By Brian McMinn, Amy Booth, Elizabeth Grist and Anthony O’Brien

Older people in Mental Health Inpatient Units for Older People (MHUOP) are a serious ‘at risk’ group, both for falling and osteoporotic injury post fall (Stubbs, 2010), as well as prolonged length of stay (Greene et al. 2001).

Falls and fall injury are a leading cause of mortality and morbidity in older people generally, but the risk of falling can be exacerbated when affected by a mental health condition. NSW Health policy mandates that older person units must have falls-prevention processes in place as part of their strategy to prevent the development of secondary comorbidities (NSW Health, 2011, 2012).

From the point of admission, the risk of falling is high among older people, even in the absence of a history of falls or mental illness. The mental health unit environment places the person at an even greater fall risk due to a multiplicity of issues that include: psychotropic medications, overactivity due to mania, depression, confusion, an/or agitation and frequency of micturition due to bladder control problems (Blair and Gruman, 2005). Older people in mental health units can also behaviourally unpredictable due to their mental status at different times of the day and night. They may be restless and agitated and are often on the move within the ward, in and out of bedrooms, and wandering in open spaces (Heslop et al. 2012; Blair and Gruman, 2005). Due to age and concomitant comorbid physical problems such as obesity, respiratory disease, metabolic and blood pressure instability, they may experience trans-ischemic attacks and dizziness, may be unstable on their feet, and at risk of falling, getting up from chairs, beds and particularly in bathrooms (Blair and Gruman, 2005; Heslop et al. 2012; Tsai et al. 1998).

Gait may be affected by Parkinson’s disease and other degenerative brain disorders like Alzheimer’s disease and cerebral deterioration due to alcohol and other drugs. Shuffling when walking can easily lead to a trip and fall. Those who are admitted and develop delirium can also require higher acuity care, at least initially in MHUOP. In assessing falls risk and implementing fall-prevention strategies, it is important for clinicians to recognise that this population, despite being ambulant, present with a fluctuating course of illness, and this fluctuation presents risks that require specialised falls assessment, consistent monitoring and management (Heslop et al. 2012).

Overview of the problem
While there are a number of reviews which focus on falls in older people with dementia and cognitive impairment, there is less information recognising other mental health conditions, or the special needs of mental health settings (Bunn et al. 2014).

Search strategy
For this clinical update, electronic searches were conducted within CINAHL, EMBASE, Medline and PsychInfo databases using keywords and variants of fall(s), mental health, older people, aged, inpatient and psychogeriatric. Secondary sources and policy documents were included.




Discussion
The incidence of falls within psychiatric units tends to be higher than that within general acute care hospital units (Blaire and Gruman, 2005). The proportions of falls resulting in some degree of harm are known to be higher in mental health units (45%) than in community hospitals (37%) and acute hospitals (33.7%). Patients aged 85-89 years old experience a higher-than-expected likelihood of falling, relative to bed days (Healey et al. 2008).

In a large US study of all healthcare setting, the odds of a fall injury were found to be between 1.5 and 4.5 times greater for both older men and women with mental health or substance abuse conditions. Odds of a fall injury among older people for Alzheimer’s disease and other dementias are at least three times greater, with this differential rising with age (Finkelstein, Prabhu and Chen, 2007). A study in Western Australia comparing two MHUOPs, reported a total of 139 falls in a 12 month period, with patients admitted to one of these units sustaining more falls per 1,000 bed days than patients admitted to any other clinical specialty at the tertiary hospital (Heslop et al. 2012).

The literature identifies a range of fall risk factors for hospitalised patients, a number of which have already been highlighted in the introduction to this update (Safety and Quality Council of Australia, 2005). These include patient intrinsic risk factors such as, a previous fall, postural instability and hypotension, muscle weakness, cognitive impairment, delirium, urinary frequency or incontinence, effects of medication, and visual impairment. A number of extrinsic risk factors have also been identified and include environmental factors and the time of day.

While many of the above mentioned risk factors are relevant for assessing falls risk in older people in hospital, there remains a limited understanding of the full range of mental health-specific falls risk factors for inpatients in MHUOPs (Heslop et al 2012).

Standardised falls risk assessment tools are used widely in healthcare settings. The Falls Risk Assessment and Management Plan (Australia. Clinical Excellence Commission NSW, 2014) details interventions to manage risk factors and is mandated for use in NSW. The tool includes strategies for increasing supervision of patients during busy times of the day, consistently and regularly reorientating patients to the environment, and providing appropriate mobility aids.  However. The Falls Risk Assessment and Management Plan does not include the known specific risk factors for older adults who have a mental illness or disorder (Heslop et al. 2012).

Many hospitals use a single instrument throughout all hospital units, but these have not been validated in psychiatric settings (Rutledge, Donaldson and Pravikoff, 2003). Inpatient psychiatric patients have unique risk factors for falling associated with the ambulatory nature of the psychiatric setting, which are compounded by other factors such as medications, anxiety and agitation, poor judgement, sleep deprivation and under-nutrition. For these reasons, a falls risk assessment targeting inpatient psychiatric patients is justified. The Edmonson Psychiatric Fall Risk Assessment Tool [EFRPAT] (Edmonson, Robinson and Hughes, 2011) is one such instrument. The EPFRAT includes higher weightings for factors such as sleep disturbance, recent increases in medication and under-nutrition, thus making it more predictive of falls in the acutely-ill psychiatric population, compared to other tools in common use. The tool however has not yet been applied to Australian MHUOPs.

Furthermore, Bunn et al. (2014) has reviewed the effectiveness of fall prevention interventions for older people with mental health problems across all setting however, the evidence relating to fall reduction was inconsistent.

Of the papers examined for this update, eight of the 14 studies identified a reduction in the number of fallers. Nine of the 14 studies reported a significant reduction in rate of number of falls. Four studies found a non-significant increase in falls. Multifactorial, multidisciplinary interventions and those involving exercise, medication review and increasing staff awareness appear to reduce the risk of falls, but the evidence is mixed and the study quality varied. Most of the studies were undertaken in nursing and residential homes and not in MHUOPs. Changes to the environment such as increased supervision or sensory stimulation to reduce agitation may be promising for people with dementia, but further evaluation is needed on an ongoing basis in all units providing treatment to older people living with mental illness. In a mental health hospital setting, increased staff awareness, monitoring and supervision of patients is known to produce a reduction in falls (Savage and Matheis-Kraft, 2001).

A Cochrane collaboration systematic review of interventions for preventing falls in older people in care facilities and hospitals (Cameron et al. 2012) found evidence that Vitamin D supplementation and exercise in subacute hospital setting appear to be effective in reducing the rate of falls. There is also evidence that multifactorial interventions reduce falls in hospitals. Multifactorial intervention to prevent falls and fall-related injury may typically include: exercise, increased supervision, safe wandering areas, patient education, sensory interventions (vision and hearing), safe footwear, safe flooring, medication review and staff education.





Conclusion
There is a dearth of falls research in mental health settings for the older person, or which focus on patients with mental health problems despite the high number of falls experienced by this population group (Bunn et al. 2014).
Patients admitted to MHUOPs are automatically at high risk of falls from the moment of their admission; they have unique risk factors for falling created by the ambulatory nature of the psychiatric setting, in conjunction with other factors such as the environment and other patients, medications, the postictal effects of electro convulsive therapy (ECT), anxiety and agitation, depression, psychosis, poor judgement, sleep deprivation and under-nutrition (Edmonson, robinson and Hughes, 2011; Bunn et al. 2014).

This review highlights that there is little evidence to support the use of single interventions in reducing the rate of falls in MHUOPs, although Vitamin D supplementation and exercise may have some utility.

Recommendations
The following recommendations have arisen from the literature review conducted for this update:
• Multifactorial individualised interventions based on the findings specific and comprehensive assessment tools should be tailored to the unique needs of the population;
• Increased attention should be given to problems with sleep disturbance and under-nutrition as part of falls assessments;
• Thorough clinical care planning and reassessment should occur upon change of condition, change of location, or following a fall and;
• Close supervision is vitally important in the prevention of falls in the ambulant population – in particular including at least hourly rounds when patients are resting or asleep.

About the Authors
Bryan McMinn is Clinical Nurse Consultant, Specialist Mental Health Service for Older People, Hunter New England Local Health District, Calvary Mater Hospital, NSW (RN, CMHN, BSc., MNURS.(NP), FACMHN)
Amy Booth is Clinical Nurse Specialist, Specialist Mental Health Service for Older People, Hunter New England Local Health District, Calvary Mater Hospital, NSW (BNurs., Grad Cert Dual Dgn. MMHNsg.)
Elizabeth Grist is Executive Director of Clinical Services, Nursing and Midwifery, Hunter New England Local Health District, NSW (BNurs., Grad Cert HSMgt., Grad Dip Midwifery, MN {Mental Health})
Anthony O’Brien is Professor, Head of Discipline (Nursing), School of Nursing and Midwifery, University of Newcastle, NSW, (RN, PhD, BA, Master Ed.Studies)


References
Australia. Clinical Excellence Commission NSW, 2014. Falls Risk Assessment and Management Plan.

Australia. NSW Health, 2011. Falls – Prevention of Falls and Harm from Falls among Older People; 2011-2015. Sydney: Ministry of Health, NSW.

Australia. Specialist Mental Health Services for Older People (SMHSOP), 2012 Acute Inpatient Unit Model of Care Project Report. North Ryde: NSW Ministry of Health.

Blair, E., and C. Gruman, 2005. Fall in an Inpatient Geriatric Psychiatric Population. Journal of the American Psychiatric Nurses Association 11(6):351-354, doi:10,1177/1078390305284659.

Brassington, G.S., A.C. King, and D.L. Bliwise, 2000. Sleep Problems as a Risk Factors for Falls in a Sample of Community-Dwelling Adults Aged 64-99 years. Journal of the American Geriatrics Society. 48(10):1234-1240. doi: 10,1111/j.1532-5415.2000.tb02596x

Bunn, F., A. Dickinson, C. Simpson, V. Narayanan, D. Humphrey, C. Griffiths, W. Martin, and C. Victor, 2014. Preventing falls among older people with mental health problems; a systematic review. BMC Nursing. 13(1):1-15. doi: 10.1186/1472-6955-13-4.

Cameron, I.D., L.D. Gillespie, M.C. Robertson, G.R. Murray, K.D. Hill, R.G. Cumming and N. Kerse, 2102. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane database of systematic Reviews. 12. Art. No.: CD005465. doi: 10.1002/14651858.CD005465.pub3.

de Carle, A.J., and R. Kohn, 2001. Risk factors for falling in a psychogeriatric unit. International Journal of Geriatric Psychiatry 16(8):762-767. doi: 10.1002/gps.407.

Donald, I.P., L. Pitt, E. Armstrong and H. Shuttleworth, 2000. Preventing falls on an elderly care rehabilitation ward. Clinical Rehabilitation 14(2):178-185. Doi: 10.1191/026921500677888641.

Edelstein, B. A., and S. A. Brown, 2000. Falls among Psychogeriatric Patients. Clinical Gerontologist 21(4):3-17. Doi: 10.1300/J018v21n04_02.

Edmonson, D., S. Robinson and L. Hughes, 2011. Development of the Edmonson psychiatric fall risk assessment tool. Jounrla of Psychosocial Nursing and Mental Health Services 49(2):29-36.

Eriksson, S., S. Standberg, Y. Gustafson. And L. Lundin-Olsson, 2009. Circumstances surrounding falls in patients with dementia in a psychogeriatric ward. Archives of Gertonology and Geriatrics 49(1):80-87. http://dx.doi.org/10.1016/j.archger.2008.05.005.

Evans, D., B. Hodgkinson, L. Lambert, J. Wood, and I. Kowanko, 1998. Falls in acute hospitals: a systematic review. In conjunction with the Royal Adelaide Hospital, The Joanna Briggs Institute for Evidence Based Nursing and Midwifery Vol. 1. Adelaide, South Australia: Citesser.

Finkelstein, E., M. Prabhu, and H. Chen, 2007. Increased prevalence of falls among elderly individuals with mental health and substance abuse conditions. The American Journal of Geriatric Psychiatry 15(7):611-619. http://dx.doi.org/10.1098/JGP.0b013e318033ed97

Fossey, J., C. Ballard, E. Juszczak, I. James, N. Alder, R. Jacoby, and R. Howard, 2006. Effect of enhanced psychosocial use in nursing home residents with severe dementia: cluster randomised trial. BMJ. 332(7544):756-761. Doi: 10.1136/bmj.38782.57868.7C.

Greene, E., C.J. Cunningham, A. Eustance, N. Kidd. A.W Clare, and B.A. Lawlor, 2001. Recurrent falls are associated with increased length of stay in elderly psychiatric inpatients. International Journal of Geriatric Psychiatry 16(10):965-968. Doi: 10.1002/gps.463

Harlein, J., T. Dassen, R.J.G. Halfens and C. Heinze, 2009. Falls risk factors In older people with dementia or cognitive impairment: a systematic review. Journal of Advanced Nursing. 65(5):922-933. Doi: 10.111/j.1365-2648.2008.04950.x.

Healey, F., 1994. Does flooring type affects risk of injury in older inpatients? Nursing Times 90(27):40-41.

Heslop, K., D. Wynaden, K. Bramanis, C. Connolly, T. Gee, R. Griffiths and O. A; Omari, 2012. Assessing falls risk in older adult mental health patients: A Western Australian review., International Journal of Mental Health Nursing 21(6):567-575. Doi: 10.1192/bjp.bp.106.023671.

Knight, M., and C. Coakley, 2010. Fall Risk in Patients with Acute Psychosis. Journal of Nursing Care Quakity 25(3):208-215. Doi: 10.1097/NCQ.0b013e3181d3766f.

Kuchynka, J., L Kaser, and A. Wettstein. 2004. Can falls in nursing homes be avoided? Praxis. 93(37):1503-1508. Doi: 10.1024/0369-8394.93.37.1503.