Falls prevention and mental health for inpatients

Falls prevention information related to inpatients with a primary or secondary mental health diagnosis

All adults admitted to mental health inpatient units need to be risk assessed for falls. If a risk of falls is identified, individualised multifactorial intervention strategies must be put in place to minimise the risk of falls.

Falls risk assessments should not be considered as a one off assessment. Inpatients should be reassessed:

• on admission
• on transfer
• directly after a fall
• on medical condition improvement or decline
• as regularly as per local health service guidelines.

Points to consider

• The most common diagnoses within mental health populations which require hospital admission are:
  • mental illness such as depression, mania, anxiety and psychosis
  • behavioural disturbances associated with dementia
  • deliriums associated with physical co-morbidities.
• 60 to 80 per cent of falls occur in patients who have cognitive decline (+/- a co-occurring mental illness).¹
• Most inpatients are ambulant.  As most falls occur in areas of the ward with low staff presence such as corridors, courtyards and dayrooms ^2,4 80 to 90 per cent, falls are unwitnessed ³ – Vigilance or surveillance is the most effective way to decrease falls risk in the mental health setting.
• Inpatients with a mental illness are at a high risk of falling both in the acute phase of their illness and when they improve and become a patient gets well and becomes more independent with their activities of daily living.
• The primary aim of the inpatient stay is to treat the mental illness – unfortunately, this primary treatment may increase the risk of falling. Therefore the falls risk benefit must be considered by the treating team, see Medication section below.
• Treatments may include the use of high dose anti-psychotic and/or sedatives to minimise harm to self or others (minimise aggression) and/or electroconvulsive therapy (ECT) to treat severe depression or mania which are all associated with increased falls risk.

Medication

• The most commonly prescribed medication groups are:
  • antipsychotics
  • antidepressants
  • mood stabilisers
  • benzodiazepines.
• Medication reduction/cessation may not be possible if therapeutic levels need to be maintained for treatment of the mental illness, however, adequate medication review should be considered to include impact of falls prevention.
• Management of side effects that impact on balance and gait and increase falls risk, should be considered.

Delirium

• Consider:
  • increasing surveillance as this is the most effective way to reduce risk of falls
  • positioning patient in close proximity to nurses station
  • completing urine analysis/midstream specimen of urine
  • reviewing and taking regular physical vital signs
  • adequate hydration/nutrition status-consider referral to dietician as needed.

Refer to the Falls Prevention Model of Care (PDF 1.31MB) for more information.

References

• Harlein, J., et al. (2009). "Fall risk factors in older people with dementia or cognitive impairment: a systematic review." J Adv Nurs 65 (5): 922-933.
• Heslop, K., et al. (2012). "Assessing falls risk in older adult mental health patients: a Western Australian review." Int J Ment Health Nurs 21 (6): 567-575.
• Johnson, M., et al. (2011). "Analysis of falls incidents: Nurse and patient preventive behaviours." Int J Nurs Pract 17 (1): 60-66. 
• Vassallo, M., et al. (2000). "Falls on integrated medical wards." Gerontology 46 (3): 158-162.