), adjusted for the other risk factors. Most falls occurred during the day. Approximately 25% of the falls caused slight-to-severe injury, whereas three falls (2%) led to hip fractures. CONCLUSIONS: Stroke patients have at risk of falling. The identification of patients at risk may be a first step toward the implementation of fall-prevention measures for these patients.     

Risk for falls in the elderly. Role of activities of daily living and of the subjective assessment of health status. A case-control study

Prevention and treatment of falls in the elderly are today important questions the primary care physicians has to face. It is known that falls are associated with numerous factors related to health status and demographic variables. The role played by the activities of daily living (ADL) and by a negative subjective health rating of one's own health status, and how both could increase the incidence of diseases due to home accidents, is less known. This case-control study carried out in the accident ward of S. Camillo Hospital in Rome, studied 110 elderly patients, who suffered from fractures caused by falls. The main goal was to identify the possible associations among falls, ADL and lower limb mobility, as well as studying the importance of a positive subjective health rating to prevent these accidents. Controls have been selected in other wards of the same hospital and in an out-patient's department. Results show that the risk of falling is associated with previous falls (odds ratio = 3.81), with poor mobility at home (OR = 2.49), outside home (OR = 2.06), out of one's own area (OR = 1.74), and with a negative subjective health rating (OR 3.33). Multivariate analysis has pointed out that a negative subjective health rating keeps being a statistically significant risk factor for falls (OR = 2.86), independently from the objective health conditions of the subject. Such a negative subjective rating often develops itself just as a consequence of a previous fall without injuries.     

The relationship between physical restraint removal and falls and injuries among nursing home residents

BACKGROUND: A major reason cited for continued restraint use in American nursing homes is the widely held belief that restraint reduction will lead to fall-related incidents and injuries. METHODS: This study represents an analysis of data collected in a clinical trial of interventions aimed at reducing the use of restraints in nursing homes. Two different designs were employed to test the relationship between restraint reduction and falls/injuries. First, multiple logistic regression was used to compare fall/injury rates in subjects who had restraints removed (n = 38) to those who continued to be restrained (n = 88); second, survival analysis was employed to test the relationship between physical restraint removal and falls/injuries at the institutional level by comparing fall/injury rates among three nursing homes (n = 633) with varying rates of restraint reduction. RESULTS: Based on the multiple logistic regression analysis, there was no indication of increased risk of falls or injuries with restraint removal. Moreover, restraint removal significantly decreased the chance of minor injuries due to falls (adjusted odds ratio: 0.3, 95% CI: 0.1, 0.9; p < .05). The survival analysis demonstrated that the nursing home that had the least restraint reduction (11%) had a 50% higher rate of falls (p < .01) and more than twice the rate of fall-related minor injuries (p < .001) when compared to the homes with 23% and 56% restraint reduction, respectively. CONCLUSIONS: Physical restraint removal does not lead to increases in falls or subsequent fall-related injury in older nursing home residents.     

Monocyte chemotactic protein-1 as a chemoattractant for human hepatic stellate cells

Patients admitted acutely to hospital may be at risk of increased morbidity and mortality as a result of gastroesophageal reflux and its complications. The recognized association of gastroesophageal reflux with cardiac and respiratory disease, the use of drugs that reduce lower esophageal sphincter pressure, and the supine position in which many patients are nursed may increase the risk of gastroesophageal reflux. This study aimed to determine the prevalence and severity of refluxlike symptoms in a series of consecutive unselected patients admitted acutely through the accident and emergency department of a district general hospital and to study the effect of hospitalization on these symptoms. Patients were interviewed by questionnaire on two occasions: immediately following admission and again 7-10 days later. The frequency of symptoms of heartburn, acid regurgitation, dysphagia, nausea, and belching were recorded on a 6-point scale, in addition to whether these symptoms occurred at night. Medication history, the number of days spent on bed rest, nasogastric intubation, and operation history were also recorded. In all, 275 patients were interviewed, of whom 229 had a second interview; 27% (62) had symptoms at least once a week (49% reported symptoms at least once a month) prior to admission, of whom 4% (9) had daily heartburn and/or acid regurgitation. Following admission to hospital there was a significant (P < 0.001) fall in the prevalence and frequency of refluxlike symptoms. There was a significant association of refluxlike symptoms with number of days spent in bed (P < 0.05) and with the use of nonsteroidal antiinflammatory drugs in hospital (P < 0.0001). Logistic regression analysis confirmed the association of NSAIDs with refluxlike symptoms. Nasogastric intubation and surgery were not associated with heartburn. In conclusion, symptoms of heartburn and acid regurgitation become less frequent following admission to hospital. This probably relates to a reduction in physical exertion following hospital admission but may reflect a reduction in anxiety levels or treatment of underlying disease. Patients on prolonged bed rest and those given non-steroidal anti-inflammatory drugs are at increased risk of refluxlike symptoms and may require antireflux measures.     

Should physical restraints be used in an acute geriatric ward?

A prospective study was carried out in an acute geriatric ward to determine the incidence of the use of physical restraints, the reasons for using them and the consequences. Over a period of 8 months an independent observer documented all cases in which a restraint was used and followed them until it was removed. A questionnaire was submitted to the nurses as to why they applied the restraints. 16% of patients had some form of restraint applied, in 2/3 of them for up to half of their stay in the ward. In over 90% of those restrained, functional (Barthel) and cognitive (mini-mental) scores were between 0-5. In unrestrained patients, the functional score was 0-5 in 79% and the cognitive score 0-5 in 72%. The main reason for applying restraints, usually sheets or body binders, was to prevent the patient from falling out of, or slipping from chairs, rather than to stop them from rising out of them. Other important reasons, which overlapped, were to prevent the patient from interfering with nasogastric tubes, catheters, and i.v. cannulas, each in 1/3 of the group. Restraints were discarded when deterioration did not allow the patient to sit out of bed, to decrease agitation, to allow enteral or parenteral treatment, and in 12%, when there was supervision by the family. Of 33 families interviewed, none opposed application of restraints, and most left the decision to the responsible ward staff. We conclude that restraints cannot be avoided in some acutely ill, old patients with severe physical and mental dysfunction. However, ways should be sought to minimize their use, as recommended in the literature, by demanding from the staff a specific reason, signed agreement of a physician, close follow-up, and favorable environmental conditions such as suitable chairs, occupational activity, and staff cooperation in removing the restraints.     

Falls, injuries due to falls, and the risk of admission to a nursing home

BACKGROUND: Falls warrant investigation as a risk factor for nursing home admission because falls are common and are associated with functional disability and because they may be preventable. METHODS: We conducted a prospective study of a probability sample of 1103 people over 71 years of age who were living in the community. Data on demographic and medical characteristics, use of health care, and cognitive, functional, psychological, and social functioning were obtained at base line and one year later during assessments in the participants' homes. The primary outcome studied was the number of days from the initial assessment to a first long-term admission to a skilled-nursing facility during three years of follow-up. Patients were assigned to four categories during follow-up: those who had no falls, those who had one fall without serious injury, those who had two or more falls without serious injury, and those who had at least one fall causing serious injury. RESULTS: A total of 133 participants (12.1 percent) had long-term admissions to nursing homes. In an unadjusted model, the risk of admission increased progressively, as compared with that for the patients with no falls, for those with a single noninjurious fall (relative risk, 4.9; 95 percent confidence interval, 3.2 to 7.5), those with multiple noninjurious falls (relative risk, 8.5; 95 percent confidence interval, 3.4 to 21.2), and those with at least one fall causing serious injury (relative risk, 19.9; 95 percent confidence interval, 12.2 to 32.6). Adjustment for other risk factors lowered these ratios to 3.1 (95 percent confidence interval, 1.9 to 4.9) for one noninjurious fall, 5.5 (95 percent confidence interval, 2.1 to 14.2) for two or more noninjurious falls, and 10.2 (95 percent confidence interval, 5.8 to 17.9) for at least one fall causing serious injury, but the association between falls and admission to a nursing home remained strong and significant. The population attributable risk of long-term admission to a nursing home for these three groups (the proportion of admissions directly attributable to the three categories of falls) was 13 percent, 3 percent, and 10 percent, respectively. CONCLUSIONS: Among older people living in the community falls are a strong predictor of placement in a skilled-nursing facility; interventions that prevent falls and their sequelae may therefore delay or reduce the frequency of nursing home admissions.     

The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults

BACKGROUND: The study tested the effect of strength and endurance training on gait, balance, physical health status, fall risk, and health services use in older adults. METHODS: The study was a single-blinded, randomized controlled trial with intention-to-treat analysis. Adults (n = 105) age 68-85 with at least mild deficits in strength and balance were selected from a random sample of enrollees in a health maintenance organization. The intervention was supervised exercise (1-h sessions, three per week, for 24-26 weeks), followed by self-supervised exercise. Exercise groups included strength training using weight machines (n = 25), endurance training using bicycles (n = 25), and strength and endurance training (n = 25). Study outcomes included gait tests, balance tests, physical health status measures, self-reported falls (up to 25 months of follow-up), and inpatient and outpatient use and costs. RESULTS: There were no effects of exercise on gait, balance, or physical health status. Exercise had a protective effect on risk of falling (relative hazard = .53, 95% CI = .30-.91). Between 7 and 18 months after randomization, control subjects had more outpatient clinic visits (p < .06) and were more likely to sustain hospital costs over $5000 (p < .05). CONCLUSIONS: Exercise may have beneficial effects on fall rates and health care use in some subgroups of older adults. In community-living adults with mainly mild impairments in gait, balance, and physical health status, short-term exercise may not have a restorative effect on these impairments.     

Restraints and the elderly with mental illness: ethical issues and moral reasoning

The use of restraints to enable the care provided to the elderly has long been a source of contention and fodder for argument among health care professionals. The question of whether to use mechanical restraints to prevent falls in the elderly is an ongoing debate. An ethical framework is presented to assist the decision-making process.     

Individualized assessment and intervention in bilateral siderail use

The use of bilateral siderails, similar to physical restraints, can be safely reduced by a comprehensive assessment process. This article presents an individualized assessment for evaluating siderail use to guide nurses in managing resident characteristics for falling out of bed and intervening for high-risk residents. The individualized assessment is consistent with federal resident assessment instrument requirements and includes risk factors specific to falls from bed.     

The effect of falls and fall injuries on functioning in community-dwelling older persons

BACKGROUND: Several preventive strategies have proven effective at reducing the occurrence and rate of falling. It remains to be determined, however, whether, and to what extent, falls and/or fall injuries are independent determinants of adverse functional outcomes in older persons. METHODS: A probability sample of 1,103 community-dwelling persons over age 71 years was followed for 3 years. The 957 cohort members (87%) who participated in at least one follow-up interview while residing in the community were included in this study. Outcome measures included one and three year change in basic and instrumental activities of daily living (BADLs-IADLs), social activities, and physical activities. Based on daily calendars and hospital surveillance, participants were placed into one of four levels of fall status: no falls, one fall without serious injury, at least two falls without serious injury, and one or more falls with serious injury. Hierarchical linear regression models, sequentially adding six domains of covariates, were constructed to examine fall status as a risk factor for change in function. RESULTS: One noninjurious fall (beta = -.437; p < .01), at least two noninjurious falls (beta = -.877; p < .001); and at least one injurious fall (beta = -1.254; p < .001) were each associated with decline in BADL-IADL function over 3 years after adjusting for covariates (model R2 = .2617). Experiencing two or more noninjurious falls (beta = -.538; p < .05) was associated with decline in social activities (model R2 = .2779) while experiencing at least one injurious fall (beta = -.580; p < .01) was associated with decline in physical activity (model R2 = .4231). CONCLUSIONS: Falls and fall injuries appear to be independent determinants of functional decline in community-dwelling older persons. Falling is a health condition meeting all criteria for prevention: high frequency, evidence of preventability, and high burden of morbidity.     

Factors predicting fractures during falling impacts among home-dwelling older adults

OBJECTIVE: To investigate the predictors of fractures during falling impacts among home-dwelling older adults. DESIGN: A case-control study within a prospective, population-based survey. SETTING: Five rural municipalities in northern Finland. PARTICIPANTS: The study population consisted of all home-dwelling persons aged 70 or older living in these five municipalities (n = 790 (85%)). The cases for this study were those with fracture, using the first fracture (n = 82) in the analyses, during a follow-up period of 4 years. Controls (n = 82) were selected from among the persons who suffered soft tissue injuries; matching was by age, sex, and location of the first injury during the period. MEASUREMENTS: During a 4-year follow-up period, all falls in the population were recorded using fall diaries, telephone interviews, and information from medical records. Risk factors for fractures during the 4-year follow-up were determined according to the number and severity of previous falls, circumstances and place of falls, disease history, use of medicines, symptoms, clinical examinations and tests, nutritional status, functional abilities and social and health behavior. Cross-tabulations for categorial variables, paired t tests for the means of continuous variables, and conditional logistic regression analysis were performed. RESULTS: According to the bivariate analyses, the risk factors for falls resulting in a fracture were frequent fear of falling, abnormal heel-shin test, reduced knee extension strength, reduced grip strength, poor distance visual acuity, low supine pulse rate, inability to carry a 5-kg load 100 meters, not doing heavy outdoor work, and no habitual exercise. A limited amount of social participation was associated negatively with fracturing. Conditional logistic regression analysis showed that the risk factors for fracture-causing falls were frequent fear of falling (OR 2.50; CI 1.11-5.65), reduced knee extension strength (OR 3.38; CI 1.00-11.4), and poor distance visual acuity (OR 3.45; CI 1.13-10.6), whereas limited social participation (OR 0.29; CI 0.11-0.79) protected against the occurrence of fractures. CONCLUSION: Impaired perception, muscle strength, and psychological and social functioning may influence fracture risk during injurious fall impacts. Studies with larger sample sizes are needed to confirm this and to examine the circumstances and mechanisms contributing to the fracture risk during falls via these risk factors.     

Neuromuscular transmission and its pharmacological blockade. Part 3: Continuous infusion of relaxants and reversal and monitoring of relaxation

The use of seclusion or seclusion and restraints (S/SR) may affect patients negatively, even if controlling their behavior in the short run, by placing them in the "victim" role and fostering a corrosive atmosphere of patient-caregiver mistrust and alienation. This project's goal was to reduce the use of the most restrictive measures by increasing the use of the less restrictive removal from stimuli (RFS). Verbally and even physically threatening patients in a psychiatric intensive care unit were removed from stimuli if their behaviors were not sustained and they ultimately cooperated with staff. RFS was deemed successful when a patient did not need more restrictive measures following its use. The data for this study were obtained by tabulating RFS and S/SR utilization rates for a year. Frequencies, measures of variance, ratios, and t ratios were used to analyze the data. The use of RFS and other nonrestrictive measures to reduce patient stress and frustration resulted in decreased utilization of seclusion and restraints. The frequency and severity of negativistic, aggressive behaviors of patients were also observed to have diminished.     

How does the quality of life of long-term hospitalized psychiatric patients change after their discharge into the community?

BACKGROUND: In order to identify the risk factors essential for preventing major injurious falls, the associations between injurious falls and certain factors were assessed among disabled and independent elderly, respectively, who had fallen during a 2-year period. METHODS: A prospective population-based study was conducted in five rural northern Finnish municipalities. The series consisted of all inhabitants aged 70 years or over, initially 979 persons. During a 2-year follow-up period, all injurious falls were recorded on the basis of telephone contacts, diary reporting and a review of the medical records of the participants. RESULTS: Thirty percent of the subjects having fallen sustained a major injury. The multivariate model applied to the disabled elderly showed the following variables to be related to a high risk for major injurious falls: divorced, widowed or unmarried marital status (odds ratio = 2.2), a low body mass index (odds ratio = 3.1), incomplete step continuity (odds ratio = 2.2), poor distant visual acuity (odds ratio = 2.3) and the use of long-acting benzodiazepines (odds ratio = 2.4). Among the independent elderly, the risk of a fall resulting in major injury was high among the subjects who had peripheral neuropathy (odds ratio = 2.5) or were suffering from insomnia (odds ratio = 4.1). CONCLUSIONS: The risk factors for major injuries in fall occurrences differ between the disabled and independent elderly. Preventive measures should be targeted according to the disabilities of the population.     

The contribution of predisposing and situational risk factors to serious fall injuries

OBJECTIVES: The objectives were to identify situational risk factors associated with suffering a serious fall injury and to determine whether, and to what extent, predisposing and situational risk factors contributed independently to risk of suffering a serious fall injury. DESIGN: Nested cohort study. SETTING: General community. PARTICIPANTS: 568 members of a representative sample of community-living persons 72 years of age or older who fell during a median follow-up of 36 months. MEASUREMENTS: Candidate predisposing factors, identified during a baseline face-to-face home assessment, were the demographic, cognitive, medical, and physical performance measures associated with an increased risk of serious injury among fallers in a previous analysis of the cohort. Acute host, behavioral, and environmental factors present at the time of the participants' first reported fall constituted potential situational risk factors. The primary outcome was occurrence of a serious fall injury, defined as a fracture, joint dislocation, or head injury resulting in loss of consciousness and hospitalization, during the first fall recorded during follow-up. RESULTS: Sixty-nine subjects (12%) suffered a serious injury during their first reported fall. No acute host factor was associated with increased risk of injury. The environmental and activity factors associated independently with serious injury in multivariate analysis included falling on stairs (adjusted relative risk 2.0; 95% confidence intervals 1.1-3.5), during displacing activity (1.8; 1.0-3.0), and from at least body height (2.1; 1.0-4.7). The independent predisposing factors included female gender (2.1; 1.0-4.4), low body mass index (1.8; 1.2-2.9), and cognitive impairment (2.8; 1.7-4.7). Although 12% of first falls resulted in a serious injury overall, this percentage ranged from 0% to 36% as the number of predisposing risk factors increased from zero to three and from 5% to 40% as the number of situational risk factors increased from zero to three. Further, for any given number of predisposing risk factors, the percentage of fallers suffering a serious injury increased with the number of situational risk factors. CONCLUSIONS: Several environmental and behavioral factors contributed to the risk of serious fall injury; this contribution was independent of the effect of chronic predisposing risk factors. Preventive programs that address both predisposing and situational risk factors may result in the greatest injury reduction. These findings support previously recommended multicomponent intervention programs that combine medical, rehabilitative, and environmental components.     

Reducing high-risk interventions for managing aggression in psychiatric settings

Seclusion and restraints have traditionally been major interventions for controlling patient aggression. The implementation of less restrictive measures may or may not be an option in managing individual cases of psychiatric emergencies. Improvement in patients, knowledge of alternatives and the need to reduce the use of restraints have led to the development of new tools to enhance prevention of high-risk interventions. At one institution, an anger management assessment tool and "Triangle of Choices" have assisted patients in identifying and managing feelings of frustration and anger. Since their inception 1 year ago, the implementation of documented alternatives to restraints has increased, and use of most restrictive measures has decreased.     

A proposed 30-45 minute 4 page standard protocol to evaluate rheumatoid arthritis (SPERA) that includes measures of inflammatory activity, joint damage, and longterm outcomes

A proposed 4 page, 30-45 minute standard protocol to assess rheumatoid arthritis (SPERA) is described that includes all relevant measures of inflammatory activity such as joint swelling, measures of joint damage such as joint deformity, and outcomes such as joint replacement surgery, to monitor patients in longterm observational studies. Forms are included: (1) a patient self-report modified health assessment questionnaire (MHAQ) to assess function, pain, fatigue, psychological distress, symptoms, and drugs used; (2) assessor-completed forms: "RA clinical features" --criteria for RA, functional class, family history, extraarticular disease, comorbidities, joint surgery, radiographic score, and laboratory findings. (3) A 32 joint count with 5 variables: (a) a "shorthand" normal/abnormal so that normal joints require no further detailed assessment; (b) tenderness or pain on motion; (c) swelling; (d) limited motion or deformity; (e) previous surgeries; physical measures of function, i.e., grip strength, walk time, and button test. (4) Medication review of previous disease modifying antirheumatic drugs (DMARD), work history, and years of education. The forms allow cost effective acquisition of all relevant measures of activity, damage, and outcomes in routine clinical care, and allow recognition that measures of activity may show similar or improved values over 5-10 years, while measures of damage and outcomes indicate severe progression in the same patients. The SPERA is feasible to acquire most known relevant measures of activity, damage, and outcomes in RA in 30-45 min in usual clinical settings, to provide a complete database for analyses of longterm outcomes.     

Self-attention and reported symptoms: Implications for forensic assessment.

Does patient self-attention to physical and psychological symptoms compared to self-distraction result in different clinical conclusions in forensic contexts? Participants in 2 studies were instructed either to attend carefully to somatic symptoms and sensations (attention instructions), to tally how many questionnaire items were related to physical versus emotional symptoms (distraction instructions), or received no attentional instructions (controls). The principal findings were that physical symptoms and reports of anxiety and depression were greater after attention instructions than after distraction instructions. Insofar as assessment contexts produce differential attention to self, examiners are advised to use caution in drawing conclusions regarding accuracy of self-reported symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)