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.
Implications for clinical practice
Decreasing the use of coercion in elderly people requires an awareness of the associated specific risk factors. This awareness can serve in clinical practice as an indicator for patients who require special attention to avoid coercion. It should also lead to the development of interventions tailored to deal with these specific clinical factors. The present work should be considered a first step towards the implementation of such new interventions.
As mentioned before, the lack of publications focusing on seclusion – the most used coercive measure in our hospital – in this population renders comparisons between studies somewhat difficult. We can still contrast some of our results with the known literature, as parallels between restraint and seclusion can be drawn. Prevention of falls and injuries and management of disruptive behaviors are the principal reasons for using restraint in elderly people [17, 59]. As a parallel, the present study shows that the risk factors for seclusion are mainly cognitive disorders and agitated behaviors. Restraint is also known to be a risk factor for confusion, agitation, and risk of falls, reasons often evoked to justify its use [40, 60, 61]. Similarly, it can be clinically argued that secluding a patient suffering from cognitive disorders could lead to the risk of increasing confusion and agitation through loss of orientation and isolation. These two coercive methods seem, therefore, to have similar risk factors and side effects and might not be the most appropriate to treat elder patients with cognitive impairment [32, 60].
Alternatives and oriented interventions to decrease the use of coercion in the older population are thus more than needed [18, 62]. Interventions directly targeting the symptoms of disorientation and/or derealization that increase the risk of disruptive behaviors among patients suffering from cognitive impairments might be interesting and promising alternatives. For example, architectural changes in wards, such as multisensory rooms or senses-based interventions, including Snoezelen therapy or a “controlled multisensory environment,” aimed at alleviating the symptoms of disorientation and/or derealization through sensory stimuli seem promising [63, 64]. Including a patient’s relatives in clinical discussions and decisions is also an alternative for the care of patients with cognitive impairments [61, 65]. Regarding staff, some studies examining geriatric care have found that specific staff training in geriatrics and psychiatry sensitizes nurses to cognitive impairment management and thus helps reduce the use of restraint [16, 39].