Factors associated with risk of falling among younger inpatients in a mental health setting-A systematic review

AIM

To synthesise evidence related to risk factors of falls among younger mental health inpatients age ≤65 years old.

BACKGROUND

Hospitalised patients with mental illness are at increased risk of falling. Specific risk factors for falls for younger inpatients are poorly understood.

DESIGN

Systematic review.

METHODS

Medline, CINAHL, APA PsycINFO, Scopus and Web of Science were searched for studies published in English till December 2022. The review followed the 2020 PRISMA checklist. Odds ratios and P values of significant risk fall factors and the frequency of factors related to circumstances of falls were extracted.

RESULTS

Nine studies were included and 95 risk factors, across seven categories were extracted. These categories included socio-demographic, fall-related factors, functional status, health and mental status, psychiatric diagnosis and assessment, medication, and staff related factors. Factors related to medication, health and mental status are most reported. Majority of the patients sustained minor or no injury from the fall and circumstances of fall vary across studies.

CONCLUSION

Factors strongly associated with risk of falls were dizziness, use of psychotropics and antihypertensive drugs. A meta-analysis of risk factors was not possible due to different dependent variables studied, controlled confounding variables and control groups used.

RELEVANCE TO CLINICAL PRACTICE

Fall prevention is relevant to all patients in mental health settings. Approaches to fall risk assessment and management need to be better tailored to younger mental health patients in the psychiatric setting.

PATIENT AND PUBLIC CONTRIBUTION

Patient or public contribution was not possible because of the study design.

Clinical Characteristics and Outcomes of Inpatient Falls During Inpatient Rehabilitation: A Case-Control Study

ABSTRACT

Inpatient falls have a significant impact on the outcomes of older patients during inpatient rehabilitation. A retrospective case-control study was conducted using data of 7066 adults aged 55 yrs or older to evaluate significant predictors of inpatient falls during inpatient rehabilitation and the association of inpatient falls with discharge destination and length of stay. A stepwise logistic regression was used to model odds of inpatient falls and home discharge with demographic and clinical characteristic variables and a multivariate linear regression to evaluate the association between inpatient falls and length of stay.Nine hundred thirty-one of 7066 patients (13.18%) had inpatient falls during inpatient rehabilitation. The group with inpatient falls had longer length of stay (14.22 ± 7.82 vs. 11.85 ± 5.33 days, P < 0.0001) and a decreased proportion of home discharges when compared with the group without inpatient falls. There were increased odds of inpatient falls among patients with diagnoses of head injury, other injuries, a history of falls, dementia, a divorced marital status, and a use of laxatives or anticonvulsants. Inpatient falls were associated with an increased length of stay (coefficient = 1.62, confidence interval = 1.19-2.06) and decreased odds of home discharge (odds ratio = 0.79, confidence interval = 0.65-0.96) after inpatient rehabilitation. This knowledge may be incorporated into strategies for reducing inpatient falls during inpatient rehabilitation.

Management of use of urinary antimuscarinics and alpha blockers for benign prostatic hyperplasia in older adults at risk of falls: a clinical review

PURPOSE

We aimed to outline the existing information and the underlying mechanisms of risk of falls associated with the use of urinary antimuscarinics for overactive bladder (OAB) or alpha-blockers for benign prostatic hyperplasia (BPH) in older adults. In addition, we aimed to provide assistance to clinicians in decision-making about (de-)prescribing these drugs in older adults.

METHODOLOGY

Based on a literature search in PubMed and Google Scholar, we reviewed the literature, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in OAB and BPH in older patients. We discussed the use of bladder antimuscarinics and alpha-blockers, their potential side effects related to falls, and the deprescribing of these drugs in older adults.

RESULTS

Urinary urgency or incontinence and lower urinary tract symptoms due to untreated OAB and BPH contribute to fall risk. On the other hand, the use of bladder antimuscarinics and alpha-blockers is also related to fall risk. They contribute to (or cause) falling through dizziness, somnolence, visual impairment, and orthostatic hypotension while they differ in their side-effect profiles regarding these problems. Falls are common and can cause a remarkable amount of morbidity and mortality. Thus, preventive measures should be taken to lower the risk. If the clinical condition allows, withdrawal of bladder antimuscarinics and alpha-blockers is recommended in fall-prone older adults. There are practical resources and algorithms that guide and assist clinicians in deprescribing these drug groups.

CONCLUSIONS

The decision to prescribe or deprescribe these treatments in patients at high risk of falls should be individualized. In addition to explicit tools that are helpful for clinical decision-making in (de-)prescribing these drugs, STOPPFall (a recently developed expert-based decision aid specifically aiming to prevent falls) is present to assist prescribers in attaining decisions.

Patient Falls in Seclusion Rooms in Psychiatric Inpatient Care: A Sociotechnical Probabilistic Risk Modeling Study

BACKGROUND

Patient falls are a major adverse event in psychiatric inpatient care.

PURPOSE

To model the risk for patient falls in seclusion rooms in psychiatric inpatient care.

METHODS

Sociotechnical probabilistic risk assessment (ST-PRA) was used to model the risk for falls. Data sources were the research team, literature review, and exploration groups of psychiatric nurses. Data were analyzed with fault tree analysis.

RESULTS

The risk for a patient fall in a seclusion room was 1.8%. Critical paths included diagnosis of a psychiatric disorder, the mechanism of falls, failure to assess and prevent falls, and psychological or physical reason. The most significant individual risk factor for falls was diagnosis of schizophrenia.

CONCLUSIONS

Falls that occur in seclusion events are associated with physical and psychological risk factors. Therefore, risk assessment methods and fall prevention interventions considering patient behavioral disturbance and physiological risk factors in seclusion are warranted.

Falls in community-dwelling women with bipolar disorder: a case-control study

BACKGROUND

Falls are a common occurrence in psychiatric hospital settings, however population-based research among individuals with psychiatric disorders, in particular bipolar disorder (BD) is scant. Thus, we aimed to investigate falls risk in community-dwelling women diagnosed with BD.

METHODS

Women with BD (cases, n = 119) were recruited from health care settings located in southeast Victoria, Australia. Age-matched controls (n = 357, ratio 3:1) without BD were participants in the Geelong Osteoporosis Study drawn from the same geographical region. Lifetime history of BD was identified by semi-structured clinical interview (SCID-IV/NP). Previous 12-month falls data were obtained via questionnaire. Information on mobility, alcohol use, general health, medication use, blood pressure, body mass index, socioeconomic status and use of a walking aid was collected. Generalised Estimating Equations, binary and ordinal logistic regression were used to determine the odds ratio (OR) and 95% confidence interval (CI) for falls following adjustment for confounders.

RESULTS

During the 12-month period, 34 (28.6%, median age 48.4 yr) cases and 70 (19.6%, median age 49.1 yr) controls reported one fall; 22 (18.5%) cases and 18 (5.0%) controls reported ≥ two falls (p < 0.001). Cases had 2.5-fold increased odds of at least one fall and 2.9-fold increased likelihood of increasing falls categories (0 vs. 1 vs. 2 +), compared to controls [adjOR 2.5, 95%CI (1.8, 3.4), adjOR OR 2.9, 95%CI (2.0, 4.1)].

CONCLUSION

Risk of falls was greater among women with BD. Balance training could be a research and clinical focus for falls prevention programs among women with bipolar disorder to prevent the detrimental outcomes associated with falling.

Staffing and patient-related factors affecting inpatient falls in a psychiatric hospital: a 5-year retrospective matched case–control study

Background

The frequency and severity of falls of psychiatric inpatients in Thailand have not been previously reported. Also, the risk factors of falls have been numerous and complicated. This study aimed to investigate the staffing factors and patient-related factors that increase the likelihood of falls among psychiatric inpatients.

Methods

A five-year retrospective matched case–control study was conducted that selected cases of inpatients who fell and which were reported to the hospital risk management system. Subjects were compared to two control patients from the same hospital (1:2) by age (± 5 years), sex, and admission the same year. The total sample consisted of 240 patients. Univariate and multivariate conditional logistic regression was used to analyze the data.

Results

Of the eighty falls, 86.3% resulted in temporary harm and required intervention. The multivariate model showed that three patient-related factors were associated with increased inpatient falls: (1) having an acute psychotic condition (adjusted odds ratio (AOR) = 4.34; 95% CI 1.45, 13.05; p < 0.05), (2) polypharmacy with more than four types of medicines (AOR = 3.06; 95% CI 1.59, 5.88; p < 0.05), and (3) taking atypical psychiatric drugs (AOR = 2.74; 95% CI 1.35, 5.58; p < 0.05). Staffing for 26–50 patients in the wards was more protective for falls than with 25 or fewer patients (AOR = .17; 95% CI 0.04, 0.72; p < 0.05).

Conclusions

The risk factors found may help assess fall risk and manage the number of patients in psychiatric units. Drug dosage and drug interaction of antipsychotic drugs and cardiovascular agents with other medications and drug administration timing before falls are recommended for further investigation. Also, staff ratio per patient and the proportion of staff mix in psychiatric units need further study to establish adequate levels of surveillance to prevent inpatient falls.

Patient Falls and Injuries in U.S. Psychiatric Care: Incidence and Trends

OBJECTIVE

The goal of this study was to estimate the incidence of falls (total, injurious, and assisted) in U.S. psychiatric care across 6 years (April 2013-March 2019).

METHODS

Data on falls among patients of adult and geriatric psychiatric units of general, acute care, and psychiatric hospital inpatient units from the National Database of Nursing Quality Indicators were used for this 6-year study. Total falls, assisted falls (i.e., falls broken or slowed by staff), and injurious falls were calculated, along with trends in total and injurious fall rates.

RESULTS

The sample included 1,159 units in 720 hospitals. Of the 119,246 falls reported, 25,807 (21.6%) resulted in injury. Only 7.0% of the total falls in psychiatric units were assisted by a staff member. Falling unassisted was associated with a higher likelihood of fall-related injury (adjusted odds ratio=1.69, 95% confidence interval=1.59 to 1.80). The total fall rate (8.55 per 1,000 patient-days) and injurious fall rate (1.97 per 1,000 patient-days) were highest for geriatric psychiatric units in general hospitals. Total and injurious fall rates in psychiatric units in general hospitals declined during the study (total fall rate declined by 10% for adult psychiatric units in general hospitals). There was no clear trend in total or injurious fall rates for units in psychiatric hospitals.

CONCLUSIONS

Falls are a persistent problem in psychiatric care settings. Few fall-prevention programs have been tested in these settings, which have unique risk factors for falls. Additional research is needed to develop fall-prevention interventions in psychiatric care.

Understanding the effects of chronic benzodiazepine use in depression: a focus on neuropharmacology

Benzodiazepines are frequently prescribed on an ongoing basis to individuals with depression, mainly to alleviate anxiety or insomnia, despite current guideline recommendations that continuous use should not exceed 4 weeks. Currently, there are no efficacy trials published beyond 8 weeks. Several antidepressant trials demonstrate that the concomitant use of a benzodiazepine is associated with poorer depressive outcomes and functional status; however, it is unclear why this is the case. Patients with depression receiving a benzodiazepine may reflect a more ill or high anxiety group, although even within anxiety disorders, the use of a benzodiazepine is associated with poorer outcomes. The neuroadaptive consequences of long-term benzodiazepine use may be a factor underlying these findings. Chronic benzodiazepine use results in decreased gamma-aminobutyric acid and monoaminergic function, as well as interference with neurogenesis, which are all purported to play a role in antidepressant efficacy. This review will discuss the oppositional neuropharmacological interactions between chronic benzodiazepine use and antidepressant mechanism of action, which could result in reduced antidepressant efficacy and function in depression.

Add-on benzodiazepines for psychosis-induced aggression

In severely psychotic, violent patients, add-on benzodiazepines are often prescribed with antipsychotic agents. We examined aggression, suicidality, and self-harm among psychotic patients treated with antipsychotic monotherapy, compared with those treated with add-on benzodiazepines, during the first 2 weeks of psychiatric hospitalization to clarify the association of add-on benzodiazepines and aggression. Electronic medical records of 400 patients consecutively admitted to Abarbanel Mental Health Center from 2012 to 2014 for psychosis, and remained hospitalized for at least 2 weeks were evaluated. Violence toward staff, patients, and property, physical restraints, seclusion, self-harm, and suicidal thoughts, were examined. Falls and referrals to general hospital indicated adverse medication effects, and were recorded. No significant between-group differences were found for sex, age, psychiatric diagnosis, compulsory admissions, antipsychotic dosages, number of previous hospitalizations, or hospitalization days were detected. Maximum dosage for antipsychotics in the monotherapy group did not reveal a statistically significant difference from the add-on benzodiazepine group (2.2 ± 1.4 vs. 2.2 ± 1.3, respectively), expressed in defined daily dose. There were no between-group differences in frequency of any violent event, incidence of self-harm, suicidal thoughts, frequency of falls, and/or referrals to a general hospital. Addition of benzodiazepines might be unnecessary. Benzodiazepine addition to antipsychotic drugs for patients with severe psychosis should be with caution.

Geriatric Polypharmacy: Pharmacist as Key Facilitator in Assessing for Falls Risk: 2019 Update

This article highlights the significant health impact of falls among older adults. An emphasis is placed on the vital role of the pharmacist, regardless of practice setting, in assessing and reducing falls risk for this growing population. In addition, the importance of a stepwise comprehensive approach to falls assessment by pharmacists in collaboration with other clinicians is elucidated.

Understanding Design Vulnerabilities in the Physical Environment Relating to Patient Fall Patterns in a Psychiatric Hospital: Seven Years of Sentinel Events

BACKGROUND

The influence of the physical environment on patient falls has not been fully explored in psychiatric units, despite this patient population's vulnerability and the critical role of the physical environment in patient safety.

AIMS

The research objective is to describe the spatial and temporal pattern of falls occurrences and their location in relation to the levels of safety continuum model.

METHOD

This article presents an exploratory case study design. Seven years of retrospective data on patient falls, yielding 818 sentinel events, in an 81-bed psychiatric hospital in the United States were collected and analyzed. Data focused on extrinsic factors for falls, emphasizing the physical environment. Through a content analysis of the sentinel event narratives, recorded by the hospital staff, this study explored patient falls related to location and elements of the physical environment.

RESULTS

The analysis revealed that 15% of recorded falls were attributed to some aspect of or element within the physical environment. The most typical locations of falls were patient rooms (39%), patient bathrooms (22%), and dayrooms (20%). Also, the results identified patterns of environmental factors that appeared linked to increasing patients' susceptibility to falls. Risk factors included poor nighttime lighting, flooring surfaces that were uneven, and spaces that inadvertently limited visual access and supervision.

CONCLUSIONS

The physical environment plays an often-unexamined role in fall events and specific locations. These results are deserving of further research on design strategies and applications to reduce patient falls in psychiatric hospital settings.

Falls in Older Patients with Cancer Undergoing Surgery: Prevalence and Association with Geriatric Syndromes and Levels of Disability Assessed in Preoperative Evaluation

Falls are common among older adults. However, not much is known about the prevalence of falls among older patients with cancer. In 2015, older patients with cancer referred to Geriatrics service for preoperative evaluation were assessed for fall history, basic and instrumental activities of daily living (ADL and IADL), KPS, and use of assistive device. Of 806 patients, 215 (26.7%) patients reported fall. Incidence of last fall inside and outside home was 54.4% and 45.5%, respectively. Among patients with no falls, 33.6% had KPS ≤ 80 compared to 59.6% with one-time fall and 60.7% with multiple falls (p < 0.001). Among IADL, 8.5% of patients with no falls were unable to do shopping compared with 14.7% in one-time fall and 18.8% in multiple fallers (p < 0.001). In ADL items, the percentage of patients who were limited a lot in walking outside was 10.7% in no falls, 20.2% in one-time fall, and 27.1% in multiple fallers groups (p < 0.001). Only 17.8% of patients with no falls were using canes while 27.7% of patients with one-time fall and 38.8% with multiple falls were using canes (p < 0.001). Falls are prevalent among older patients with cancer. Fall history and number of falls are associated with functional status.

Effects of chair yoga therapy on physical fitness in patients with psychiatric disorders: A 12-week single-blind randomized controlled trial

INTRODUCTION

Since falls may lead to fractures and have serious, potentially fatal outcomes, prevention of falls is an urgent public health issue. We examined the effects of chair yoga therapy on physical fitness among psychiatric patients in order to reduce the risk of falls, which has not been previously reported in the literature.

METHODS

In this 12-week single-blind randomized controlled trial with a 6-week follow-up, inpatients with mixed psychiatric diagnoses were randomly assigned to either chair yoga therapy in addition to ongoing treatment, or treatment-as-usual. Chair yoga therapy was conducted as twice-weekly 20-min sessions over 12 weeks. Assessments included anteflexion in sitting, degree of muscle strength, and Modified Falls Efficacy Scale (MFES) as well as QOL, psychopathology and functioning.

RESULTS

Fifty-six inpatients participated in this study (36 men; mean ± SD age, 55.3 ± 13.7 years; schizophrenia 87.5%). In the chair yoga group, significant improvements were observed in flexibility, hand-grip, lower limb muscle endurance, and MFES at week 12 (mean ± SD: 55.1 ± 16.6 to 67.2 ± 14.0 cm, 23.6 ± 10.6 to 26.8 ± 9.7 kg, 4.9 ± 4.0 to 7.0 ± 3.9 kg, and 114.9 ± 29.2 to 134.1 ± 11.6, respectively). Additionally, these improvements were observable six weeks after the intervention was over. The QOL-VAS improved in the intervention group while no differences were noted in psychopathology and functioning between the groups. The intervention appeared to be highly tolerable without any notable adverse effects.

CONCLUSIONS

The results indicated sustainable effects of 20-min, 12-week, 24-session chair yoga therapy on physical fitness. Chair yoga therapy may contribute to reduce the risk of falls and their unwanted consequences in psychiatric patients.

Managing Patient Falls in Psychiatric Inpatient Units: Part 2

Patient falls in the hospital psychiatric inpatient units are more frequent than in the medical-surgical units. The purpose of this study was to explore psychiatric unit directors' perceptions of the factors that contribute to patient falls in the State of Michigan. A quantitative online questionnaire was sent to the directors of psychiatric units in Michigan. Two research questions (RQs) guided the study: (a) What are psychiatric unit directors' perceptions of the possible intrinsic factors that contribute to patient falls in the psychiatric inpatient units, and (b) what are psychiatric unit directors' perceptions of the possible extrinsic factors that contribute to patient falls in the psychiatric inpatient units? In comparing the results, 6 of the 7 factors with the highest mean levels of agreement were intrinsic factors. In the current study, patient gait (mean, 4.65) ranked first, history of falls (mean, 4.52) second, and multiple medications (mean, 4.50) third as fall-risk factors. The need for the involvement of the team members (mean, 4.55) in preventing falls was the most highly rated factor among the extrinsic factors. Educating unit team members in assisting with fall prevention is a critical consideration for leaders.

Geriatric Polypharmacy: Pharmacist as Key Facilitator in Assessing for Falls Risk

This article highlights the significant health impact of falls among older adults. An emphasis is placed on the vital role of the pharmacist, regardless of practice setting, in assessing and reducing falls risk for this growing population. In addition, the importance of a stepwise comprehensive approach to falls assessment by pharmacists in collaboration with other clinicians is elucidated.

Unintentional Injuries among Psychiatric Outpatients with Major Depressive Disorder

Background

No study has investigated the percentages of and factors related to unintentional injuries among psychiatric outpatients with major depressive disorder (MDD). This study aimed to investigate these issues.

Methods

One-hundred and forty-one outpatients with MDD at baseline were enrolled from psychiatric outpatients by systematic sampling, and 119 subjects attended a one-year follow-up. Self-reported unintentional injuries in the past one year were recorded. Psychiatric disorders were diagnosed using the Structured Clinical Interview for DSM-IV-TR. The severity of depression was evaluated by the Hamilton Depression Rating Scale. Other data, including body weight and height, cigarette smoking, headaches, and medications, were collected. Generalized Estimating Equations were used to investigate independent factors related to unintentional injuries.

Results

At baseline and follow-up, 40.4% and 27.7% of subjects had experienced at least one unintentional injury in the past one year, respectively. About half of subjects with unintentional injuries needed medical treatment for injuries and had functional impairment due to injuries. A greater severity of depression, cigarette smoking, a higher body mass index, and an older age were independent risk factors related to unintentional injuries.

Conclusion

Unintentional injuries that increased the medical burden and functional impairment were common among outpatients with MDD and should not be neglected. Treatment of depression, control of body weight, and quitting cigarettes might be helpful to prevent unintentional injuries.

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

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 and aged care settings, the findings are relevant to the assessment and management of falls risk across all health care settings.

Impact of falls on mental health outcomes for older adult mental health patients: An Australian study

Sustaining a fall during hospitalization reduces a patient's ability to return home following discharge. It is well accepted that factors, such as alteration in balance, functional mobility, muscle strength, and fear of falling, are all factors that impact on the quality of life of elderly people following a fall. However, the impact that falls have on mental health outcomes in older adult mental health patients remains unexplored. The present study reports Health of the Nation Outcome Scale scores for people over the age of 65 (HoNOS65+), which were examined in a cohort of 65 patients who sustained a fall and 73 non-fallers admitted to an older adult mental health service (OAMHS). Results were compared with state and national HoNOS65+ data recorded in Australian National Outcome Casemix Collection data to explore the effect that sustaining a fall while hospitalized has on mental health outcomes. Australian state and national HoNOS65+ data indicate that older adults generally experience improved HoNOS65+ scores from admission to discharge. Mental health outcomes for patients who sustained a fall while admitted to an OAMHS did not follow this trend. Sustaining a fall while admitted to an OAMHS negatively affects discharge mental health outcomes.

Correlates of benzodiazepine use in major depressive disorder: The effect of anhedonia

BACKGROUND

Current treatment guidelines emphasize the limited role of benzodiazepines in Major Depressive Disorder (MDD), mainly due to the absence of long-term data, risk of abuse and potential adverse effects. However, benzodiazepines continue to be prescribed for long-term use in a significant number of patients. This study sought to evaluate benzodiazepine use in a large sample of MDD patients seen at a tertiary care clinic, and determine whether use is related to illness severity or complexity, as well as to identify the clinical predictors of benzodiazepine use.

METHODS

This was a naturalistic cross-sectional study conducted in MDD patients seen at the Mood Disorders Pyschopharmacology Unit at the University Health Network (N=326). Detailed information on current medication regimens was collected. A structured diagnostic interview, in addition to measures of symptom severity, quality of life, and personality were administered. Participants were grouped according to the presence or absence of prescribed benzodiazepines for daily use.

RESULTS

The prevalence of regular benzodiazepine use was 25%. Benzodiazepine users were more likely to be female, unemployed, have a history of child abuse, and have comorbid panic disorder. Depression and anxiety scores were not significantly different between groups, although anhedonia was greater in the benzodiazepine group. A logistic regression revealed anhedonia was the strongest predictor of regular benzodiazepine use.

CONCLUSION

The groups were similar in clinical profile suggesting benzodiazepine use is not necessarily linked to greater illness complexity or severity. Benzodiazepine use appears to be associated with specific diagnostic and symptom characteristics, possibly providing insight into the potential pharmacodynamic and neurobiological effects of frequent use.

Comorbid Medical Conditions in Vascular Dementia: A Matched Case-Control Study

The objective of the study was to compare the presence of comorbid medical conditions between patients with a vascular dementia (VaD) and a control group, from the Integrated Healthcare Information Services (IHCIS) database. VaD was defined by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 290.40, 290.4, 290.41, 290.42, and, 290.43. An individual matching method was used to select the controls, which were matched to cases on a 15:1 ratio by age, gender, type of health plan, and pharmacy benefits. Alzheimer's disease, any other dementia or cognitive deficits associated were considered exclusion criteria. Among the IHCIS patients 60 years of age or older and full year of eligibility during 2010, there were 898 VaD patients, from which 63.6% were women. Concurrent presence of cerebrovascular disease, atherosclerosis, heart failure, and atrial fibrillation were found at 12.6, 4.6, 2.8, and 1.7 times higher in VaD patients, respectively. Compared to controls, VaD patients had more septicemia, injuries, lung diseases including chronic obstructive pulmonary disease, and urinary diseases (all with df = 897,1; p < 0.0001). The present study confirms that these four medical comorbidities are frequent complications of VaD and physicians should be alert to the presence of them in patients with VaD.

A qualitative understanding of patient falls in inpatient mental health units

BACKGROUND

Falls are the leading cause of injury-related deaths among people age 65 and older, and fractures are the major category of serious injuries produced by falls.

OBJECTIVE

Determine market segment-specific recommendations for "selling" falls prevention in acute inpatient psychiatry.

DESIGN

Descriptive using focus groups.

SETTING

One inpatient unit at a Veterans' hospital in the Southeastern United States and one national conference of psychiatric and mental health nurses.

PATIENTS

A convenience sample of 22 registered nurses and advanced practice nurses, one physical therapist and two physicians participated in one of six focus groups.

INTERVENTION

None.

MEASUREMENTS

Focus groups were conducted by expert facilitators using a semistructured interview guide. Focus groups were recorded and transcribed. Content analysis was used to organize findings.

RESULTS

Findings were grouped into fall risk assessment, clinical fall risk precautions, programmatic fall prevention, and "selling" fall prevention in psychiatry. Participants focused on falls prevention instead of fall injury prevention, were committed to reducing risk, and were receptive to learning how to improve safety. Participants recognized unique features of their patients and care settings that defined risk, and were highly motivated to work with other disciplines to keep patients safe.

CONCLUSIONS

Selling fall injury prevention to staff in psychiatric settings is similar to selling fall injury prevention to staff in other health care settings. Appealing to the larger construct of patient safety will motivate staff in psychiatric settings to implement best practices and customize these to account for unique population needs characteristics.

Treatment-resistant depression in primary care across Canada

OBJECTIVE

Treatment-resistant depression (TRD) represents a considerable global health concern. The goal of the InSight study was to investigate the prevalence of TRD and to evaluate its clinical characterization and management, compared with nonresistant depression, in primary care centres.

METHODS

Physicians completed a case report on a consecutive series of patients with major depressive disorder (n = 1212), which captured patient demographics and comorbidity, as well as current and past medication.

RESULTS

Using failure to respond to at least 2 antidepressants (ADs) from different classes as the definition of TRD, the overall prevalence was 21.7%. There were no differences in prevalence between men and women or among ethnicities. Patients with TRD had longer episode duration, were more likely to receive polypharmacy (for example, psychotropic, lipid-lowering, and antiinflammatory agents), and reported more AD related side effects. Higher rates of disability and comorbidity (axes I to III) were associated with treatment resistance. Obesity and being overweight were also associated with treatment resistance. While the selection and sequencing of pharmacotherapy by family physicians in this sample was in line with recommendations from evidence-based treatment guidelines, the wait time to make a change in treatment was 6 to 8 weeks in both groups, which exceeds guideline recommendations.

CONCLUSIONS

These real-world data demonstrate the high prevalence of TRD in primary care settings, and underscore the substantial burden of illness associated with TRD.

Comorbidity profile and healthcare utilization in elderly patients with serious mental illnesses

OBJECTIVES

Patients with serious mental illness are living longer. Yet, there remain few studies that focus on healthcare utilization and its relationship with comorbidities in these elderly mentally ill patients.

DESIGN

Comparative study. Information on demographics, comorbidities, and healthcare utilization was taken from an electronic medical record system.

SETTING

Wishard Health Services senior care and community mental health clinics.

PARTICIPANTS

Patients age 65 years and older-255 patients with serious mental illness (schizophrenia, major recurrent depression, and bipolar illness) attending a mental health clinic and a representative sample of 533 nondemented patients without serious mental illness attending primary care clinics.

RESULTS

Patients having serious mental illness had significantly higher rates of medical emergency department visits (p = 0.0027) and significantly longer lengths of medical hospitalizations (p <0.0001) than did the primary care control group. The frequency of medical comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, thyroid disease, and cancer was not significantly different between the groups. Hypertension was lower in the mentally ill group (p <0.0001). Reported falls (p <0.0001), diagnoses of substance abuse (p = 0.02), and alcoholism (p = 0.0016) were higher in the seriously mentally ill. The differences in healthcare utilization between the groups remained significant after adjusting for comorbidity levels, lifestyle factors, and attending primary care.

CONCLUSIONS

Our findings of higher rates of emergency care, longer hospitalizations, and increased frequency of falls, substance abuse, and alcoholism suggest that seriously mentally ill older adults remain a vulnerable population requiring an integrated model of healthcare.

Pattern of underreporting falls in a general psychiatric hospital in Japan

PURPOSE

To examine the pattern of underreporting of fall incidents in a general psychiatric hospital in Japan.

DESIGN AND METHODS

All fall incidents were analyzed and stratified by ward.

FINDINGS

A discrepancy in fall rates was found in acute psychiatric and dementia wards. The following indicators were suggestive of underreporting: "zero fall/1,000 patient-days," "proportion of falls without injury," and "proportion of falls identified as occurring in the bedroom as a fall location during certain time periods."

PRACTICE IMPLICATIONS

Ward-specific fall rates, with further stratifications by time and location of the fall, were useful for identifying a pattern of underreporting.

Laxative use and incident falls, fractures and change in bone mineral density in postmenopausal women: results from the Women's Health Initiative

Background

Laxatives are among the most widely used over-the-counter medications in the United States but studies examining their potential hazardous side effects are sparse. Associations between laxative use and risk for fractures and change in bone mineral density [BMD] have not previously been investigated.

Methods

This prospective analysis included 161,808 postmenopausal women (8907 users and 151,497 nonusers of laxatives) enrolled in the WHI Observational Study and Clinical Trials. Women were recruited from October 1, 1993, to December 31, 1998, at 40 clinical centers in the United States and were eligible if they were 50 to 79 years old and were postmenopausal at the time of enrollment. Medication inventories were obtained during in-person interviews at baseline and at the 3-year follow-up visit on everyone. Data on self-reported falls (≥2), fractures (hip and total fractures) were used. BMD was determined at baseline and year 3 at 3 of the 40 clinical centers of the WHI.

Results

Age-adjusted rates of hip fractures and total fractures, but not for falls were similar between laxative users and non-users regardless of duration of laxative use. The multivariate-adjusted hazard ratios for any laxative use were 1.06 (95% confidence interval [CI], 1.03-1.10) for falls, 1.02 (95% CI, 0.85-1.22) for hip fractures and 1.01 (95% CI, 0.96-1.07) for total fractures. The BMD levels did not statistically differ between laxative users and nonusers at any skeletal site after 3-years intake.

Conclusion

These findings support a modest association between laxative use and increase in the risk of falls but not for fractures. Its use did not decrease bone mineral density levels in postmenopausal women. Maintaining physical functioning, and providing adequate treatment of comorbidities that predispose individuals for falls should be considered as first measures to avoid potential negative consequences associated with laxative use.

Risk factors for falling in psychiatric inpatients: a prospective, matched case-control study

Falling is one the most common types of inpatient adverse events. Most fall-related research was conducted retrospectively and focused on elderly population in general hospital settings. This study aimed to timely identify all potential risk factors associated with falls and fall-related injury in a psychiatric inpatient setting. We recruited 145 fall events and 145 sex- and room-matched psychiatric control inpatients without fall in a 1002-bed psychiatric teaching hospital in northern Taiwan. In addition to medical records, the study variables included patient characteristics, circumstances and medications, which were collected from the patients and/or their families within 24 h of receiving reports right after obtaining written informed consent. A psychiatrist and three head nurses conducted a comprehensive assessment of risk factors immediately after falls occurred. A conditional logistic regression model revealed four variables significantly associated with an increased risk of falling: the clinical global impression-severity (adjusted odds ratio (aOR) = 2.19; 95% confidence interval, CI = 1.13-4.24), the parkinsonism scores of the extrapyramidal syndrome rating scale (aOR = 1.14; 95% CI = 1.08-1.21), equivalent dosage of benzodiazepines use (aOR = 1.15; 95% CI = 1.03-1.30), and medication changes within 24 h (aOR = 10.3; 95% CI = 1.37-76.8). Acute settings (aORs = 2.06, 95% CI = 1.01-4.18), a fall history in the past six months and a lack of history of medical problems (aORs = 3.04; 95% CI = 1.46-6.33) were associated with fall-related injury (aOR = 2.70; 95% CI = 1.29-5.69). Our study identified the severity of psychotic symptoms, extrapyramidal symptoms, medications usage and other several specific measures for prevention of falls in psychiatric inpatient settings.

Prevention strategies to reduce falls in psychiatric settings

A Fall Committee was developed in response to an increase in the rate of falls by patients at a primarily behavioral health, urban teaching hospital in the mid-Atlantic region of the United States. The Fall Committee identified interventions to potentially lessen the number of patient falls and areas where documentation could be improved to better describe an incident in the medical record. The Fall Committee developed paperwork to be completed after each patient fall and made changes to the low fall risk and high fall risk treatment plans. This article describes the recommendations submitted by the Fall Committee and its subsequent implementation. Although not causational, the fall rate decreased after the recommendations of the Fall Committee were implemented; however, a recent rise in the fall rate was noted and attributed to higher patient acuity on the unit. The committee investigation into this issue highlighted the paucity of research in this field and the need for a streamlined, easy-to-use, behavioral health fall scale to more accurately judge the fall risk of patients in this specialized subset.

The efficacy and safety of newer anticonvulsants in patients with dementia

Anticonvulsants are a class of medications that have received considerable interest as possible treatments in patients with behavioural disturbances in dementia. The role of these medications for such a use remains controversial. The current paper reviews the published evidence surrounding the safety and efficacy (i.e. as a behavioural and cognitive treatment) of newer anticonvulsants in patients with dementia. A MEDLINE, International Pharmaceutical Abstracts, PsycINFO and clinicaltrials.gov search through to December 2011 was conducted for anticonvulsants that have received regulatory approval since 1996. Studies reporting behavioural or cognitive outcomes in patients with dementia were included. Nine trials involving only four medications met selection criteria and were included: levetiracetam (n = 4), oxcarbazepine (n = 1), topiramate (n = 2) and zonisamide (n = 2). Levetiracetam may have a role in the treatment of behavioural symptoms in dementia but study limitations substantially hinder the strength of such a recommendation. Oxcarbazepine and topiramate, based on limited data, do not appear to be effective treatments of behavioural symptoms in dementia. A lack of trials do not allow for conclusions to be made regarding zonisamide. From a cognitive standpoint, levetiracetam was the anticonvulsant most examined in patients with dementia, it appears to have less deleterious effects than some anticonvulsants. Limited data are available on the safety of these medications in elderly patients; however, studies completed thus far have demonstrated some adverse events that are more common or problematic with the use of these drugs in this patient population (i.e. somnolence, dizziness, hyponatraemia, weight loss).

Mortality and causes of death in older patients with schizophrenia

OBJECTIVE

The aim of this study was to evaluate mortality and causes of death in older patients with schizophrenia in comparison with the general population. The mortality of patients experiencing relapse was also compared with those in remission.

METHODS

The study sample consists of patients (n = 9461) over 65 years by the first of January 1999, with schizophrenia or schizoaffective disorder (ICD-8, ICD-9: 295, ICD-10: F20, F25) as the main register diagnosis during the period 1969-1998. The sample was collected from nationwide registers in Finland and followed up between 1999 and 2008.

RESULTS

Overall Standard Mortality Ratio (SMR) of the older schizophrenia patients was 2.69 [95% confidence interval, 2.62-2.76]. For natural causes of death, overall SMR was 2.58 (2.51-2.65; n = 5301), and for unnatural causes of death, it was 11.04 (9.75-12.47; n = 262). The most common causes of death matched those in the general population. Of patients who died during follow-up, 31% (1709/5596) had at least one psychiatric hospitalization within 5 years before follow-up. The SMR for this group was higher (3.92; 3.73-4.11) than in those patients (2.37; 2.29-2.44) with no such treatment during that time.

CONCLUSION

All-cause mortality of older patients with schizophrenia was almost threefold that of general population. They died for similar reasons to the general population; however, deaths for unnatural causes were especially common (accidents and suicides). Those patients still experiencing relapses in older age have an increased risk of death compared with those with schizophrenia in remission.

Using root cause analysis to reduce falls with injury in the psychiatric unit

OBJECTIVE

The objective was to identify how falls on psychiatric units occur, the underlying root causes and effective action plans to reduce falls and injuries.

METHODS

A search of the Veterans Health Administration National Center for Patient Safety database was conducted to identify root cause analysis (RCA) reviews where a fall was sustained by a patient on a psychiatric unit. Seventy-five RCAs from January 2000 to March 2010 were included.

RESULTS

One hundred and thirty-eight actions were identified from the RCA reports. The most common activities the individual was engaged in during a fall included getting up from a bed, chair or wheelchair (21.3%); walking/running (10.7%); bathroom related (9.9%) or behavior related (9.9%). The most common root causes were environmental hazards (11.2%), poor communication of fall risk (8.9%), lack of suitable equipment (8.9%) and need for improvement of the current system for falls assessment (8.9%). Staff education (19.9%), development of tools to improve falls documentation (17.0%) and providing falls prevention equipment (14.2%) were the most frequent actions taken.

CONCLUSIONS

The results describe the location, activity and root causes surrounding falls that occur in psychiatric units resulting in injury, and provide some suggestions on how to implement a successful action plan.

Assessment of falls in older patients treated with duloxetine: a secondary analysis of a 24-week randomized, placebo-controlled trial

OBJECTIVE

To assess fall events in older depressed patients during treatment with duloxetine.

METHOD

Post hoc analysis of solicited fall events collected at each study visit using a questionnaire during a 24-week, multicenter, randomized, placebo-controlled, double-blind, phase 4 trial (November 2006 to November 2009). Older outpatients (≥ 65 years) with major depressive disorder (DSM-IV criteria) were randomly assigned to duloxetine 60 mg/d (n = 249) or placebo (n = 121) for the 12-week acute phase, after which the duloxetine dose could be increased to 120 mg/d and nonresponding placebo patients could be switched to duloxetine 60 mg/d. Between-treatment differences in percentages of patients with fall events were compared by Fisher exact test. Exposure-adjusted incidence rates (EAIRs) of falls per patient-year were also estimated.

RESULTS

In the acute phase, 17.3% of patients treated with duloxetine 60 mg versus 11.6% treated with placebo (P = .170) experienced a fall event. Over 24 weeks, the percentage of patients with a fall while taking duloxetine 60 mg versus placebo was 24.0% versus 15.7% (P = .078), and the percentage was significantly higher in patients taking duloxetine regardless of dose (25.3%) than with placebo (15.7%, P = .045). Between-treatment differences in EAIRs over 12 weeks (0.26; 95% CI, -0.20 to 0.72) and over 24 weeks (0.27; 95% CI, -0.10 to 0.65) were not significant.

CONCLUSIONS

Direct assessment of fall events greatly increases the number of falls reported by patients. Although the EAIR of falls per patient-year associated with duloxetine was not significant in this trial, clinicians should remain vigilant about the possibility of falls in older patients with duloxetine or any antidepressant treatment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT00406848.

Effectiveness of interventions for the assessment and prevention of falls in adult psychiatric patients: A systematic review

BACKGROUND

Patient fall is among the top five sentinel events in hospitals due to the resultant functional loss and injury sustained. Precise fall risk assessment and prevention strategies are important components of a fall prevention program. Due to psychiatric conditions and medications, these patients may require a different fall management program compared to other patient populations.

OBJECTIVE

The objective of this review was to identify the best available evidence for the effectiveness of nursing fall risk assessment tools, interventions to reduce incidence of falls, and common risk factors of adult psychiatric patients who fall.

INCLUSION CRITERIA

Adults (19 to 64 years) diagnosed with mental illnessEvaluation of nursing fall risk assessment tools in adult psychiatric settings, and interventions, which minimised fall risk or fall rates.Number of patient falls during hospitalisation was the main outcome.Primary quantitative studies published in English language.

SEARCH STRATEGY

The literature search sought published studies, and was limited to English language reports. There were no date restrictions applied to the search. Electronic databases searched included:CINAHLPubMedCochrane Central Register of Controlled TrialsPsycINFOScienceDirectScopusWeb of ScienceWiley-InterScienceProQuestMedNar METHODOLOGICAL QUALITY: Studies retrieved were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI-SUMARI).

DATA EXTRACTION

Data including specific details about the methods, settings, purposes, populations, interventions, and outcomes significant to the review's objectives were extracted by two independent reviewers using standardised data extraction tools from JBI-SUMARI.

RESULTS

Eleven studies were included in this review: three before-and-after studies, four descriptive studies, two case control studies and two cohort studies. Evidence with regards to the effectiveness of fall risk assessment tools and prevention strategies was inconclusive. Certain risk factors which were more frequently associated with falls included diagnoses of depression, bipolar disorder, and dementia / Alzheimer's disease, altered mental status, physiological symptoms, past history of falls, mobility and gait problems, concurrent medical conditions, polypharmacy, and taking of certain medications such as sedatives, antidepressants and mood stabilisers, particularly lithium.

CONCLUSION

Evidence on the effectiveness of fall risk assessment tools and prevention strategies in psychiatric setting was inconclusive due to a paucity of studies. However, certain risk factors were found to be more commonly associated with falls in adult psychiatric patients (Level III Evidence).Constant observation of the side effects of medications, particularly orthostatic hypotension, and review of patients' medical profile by doctors or pharmacists may be helpful in preventing falls in psychiatric patients. Findings on common risk factors can better aid healthcare professionals in identifying psychiatric patients who are at risk for falls.More research is needed on the evaluation of fall risk assessment tools and fall prevention strategies, specifically for the adult psychiatric patients. More prospective and better quality studies examining fall risk factors in psychiatric patients are needed.

Falls in older adult psychiatric patients: equipping nurses with knowledge to make a difference

Falls are the most common cause of accidental death among older adults and are associated with increased morbidity and mortality. A particularly serious sequela of falls is osteoporotic fractures. Older adults with mental illness are at increased risk of both falls and subsequent fractures, because of a range of complex risk factors. Many falls are preventable and an awareness of the risk factors for falls among nurses will empower them to promptly refer a patient at risk to the multidisciplinary team. A multidisciplinary approach is required to be successful in any efforts to reduce an individual's risk of falls and nurses have a central role in achieving this. This article reviews the relevant literature on the causes and consequences of falls in older adults with mental illness in order to enable nurses to reduce falls and subsequent fractures.