This study showed the trends of dementia patients requiring nursing care who were physically restrained per 1,000 hospitalizations and tracked important changes in this regard during the COVID-19 pandemic in Japan. The main finding of our study was that following the MHLW’s announcement of COVID-19 hospital restrictions, dementia patients who required nursing care were significantly more likely to be physical restrained.
Dementia has increasingly gained importance as a public health concern because of the increase in aging societies worldwide.25 The increasing prevalence of dementia in older adults has resulted in a situation where medical staff in acute care hospitals often need to provide dementia care to elderly patients, although the patients are admitted for acute diseases.26 Moreover, hospital staff is often not sufficiently trained to provide care for dementia patients. Physical restraining is often performed in acute care settings, especially in elderly patients and those with dementia,7,8,15,27−29 to prevent falls and self-extubation and because of low availability of medical staff and inadequate resources to constantly monitor at-risk patients owing to the large workload of the hospital staff.6,30 However, physical restraints should be avoided, wherever possible, in conformance with recommendations that have been issued worldwide, including in Japan.14–17
We considered the following two major reasons for the increased use of physical restraints in elderly dementia patients compared with recent trends in the previous year: 1) patient factors and 2) factors associated with the care system.
The former is attributable to the hospitalization of elderly patients with increased progression of cognitive impairment because of the COVID-19 pandemic.31 During the COVID-19 pandemic, many people refrained from social gatherings and other interpersonal communications even with their families. The Japanese government repeatedly made announcements asking citizens to reduce physical contact with others by 80% using the phrase “Three Cs”: avoiding closed spaces, crowded places, and close-contact settings.32 However, social isolation is considered to be associated with poor cognitive functioning in older adults.33 The Japan Association of Geriatric Health Services Facilities and Hiroshima University published findings that restrictions on going out and meeting visitors, including family and friends, worsened the cognitive and physical functions of dementia patients.31 Moreover, social restrictions have had a substantial impact on the management of outpatient clinics because of cancelations or triage of patients.34 Dementia patients with more severe cognitive function impairment could possibly have been hospitalized during the COVID-19 pandemic, which led to the increased frequency of physical restraint.
Factors associated with the care system and quality of care in general hospitals could have changed during the COVID-19 pandemic. Dementia patients often experience a challenging environment during hospitalization for acute diseases, and therefore, communicating with visitors, especially family members, is important to maintain their cognitive function.29,35,36 The Centers for Disease Control and Prevention guidance allows care partners to visit patients if they are essential to the patients’ physical or emotional well-being, even during the COVID-19 pandemic.37 Furthermore, use of telemedicine and digital technology can be helpful for the management of chronic neurological disease, including dementia and cognitive impairment.38 In addition, the mental and physical statuses of medical staff are important to provide the best care for patients. During the COVID-19 outbreak, the medical staff were under pressure owing to the heavier workload, risk of infection, and defamation in public spaces.39–41 Nurses are required to take care of several patients at once during pandemics, such as the COVID-19 pandemic,42 while wearing personal protective equipment, which makes communication more complex. The threshold for physically restraining elderly dementia patients may have been lowered owing to changes in the care system that have occurred consequent to the implementation of hospital strategies or due to increased strain on medical staff.
This study had several limitations. First, the severity of manpower shortage and the extent to which the restriction regarding family visitation was strictly enforced were unclear in the target hospitals. This study included hospitals to which COVID-19-positive or -suspected patients were admitted; more thorough infection control measures were considered to be practiced in these hospitals than in hospitals that did not accept COVID-19-positive or -suspected patients. However, we could not consider and evaluate different burdens on medical staff owing to differences in the number of admissions of COVID-19-positive patients in the target hospitals. To manage restriction on in-person visits owing to the COVID-19 pandemic, some hospitals have been attempting to ensure a virtual connection between patients and their loved ones via tablets or smartphones. Despite the limitations in the use of technology, including difficulty in hearing over devices, patients can reap benefits by communicating with their family members.43 Second, we could not detect the type or severity of dementia, which is often not recognized in general hospitals,18 because the applicable benefit did not require precise information about dementia. However, patients who were eligible for inclusion in this study were patients who were judged by medical staff, trained in dementia care, as having dementia or an equivalent cognitive impairment that interfered with their daily lives and necessitated nursing care. 17 Moreover, the dementia care benefit cannot be applied to those who have severe disorientation (indicated by a Glasgow Coma Scale score < 9).9,17 Therefore, we believe that patients with dementia of severity within a certain range were selected.
A strength of our study is its large sample size. Multicomponent interventions that increase medical staff awareness have limited effectiveness in reducing physical restraint use16; however, we believe that examining the current situation during the pandemic can significantly help prepare for similar future circumstances.