+Model COLEGN-301; No of Pages ARTICLE IN PRESS Collegian (2015) xxx, xxx—xxx Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/coll Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population Dianne Wynaden, RN, MHN, PhD a, Jenny Tohotoa, BSc, MSc, PhD a,∗, Karen Heslop, RN, PhD b, Omar Al Omari, PhD, RN c a School of Nursing and Midwifery/Curtin Health Innovation Research Institute, Curtin University, Australia Department of Psychiatry, Royal Perth Hospital, Joint Position with Curtin University, Australia c School of Nursing and Midwifery, Jerash University, Jordan b Received 11 April 2014; received in revised form 30 September 2014; accepted 19 December 2014 KEYWORDS Older adult; Mental health; Falls risk; Fall risk management ∗ Summary Older adults admitted to inpatient mental health units present with complex mental health care needs which are often compounded by the challenges of living with physical co-morbidities They are a mobile population and a high risk group for falling during hospitalisation To address quality and safety concerns around the increased risk for falls, a qualitative research study was completed to obtain an improved understanding of the factors that increase the risk of falling in this patient cohort Focus groups were conducted with mental health professionals working across older adult mental health services in metropolitan Western Australia Data were analysed using content analysis and three themes emerged that were significant concepts relevant to falls risk in this patient group These themes were (1) limitations of using generic falls risk assessment and management tools, (2) assessment of falls risk not currently captured on standardised tools, and (3) population specific causes of falls The findings demonstrate that older adult mental health patients are a highly mobile group that experience frequent changes in cognition, behaviour and mental state The mix of patients with organic or functional psychiatric disorders within the same environment also presents complex and unique care challenges and multi-disciplinary collaboration is central to reduce the risk of falls As this group of patients are also frequently admitted to both general inpatient Corresponding author Tel.: +61 892662090 E-mail address: j.tohotoa@curtin.edu.au (J Tohotoa) http://dx.doi.org/10.1016/j.colegn.2014.12.002 1322-7696/© 2015 Australian College of Nursing Ltd Published by Elsevier Ltd Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population Collegian (2015), http://dx.doi.org/10.1016/j.colegn.2014.12.002 +Model COLEGN-301; No of Pages ARTICLE IN PRESS D Wynaden et al and aged care settings, the findings are relevant to the assessment and management of falls risk across all health care settings © 2015 Australian College of Nursing Ltd Published by Elsevier Ltd Introduction and background In 2011, falls claimed the lives of 1530 Australians over the age of 75, which was an increase from 365 in 2002 (ABS, 2011), 30% of people over 65 years who live in the community fall each year (Gillespie et al., 2009) Falls in older adults impose a substantial burden on health services and contribute significant costs to an already over stretched health budget (Australian Institute of Health and Welfare, 2013) A fall is defined as any unexplained event that results in the person inadvertently coming to rest on the floor, ground, or lower level (Venes, 2009) While the majority of falls in older adults occur in the community, they are also the most common adverse event experienced during hospitalisation and the most reported safety incident occurring across all adult clinical areas (Oliver & Healy, 2009) Cognitively impaired older adults constitute a high-risk group for falling while hospitalised (Harlein, Halfens, Dassen, & Lahmann, 2011) and the falls are often unwitnessed and close observation of patients, particularly those prone to falling, is a key factor in preventing falls (Oliver, 2002) The causes of falls are multi-factorial with both intrinsic and extrinsic aetiologies (Lord, Sherrington, & Menz, 2001; Tzeng, 2010) Intrinsic factors include a history of falling and the fear of falling again (Fonad, Robins-Wahlin, Winblad, Enami, & Sandmark, 2008; Weber & Kelley, 2010), demographic factors of age (Edelman & Mandle, 2010), and chronic conditions like diabetes, coronary heart disease and dementia (Fonad et al., 2008; Mulley, 2001; Schoenfelder & Crowell, 1999; Titler, Shever, Kanak, Picone, & Qin, 2011) Edelman and Mandle (2010) established the link between falls and problems with vision, hearing, blood pressure, mobility and gait Additionally, altered mobility and musculoskeletal disorders can result in decreased strength, pain, fatigue, and difficulty ambulating, resulting in an increased risk for falls (Edelman & Mandle, 2010) Changes in reaction time and coordination that is often experienced with disorders like depression can also increase falls risk (Iaboni & Flint, 2013; Schoenfelder & Crowell, 1999) Medications prescribed to manage primary or co-morbid health problems can cause symptoms of dizziness, syncope, and weakness, which also increases the risk for falls by inhibiting balance and mobility (Weber & Kelley, 2010) The more medication taken by an older adult, the greater their risk of falling (Mulley, 2001) Medications with the strongest links to an increased risk of falling are those commonly used with mental health patients and include serotonin reuptake inhibitors and tricyclic antidepressants (Kerse, Flicker, Pfaff, Draper, & Lautenschlager, 2008), antipsychotic agents (Rigler et al., 2013), benzodiazepines, anticonvulsants (Lavsa, Fabian, Saul, Corman, & Coley, 2010) and in the older adult population also anti arrhythmics (Tinetti, 2003) Increased thirst, a common symptom in people who have a mental illness, whether psychogenic or medication-induced can lead to more frequent ambulation and need to urinate further increasing the opportunity for falls to occur (Tangman, Eriksson, Gustafson, & LundinOlsson, 2010) Extrinsic factors also increase falls risk (Fonad et al., 2008) and include environmental issues such as obstructed walkways, inadequate lighting, slippery floors and surfaces, tripping and the lack of or improper use of assistive devices (Edelman & Mandle, 2010) Approximately 100,000 people over 65 years of age live in the health region where this research was conducted (Australian Bureau Statistics, 2011), and form the cohort that may be admitted to older adult mental health inpatient units Falls are a major safety concern in these health settings with fall rates being up to four times higher than in general hospital settings (Blair & Gruman, 2005) One of the findings of a 12 month review of falls at two older adult mental health services in Western Australia, was the identified deficits of generic falls assessment and management tools (Heslop et al., 2012) when used for this older adult population In responding to the identified high falls risk, a qualitative study was designed to obtain a multi-disciplinary perspective on using generic falls risk assessment and management tools in the mental health setting Generic tools are historically targeted at assessing falls risk in the surgical and/or medical general hospital setting and designed for assessment in acute or inpatient care where patients are less ambulant than those admitted to the mental health setting They usually consist of two components: falls risk prediction to identify patients who are likely to fall and management strategies to prevent the patient from falling (Morse, 2006) The generic tools used at the services where this research was completed require the health professional to complete a full assessment of falls risk on patients if any of the following three criteria are met during the initial assessment: (a) the patient had a slip, trip or fall in the last six months; (b) they are unsafe when walking or transferring, or (c) they are confused If none of these criteria are met, minimum management standards outlined on the tool must still be implemented for each patient These include, orientation to the hospital environment, ensuring a call bell is within easy reach and providing the patient with appropriate mobility aids Objectives of the study The objectives of this multi-site formative study with older adult mental health patients were to: (1) Determine the effectiveness of using generic falls risk assessment and management tools with older adult mental health patients (2) Identify mental health specific triggers for falls risk and their management Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population Collegian (2015), http://dx.doi.org/10.1016/j.colegn.2014.12.002 +Model COLEGN-301; No of Pages ARTICLE IN PRESS Recognising falls risk and acknowledging the difference (3) Formulate multi-disciplinary assessment and management strategies to reduce falls risk in this older adult population Methodology The qualitative study reported on in this article formed part of a larger study on falls in older adult mental health patients This study aimed to address the first objective: to determine the effectiveness of current falls risk assessment tools and to explore expert opinion around the perceived falls risk in this specific population The research was deemed to be minimal risk and was registered as a quality improvement project at each participating health service and ethics approval was obtained from one university in Western Australia (SON&M 44-2010) The initial phase of the research involved a review of falls risk assessment and management tools used in clinical practice in Western Australia Following this review, focus groups were then conducted with health professionals from a range of disciplines between June and November 2012 to explore the study objectives All mental health nurses, occupational therapists and physiotherapists working in the older adult mental health units were invited to participate in these focus groups Interdisciplinary participation reflected the importance of the strengths each discipline brought to falls risk prevention and management for this patient group Participants were informed of the study and invited to participate and those that agreed provided written consent before the focus group commenced Any participant could withdraw at any time without penalty Each group lasted approximately 90 and a facilitator guide was used to provide consistency across groups Information was digitally recorded and transcribed After six groups, saturation of data was achieved and themes were well developed and expansive in their descriptions Data were analysed and transformed into conceptual maps with accompanying illustrative quotations Four cognitive processes were integral to data analysis: comprehending, synthesising, theorising and re-contextualising (Field & Morse, 1996) The key themes were significant concepts that linked substantial portions of the data together Researcher checks of data analysis were completed by two members of the team and analysis continued until consensus was achieved across themes Results Twenty-eight participants agreed to take part in the research; 21 mental health nurses (including EN’s [enrolled nurse], RN’s [registered nurse] and CN’s [clinical nurse]) four physiotherapists and three occupational therapists Three themes emerged from the data, namely ‘‘limitations of using generic falls risk assessment and management tools’’; ‘‘assessment of falls risk not currently captured on standardised tools’’, and ‘‘population specific causes of falls’’ 4.1 Theme 1: limitations of using generic falls risk assessment and management tools Generally, participants were critical of the generic falls risk assessment tool currently used in the mental health setting as ‘‘too much information [on the tool] is targeted at hospitalised patients in the general setting and is not relevant to [mental health] IV poles, bed tables, we don’t use them, and it cannot be individualised for each patient’’ (P21); ‘‘call bells, we don’t use them or bed rails, which are regarded as restraints [in mental health]’’ (P12) Many of ‘‘these items are contraindicated in mental health’’ (P9), and are viewed as ‘‘clutter and obstacles that could increase the falls risk for a mobile patient’’ (P7) Participants spoke of ‘‘audits demonstrating problems with the use of generic tools in the mental health setting with a mobile older adult population’’ (P24); ‘‘we audit the tool on a monthly basis — and on the basis of the audit I would say that approximately half of what is listed is not relevant It is just listed as not applicable’’ (P28); It is a ‘‘tick box management strategy for assessing risk rather than a tool that is directive of care’’ (P10) While meeting the minimum assessment and management standards outlined on the generic tools was relevant in the mental health setting, additional information was often required due to the increased mobility of this patient cohort and their fluctuating cognitive, behavioural and mental state differences According to one participant ‘‘the minimum standards should always be incorporated into the initial falls assessment However, it can be difficult with some patients to determine if they are orientated to the environment, especially if they are confused’’ (P23) Participants viewed the generic tool as limiting in ‘‘capturing information on sensory impairment’’ (P3) and ‘‘in defining a management strategy for the [mental health] patient’’ (P1) Participants expressed that ‘‘these types of assessments were very tick and flick’’ (P14) Other participants commented on the lack of space and options on the current generic tool: ‘‘I would like to be able to write a bit more here I would like the form to be a bit more person centred’’ (P6) 4.2 Theme 2: assessment of falls risk not currently captured on standardised tools In assessing falls risks in older adult mental health patients, participants articulated that it was critical to ‘‘assess the patient over a 24 h period as things change according to the time of the day, this means we [can then] things with them when they are most functional and less when they are not managing so well’’ (P3) Observing the patient closely over the first 24 h ‘‘allowed them to settle into the environment and for staff to obtain an accurate assessment of the patient’’ (P5) Participants viewed multidisciplinary collaborative assessment as fundamental to this process: ‘‘nurses need to know the medical co-morbidities the patient presents with and the medications they are prescribed as these impact on risk’’ (P15); ‘‘podiatry services are important’’ (P16); ‘‘occupational therapists assess cognition as part of their functional assessment’’ (P3); ‘‘every patient should be seen by the physiotherapist to determine Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population Collegian (2015), http://dx.doi.org/10.1016/j.colegn.2014.12.002 +Model COLEGN-301; No of Pages ARTICLE IN PRESS D Wynaden et al if they need a Zimmer frame or if their footwear is appropriate?’’ (P22); ‘‘you assess their gait and eye contact Are they walking on their own? Are they swinging their arms? How is their balance? How did they arrive at the ward?’’ (P1) Another participant commented on the value of a physiotherapy assessment: [The physio] uses the Berg balance tool to assess their level of balance: the higher the score the lower their risk of falling In assessing risk they look at functional tasks and observe the patient For example, they drop a pen and ask them ‘can you pick the pen up off the ground?’ They assess if the patient has the capacity to bend down and pick it up They also observe them getting something from the wardrobe as this skill is an indication of good balance (P2) Participants spoke of the importance of assessing the patient’s strengths rather than their deficits: ‘‘generic forms assess deficits rather than focusing on the patient’s strengths and what they could [to lessen their risk of falling]’’ (P10); ‘‘for most of our patients the [generic] form has little relevance, for example, the patient today, their falls risk was picked up quickly by the physio [therapist] by assessing the patient’s strengths not deficits’’ (P4) 4.3 Theme 3: population specific causes of falls Mobility was identified as a specific cause of falls for this population and all indoor areas and courtyards were identified as high risk environments for falls Participants explained that patients were at risk because: ‘‘we not have ensuites [so] men tend to urinate on the floor [in the bedroom] and then fall’’ (P2); ‘‘the soil [in the garden area] needs to be built up where it meets the cement as it is a trip hazard’’ (P13) Frequent changes in cognition, behaviour and mental state were also identified as specific falls risk factors in older adult mental health patients Restlessness, agitation and disorientation were commonly identified with falls risk as participants explained: ‘‘just recently we had two patients who have been very problematic at night, with one needing a ‘‘special’’ [one to one nursing care] to prevent them wandering’’ (P17); ‘‘you assess their level of frailty and then disorientation, are they lost or confused? They will walk around until they are fatigued and then be more at risk of a fall’’ (P10) The patient mix in many older adult mental health units was identified as a unique falls risk factor due to the complexity and challenges in care requirements and presentation between those patients with dementia and those with functional disorders such as schizophrenia and bi-polar disorder ‘‘When you have patients with organic disorders [e.g dementia] and functional disorders [e.g schizophrenia] in the ward together, it is a difficult patient mix’’ (P18); ‘‘patients with dementia lack insight, they are intrusive and get into trouble with other patients’’ (P5) Extrinsic factors such as the incorrect use of or refusal to use mobility aids were perceived to increase the risk of falls: ‘‘many patients have walking frames but not use them, we have a lady who drags her frame behind her we looked at ways to assist her, but when she is in that frame of mind it’s hard Sometimes she uses it appropriately and [at] other times [she does] not’’ (P18); ‘‘if they have a mobility aid, are they using it appropriately? I have seen them carried over their shoulder or even carried it in front of them’’ (P20) Footwear was also associated with falls risk in this patient population and discussed at length by participants: ‘‘many patients arrive with inappropriate footwear’’ (P21); ‘‘they are admitted and have no clothes with them .so they end up with foam slippers which are not appropriate’’ (P22); ‘‘some people don’t have the money to buy appropriate footwear’’ (P13); ‘‘some patients void in their footwear’’ (P28) Increased falls risk was also linked to medication use as participants explained: ‘‘the causes of falls include many factors, but one of them is medication and that is a huge factor, older mental health patients have lots of medication’’ (P25); ‘‘the use of pro re nata [when necessary] medications to address behavioural issues further impacts on falls risk’’ (P24); ‘‘if they are a very disturbed patient from the emergency department, they may be overly medicated and [on admission become] an immediate falls risk’’ (P5) Participants spoke of the conundrum of medication use and the associated increased risk for falls ‘‘In a perfect world we wouldn’t put them [older adult patients] on medication because they are a falls risk, but realistically they have a mental illness, behavioural disturbances and medical conditions so that is not realistic’’ (P9); ‘‘When using medication it is a fine line in managing aggression versus falls risk’’ (P7) Addressing behavioural difficulties experienced in dementia with medication was another issue ‘‘it is a fairly sticky situation to get right as the fact is there is a correlation between giving people these drugs [antipsychotics, benzodiazepines] and falls’’ (P24) One participant commented on the specific risks identified with the use of antipsychotic medication where the patient was ‘‘being heavily sedated ‘‘and with the use of aperients ‘‘because with diarrhoea the patient may fall’’ (P8) The extra pyramidal side effects of typical antipsychotics were also seen to increase falls risk: ‘‘with the last patient, we knew as soon as he came in [admitted to hospital] that he would fall He was on prescribed antipsychotics and had a real shuffle — it affected his walking and consequently he fell’’ (P6) Medical co-morbidities also increased the risk of falls: ‘‘it’s about weighing up that balance between mental state and medical health’’ (P2) Discussion Mental health units for older adults have a consistent mix of highly ambulant patients with organic disorders such as dementia and Alzheimer’s and those with functional disorders such as schizophrenia and bi-polar disorder (Heslop et al., 2012) The components of cognitive function affected in dementia include memory and learning, attention, concentration and orientation, problem-solving, calculation, language, and geographic orientation (Hsu, Nagamatsu, Davis, & Liu-Ambrose, 2012) Hence, these patients have frequently changing cognitive, behavioural and mental states that increase their risk for falling during Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population Collegian (2015), http://dx.doi.org/10.1016/j.colegn.2014.12.002 +Model COLEGN-301; No of Pages ARTICLE IN PRESS Recognising falls risk and acknowledging the difference hospitalisation While the use of generic falls risk assessment and management tools is common practice in many inpatients settings, the value of these tools with older adult mental health patients appears limited This finding is supported by Estrin, Goetz, Hellerstein, Bennett-Staub, and Seirmarco (2009) who claimed that ‘‘there is a lack of well-researched and validated fall risk models specifically developed for populations of psychiatric patients’’ (p 1245) Lee, Mills and Watts (2012) also identified the need to improve the system of falls assessment in psychiatric older adult populations The increased falls risk posed by the level of mobility of patients is further exacerbated by the fact that almost every patient is on one or more medications that also increases their fall risk (Estrin et al., 2009) and therefore, all patients could be classified as being at high risk for falls The debate surrounding the increased falls risk with the use of antipsychotic medication versus improved mental health outcomes continues Older adults may be prescribed a number of medications and taking two or more psychotropic medications is associated with a twofold to ninefold increase in the number of falls (Gustafsson, Sandman, Karlsson, Gustafson, & Lovheim, 2013; Lim, Ng, Ng, & Ng, 2001) Many of these prescriptions are linked to controlling behavioural and psychological symptoms of dementia (Richter, Mann, Meyer, Haastert, & Kopke, 2011; Seitz et al., 2013) yet withdrawal of psychotropic medications has been associated with a reduction in falls and improved cognition (Iyer, Naganathan, McLachlan, & Le Couteur, 2008; Ruths, Straand, Nygaard, & Aarsland, 2008) Selbaeck and Engedal found atypical antipsychotics had a modest effect on the behavioural and psychological symptoms of dementia and potentially serious side effects and that conventional antipsychotics appear to have even less favourable effects and adverse event profiles (Selbaek & Engedal, 2008) The dilemma of appropriate prescribing for behavioural management in an older adult mental health unit against the increased risk of falling remains an ongoing issue for clinicians and researchers To capture the complexity of the falls risk in the older adult mental health population, a comprehensive mental health assessment and management tool needs to be developed This is supported by the work of Edmonson and colleagues who identify the unique falls risk factors of psychiatric inpatient populations (Edmonson, Robinson, & Hughes, 2011) The areas of importance identified in this qualitative study for the assessment and management of falls risk in this patient cohort include: cognition, functional ability, mobility, mental state and behaviour, environmental concerns, medical co-morbidity and medication Addressing each of these criteria with an assessment and correlated management strategy could decrease the fall risk and increase the clinical skills of staff who work with this group of older adults While nurses play a large role in the assessment and management of falls risk in hospitalised patients in the general health care setting, a multidisciplinary approach to assessment and management of falls risk is promoted in the mental health setting The findings demonstrate the unique skills each profession contributes to improved falls risk prevention in older adults and the transferability of findings to other hospital settings are relevant Limitations The study was limited to the one geographical location and the health professionals who participated only worked with older adults experiencing mental health problems in public hospitals Additional intrinsic and extrinsic factors may add to the falls risk for older adult mental health patients in other health care settings Conclusion The findings of this study highlight that generic falls risk assessment and management tools identify risks associated primarily with immobile patients and have limited use with a patient population who are mobile and experience frequent fluctuations in cognitive, behaviour and mental state These patients due to their mobility are constantly exposed to many of the extrinsic risk factors for falls such as tripping and slipping The patient mix adds further to the complexity and challenges of preventing falls in this patient population Antipsychotic, antidepressant and hypnotic medication all add to the sedating and hypotensive side effects that further increase the risk for falls Many patients have multiple co-morbidities and the combination of medications used to treat their primary presenting illness and their comorbidities is a specific falls risks factor in this population The importance of multidisciplinary collaboration in reducing falls risk in this patient cohort is essential for best practice in falls risk assessment and management As mental health patients are now commonly found in all health care settings the findings and identified quality and safety issues are relevant in all settings Acknowledgement This research was funded by a Quality and Safety Grant from the Western Australian Department of Health References Australian Bureau Statistics (2011) Information paper Census of population and housing — Products and services (2011.0.55.001) Canberra: Australian Bureau Statistics Retrieved from http:// www.abs.gov.au/ausstats/abs@.nsf/mf/2011.0.55.001 Australian Institute of Health and Welfare (2013) Health expenditure Australia 2011—2012 (HWE 59) Canberra: AIHW Blair, E., & Gruman, C (2005) Falls in an inpatient geriatric psychiatric population Journal of the American Psychiatric Nurses Association, 11(6), 351—354 http://dx.doi.org/10.1177/ 1078390305284659 Edelman, C L., & Mandle, C L (2010) Health promotion throughout the lifespan (7th ed.) 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Philadelphia: Lippincott Williams & Wilkins Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population Collegian (2015), http://dx.doi.org/10.1016/j.colegn.2014.12.002