The use of involuntary treatment among older adults with cognitive impairment receiving nursing care at home: A cross-sectional study

Background: Respect for inherent dignity and individual autonomy is a basic principle in health care. However, several studies indicate that care-dependent older adults with a cognitive impairment, receiving nursing care at home, are at risk of care without their consent, referred to as 'involuntary treatment'. This includes the application of physical restraints (e.g. measures to prevent leaving bed or chair), psychotropic drugs (e.g. antidepressants, sedatives) and non-consensual care (e.g. forced hygiene, hiding medication). Research about involuntary treatment is scarce and only recently first studies have been conducted.

Objective: To investigate 1) the prevalence of involuntary treatment, 2) associated factors and 3) who requests and applies their use among older adults with cognitive impairment receiving nursing care at home.

Design: Cross- sectional study.

Setting: Homes of older adults receiving nursing care from district nurses in the eastern part of Belgium.

Participants: Data were collected from 1194 randomly selected older adults with cognitive impairments receiving nursing care at home (mean age 83; 67% female).

Method: District nurses completed an online questionnaire for each selected older adult in their caseload. Involuntary treatment was measured using a questionnaire identifying use of physical restraints, psychotropic medication and non-consensual care. In addition who requests involuntary treatment and who applies it was examined. Older adults sociodemographic characteristics, diagnosis of dementia, activities of daily living (ADL), cognitive status and informal caregiver burden were assessed.

Results: Involuntary treatment was used in 52% (95%; CI 49-55) of the total sample. Non-consensual care was most often used (73%; 95% CI 70-77), followed by psychotropic drugs (43%; 95% CI 39-47) and physical restraints (38%; 95% CI 35-42). The use of involuntary treatment was associated with dependency for activities of daily life (OR 1.50; 95% CI 1.33-1.69), cognitive impairment (1.39; 95% CI 1.25-1.55), informal caregiver burden (OR 1.05; 95% CI 1.01-1.10) and aging (OR 0.97; 95% CI 0.95-0.99). Informal caregivers (71%), followed by general practitioners (47%) most frequently requested the use of involuntary treatment, and nurses (81%) mostly applied it.

Conclusion: In Belgium, involuntary treatment is often used in older adults with a cognitive impairment receiving nursing care at home. The implication of this study for clinical practice is that it confirms the need to develop an approach to prevent and reduce it. Further research is needed to plan and develop such an approach, in order to prevent and reduce the use of involuntary treatment.