This study describes the long-term outcome after ED visit with PR among geriatric patients. More importantly, this study highlights sex-related more unfavorable long-term outcomes for men compared to women in older patients. To our knowledge no other study assess the long-term mortality after PR.
In this acute setting study, the population undergoing PR represents less than 5% of patients. This rate was higher and varied between 5% and 25% in other studies.[13, 18] This low proportion of PR could be explain by the close collaboration between emergency physician and geriatric team but not only. The mobile geriatric unit was available between 9 am and 4 pm Monday to Friday in the hospital. Another factor is that, during their emergency medicine residency, all French emergency physicians have to spend 6-month in a geriatric unit.
Symptoms of delirium (agitation, behavioral disturbances, aggressivity) were mainly causes of PR more than fall prevention in older patient in the present study. Witlox et al. demonstrated the relationship between delirium in older patients and post discharge mortality, institutionalization and dementia.[6] The in-hospital mortality rate was lower than Chou et al. study[18] because the analysis took into account all patients hospitalized or not. Note that on their 188 patients who had PR, 87% were hospitalized in internal medicine ward via ED while only 67% of patients without PR. This could mean that this population was more vulnerable. Many studies showed that PR were used on frailer patients. They were older[12, 18], with poorer autonomy or health.[12, 18, 22] This could explain why they had been more hospitalized and had larger functional decline, with a longer LOS, and higher mortality rate[17–19] after PR use. This fact must be qualified because the ED visit is described to be by itself a cause of excess of mortality and readmission for older people.[23] The ED visit was a sign of global heath decline and according this study PR could be a confounding factor of health deterioration.
Biological sex was always described as a cofounder factor for long term outcome in many diseases.[3, 24, 25] Use of PR is more associated in men[26, 27] in ED, as the present study where the proportion of PR were slightly higher in men. In practice, PR seemed useful for men first to try to contain them in contrast for women it was to continue their treatment. Biological sex modified the prioritization decision. Compared to men, women were less likely to receive emergency treatment.[28] In this study, more than half of the men were died after one year, compared to one quarter of the women. In France, in 2021, according the public health data base and the age of this study population, life expectancy is 5.6 years for women after the age of 89 years. After 85 years, for men, it was 6.2 years old.[1] According this fact, in this study women were older but had a better survival after two years of follow up with a similar autonomy level. This result was another argument on the influence of biological sex on survival even women were older than men. The use of PR in men was more associated with mortality with the highest mortality ratio at one year after the ED visit. The meaning of this result could be a sign of more important global health decline in men when the PR are needed as compared to women.
This study had several limitations. First, due to the retrospective nature of data the incidence of PR and the mortality could be underestimated. The patients included in the study were only those whose passive physical restraint was recorded or prescribed in the medical record. There are restrained patients who could not be included in the study due to a lack of traceability. This constitutes a significant selection bias. Second, the absence of a control group (patients without PR) in this study represents a weakness. But it was not really the purpose of this study and this issue, had already been investigated in few studies.[18, 29] Third, the effect of sedatives was not taken in account because of the disparity of sedative drugs used. In the literature, chemical restraint showed few effects on outcomes compared to PR.[17, 30] Lastly, it's worth noting that this study was conducted at a single center, but the hospital is situated in an area with a high density of nursing homes for older people. It's probable that the physicians involved in the study had established best practices for caring these patients.