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Restrictive interventions like acute control medications and restraints are more likely to be used in non-emergency situations among older psychiatric inpatients than younger ones, a study shows.
Researchers found a clear pattern of higher rates of these controls being used in older adults in Ontario psychiatric hospitals between 2005 and 2018.
“When considering non-emergency use of control interventions, this approach to care was most common in older adults, with the highest rates of restraint among the oldest-old,” said John Hirdes, a professor at the University of Waterloo’s School of Public Health Sciences and the study’s senior investigator.
The researchers examined 226,119 Ontario inpatient records during these years to determine how often older psychiatric inpatients are restrained in non-emergency situations compared to younger age groups, and to identify the factors associated with this non-emergency use in older psychiatric inpatients. They used data from the interRAI Mental Health assessment instrument—a comprehensive standardized assessment used routinely in psychiatric settings.
The rate for the oldest age group, 85 and over, was 1.6 times higher than among 45- to 64-year-olds (13.3 per cent compared to 8.3 per cent). Higher rates were also associated with being admitted from long-term care, being male, risk of falls, physical disability, and psychiatric symptoms. However, an important positive trend is the reduced use of restraints in older adults after the initiation of a province-wide quality improvement initiative that began in 2011.
“The use of control interventions is associated with many negative physical and psychological outcomes, particularly in older adults who are physically vulnerable,” Hirdes said. “Before resorting to these interventions, person-centred and non-pharmacological management strategies should be used to support older psychiatric inpatients with functional impairment, aggressive behaviour, cognitive impairment and delirium.”
Historically, nursing homes had rates as high as 64 per cent, but the inappropriate use of physical restraints and antipsychotics has dropped dramatically due to a different quality improvement focus, he said. Today, rates of physical restraint in Canadian nursing homes are below 5 per cent.
“Staff education and support programs could improve practice and ultimately protect older people from potential inappropriate treatment Hirdes said. “The use of control interventions in inpatient psychiatric units should be incorporated as a quality improvement activity to monitor changes at various service provision levels, and their use should be reported publicly as is already done in long-term care.”
The study, “Determinants of Non-emergency Use of Control Interventions in Older Canadian Psychiatric Inpatients: Analysing the InterRAI Mental Health Electronic Health Records,” was co-authored by Gary Cheung, Tina Mah, Yoram Barak and John Hirdes. It was published in Frontiers in Psychiatry.
University of Waterloo