Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population

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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).

/>1322-7696/© 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.

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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.

1. 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.

2. 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.

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(3) Formulate multi-disciplinary assessment and management strategies to reduce falls risk in this older adult

population.

3. 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 min
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.

4. 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’’.

3

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] do things
with them when they are most functional and do 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

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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 do [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 do 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 do 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).

5. 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

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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.

5

6. 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.

7. 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.

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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),
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