Prevalence and risk factors for seclusion and restraint in old-age psychiatry inpatient units

Coercion – defined as any intervention limiting a patient’s choice, autonomy or liberty of movement [1] – infringes upon fundamental human rights and therefore highlights legal and ethical issues [2, 3]. The use of coercion, which is legally tolerated as a last resort [2], is common in psychiatry, ordinarily to manage aggression and violence [4, 5]. The use of coercion is peculiarly contentious, as mental disorders can temporarily impair judgment capacity and hence make patients particularly vulnerable [6]. Because of the potential deleterious consequences of coercion, the worldwide trend is to prevent or at least diminish the use of coercion in psychiatry [7‐10]. The main aim is to reduce the prevalence and duration of seclusion and restraint [11].

Among the general psychiatric population experiencing coercive measures, the psychogeriatric population has been rarely studied to date. Moreover, the interpretation of the results of studies into clinical practice in this population are particularly difficult due to the methodological heterogeneity of the available studies, for example, regarding ages of inclusion [12, 13] or settings [14‐16]. Although restraint is commonly the main analyzed coercive measure in elderly people [12, 17], the wide heterogeneity of practices used in this population have resulted in wide definitions of restraint, including, for example, the use of bedrails [18, 19]. Restraint prevalence in elderly people varies between 7.4 and 85% [20, 21]. The discrepancy depends mainly on the definition used for restraint and the study setting [22]. As a comparison, in general adult hospital care, the prevalence of restraint usually trends from 6 to 17% [23, 24]. To our knowledge, no study has specifically examined the use of seclusion in elderly people. A comparison of results could thus be problematic, as in Switzerland, as opposed to other countries, restraint is rarely used compared to seclusion [25]. These methodological issues render the interpretation of available data about the prevalence of coercive measures difficult, particularly considering the often contrasting results [21].

Regarding the risk factors for coercion in elderly people, it is important to underline that most studies do not specifically address the question of coercion in specific populations, such as elderly people; they only examine younger adult psychiatric populations [26, 27] or make no distinction between adult and geriatric populations [28, 29]. Some studies exclude patients with cognitive impairments [30, 31], which are preponderant in elderly people [18, 32]. In some studies, the relevant risk factors for coercion are organic mental disorders [33‐35], older age [36, 37] and physical complications [38], three features associated with older populations. These results suggest a possible substantial difference in terms of the risk factors for coercion between adult and geriatric populations that needs to be investigated [12]. The inconsistency of the literature regarding this theme could thus come from the nondistinction between two noncomparable populations [25]. In the few studies available specifically concerning the risk of coercion in elderly people, the main risk factors for restraint (with or without seclusion) in elderly people were older age, cognitive impairment, disruptive behaviors (confusion, agitation, regression, screaming), wandering, high dependency in activities of daily living, reduced mobility, and history of falls [15, 16, 32]. Gender was usually not associated with the risk of coercion [12, 17]. The main reasons for using restraint were the prevention of falls, injuries or wandering; protection of medical devices; and management of disruptive behaviors [20, 39]. Aggression and violence were less common [14, 40], which contrasts with the adult psychiatric population in which aggressive behavior represents the main reason for using coercion [4, 5]. These discrepancies are arguments in favor of the significant differences between the two populations. As the clinical management of patients exposed to coercion may differ depending on the risk factors, those differences need to be assessed.

This study aims to determine the risk factors for coercion in the psychogeriatric population and to analyze its prevalence. Based on a previous study on patients hospitalized in the adult psychiatry division of Geneva University Hospital during 2017, this work also aims to compare the risk factors for coercion between geriatric and adult psychiatric populations [41]. This study should, therefore, help determine whether specific interventions should be implemented in psychogeriatric settings to reduce the use of coercion.

The present study uses the same retrospective design as described in a previous work [41].

In 2017, 16.4% of patients experienced at least one coercive measure during their hospitalization in geriatric psychiatry. Considering demographic factors, the risk of coercion was correlated with male gender, younger age and a history of previous psychiatric hospitalizations. Separated/divorced or married patients were at higher risk of coercion than single patients. Regarding clinical risk factors, referrals from the emergency department, involuntary admission, high item 1 HoNOS scores at admission and a diagnosis of cognitive disorder were associated with a higher risk of coercion. Diagnoses of psychotic, anxious or personality disorders were associated with a lower risk of coercion. This risk was not influenced by a diagnosis of bipolar disorder or the global HoNOS scores at admission (Table 3).

The prevalence of the patients experiencing coercion in our geriatric psychiatric division was 16.4%, which is consistent with the literature, as the known proportion is approximately 7.4–20% in acute geriatric care hospitals [21]. This result is also similar to our findings in the nongeriatric adult population at the same hospital [41].

Male gender was associated with a higher risk of coercion in our sample than female gender, a finding that differs from previous psychogeriatric studies [12, 17] but is consistent with our findings among the adult psychiatric population [41]. It is possible that men exhibit more violent behaviors and/or induce more fear in staff.

The risk of coercion decreased with age in our sample, which diverges from previous works identifying older age as a risk factor for restraint in the geriatric population [12, 15]. In adult populations and similar to our present study, younger age was correlated with an increased risk of coercion in some publications [24, 49], whereas other studies, including our previous work, found no association between age and coercion in adults [25, 41, 50]. In younger patients, coercion is mostly used to manage aggression and violence [4, 5], whereas in elderly patients, the main reasons for coercion seem to be disruptive behavior and fall prevention, often in association with cognitive disorders [16, 39]. The same intervention – coercion – seems therefore to be used for two different purposes, suggesting that there are two substantially distinct populations that need to be studied separately.

In our study, divorced or married patients were at higher risk of coercion than single patients. Reliable inferences at this stage are difficult to establish, with highly divergent results in the literature [24, 45, 51]. As a comparison, we found a lower risk of coercion in married or divorced adult patients [41]. Civil status in elderly people seems differently associated with coercion compared to that in adults. A hypothesis could be that cognitive disorders can have behavioral disturbances with a relational manifestation, such as agitation and aggression with relatives. These symptoms may lead to coercion. Another hypothesis could be that single patients more often live in protected environments or in nursing homes and therefore require less hospital care.

The risk of coercion increased with the number of previous psychiatric hospitalizations, suggesting a higher risk of coercion in cases with more severe disorders [50, 52]. This result is similar to our findings in adults [41].

Consistent with other studies, our results showed that cognitive disorders were the only diagnosis-related risk factor for coercion in geriatric psychiatric populations – using depressive disorders for comparison [12, 53]. Cognitive disorders are indeed more common in elderly people and alter their judgment capacity as well as their behavior, leading to the need for coercion. Opposite to what was found in adult populations, diagnoses of psychotic or bipolar disorders were not associated with a higher risk of coercion in this population [25, 43, 54]. Moreover, our previous results in adults showed a higher risk of coercion among patients suffering from substance use and personality disorders, whereas these risks were reduced in geriatric patients [41]. Patients suffering from substance use or a personality disorder tend to present less aggressive symptoms when their age increases [55, 56].

Referrals from the emergency department were associated with an increased risk of coercion in elderly people. Confusional states can lead to disruptive behaviors and thus to coercion [18, 32]. In such states, the somatic etiology needs to be excluded, which could explain the visit to the emergency service before hospitalization in geriatric psychiatry. A similar rationale could be applied to falls and the need for a somatic examination as well as the use of coercion as a prevention during hospitalization. Other studies in adult populations have reported comparable results [25, 57]. Our study in adults, however, showed no association with referrals from the emergency department [41].

In this study, the risk of coercion increased with the item 1 rating on the HoNOS at admission. This result was similar in adults [41]. Despite the discrepancies in disorders impacting the risk of coercion differently between the two populations, the symptoms rated by the first item of the HoNOS (overactive, aggressive, disruptive or agitated behaviors) seem to be good predictors of the risk of coercion for both populations and should thus be systematically evaluated in practice. The global HoNOS scores at admission were however not significantly associated with a risk of coercion in elderly people. Another study showed that the HoNOS score was not predictive of the use of seclusion in cases of cognitive disorders [58], whereas the global admission scores were predictors of coercion in adults [41]. Cognitive disorders, which are prevalent in elderly people could thus hinder the pertinence of the global HoNOS to predict the risk of coercion in psychogeriatric populations.

The present work outlined higher risk of coercion among men with cognitive disorders, agitated behaviors, and previous psychiatric hospitalizations. It also highlighted the differences in the use of coercion compared to younger adults, especially regarding age, civil status and diagnostic and clinical factors. These results support the specificities of the geriatric psychiatric population and indicate the need for further research investigating the clinical processes leading to the use of coercion in the elderly. This study clearly states that specific clinical interventions are needed to offer alternatives in the management of critical situations in this population and to effectively reduce the use of coercion.