Quality of care for the elderly

A paper just published in the International Journal of Geriatric Psychiatry found that Canada is a world leader in the use of restraints in the elderly in nursing homes.

This is not like winning a gold medal at the Olympics! The use of restraints in nursing homes is considered a sign of sub-standard care. It is usually an indication of unqualified or insufficient staff.

The homes surveyed in this study used restraints on almost a third of residents: more than triple the rate in the United States and higher than the three other countries (Finland, Hong Kong and Switizerland) surveyed. A rate below 5% is usually considered more appropriate.

Geriatric specialists have long believed that restraints should be avoided if at all possible just as psychiatrists believe the same to be true for psychiatric patients. So why are they being used so often?

A likely explanation is the ongoing budget and bed squeeze that has been applied over the past decade or more to reduce costs. The nursing home elderly are a weak political force and are being taken advantage of just like the homeless and the mentally ill.

There are insufficient beds and staff. In trying to make do with inadequate budgets, there has been a race to the bottom in terms of hiring the least expensive staff for the highest possible caseload. What do you do if you are all alone with minimal training and too many patients, surrounded by agitated, demented patients all needing attention? Answer: you tie them down until you have time to get back to them.

As well as being dehumanizing, restraints can lead to loss of mobility, pressure ulcers and increased agitation. Patients have been known to die struggling against their restraints if no one is watching.

The same study found the use of anti-psychotic medication in Canadian nursing homes at about 27% in the previous 7 days which was in the middle of the group compared to the other countries. These medications, although sometimes appropriate can lead to increased falls, cardiovascular problems and death. The increased use of chemical restraints has the same significance as the use of physical restraints. It is expedient and inexpensive in the short term.

In the U.S. there are specific standards surrounding the use of restraints and other related issues and government funding is dependent on meeting those standards.

It should not be expected, however, that regulations alone will solve this problem. Training, properly designed facilities and adequate staffing will all be necessary.

We can add this to the growing list of deficiencies in our heath care system along with unacceptable waiting lists, lack of hospital beds and lack of a National Mental Health Care plan.

The challenges are only going to increase over the next decade as the baby boomers age.


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