The provision of walking aids to the overtly aggressive older adult who is a high risk of falls: a careful balancing act

Older adult psychiatric inpatients may have impaired balance and have an increased risk of falling for many reasons (Pellfolk et al., 2009; Ko et al., 2009). This population may be on psychotropic medication, which is in itself an independent risk factor for falls (Stubbs et al., 2009). This is a group that may also be at elevated risk of osteoporosis and osteopenia; should they fall, they are more susceptible to osteoporotic fractures which are associated with high morbidity and mortality (Stubbs et al., 2009). To counteract this risk, older adult psychiatric services should seek to adopt the strategies identified as being “gold standard” in general older adult rehabilitation settings, such as a multifactorial falls intervention program (Gillespie et al., 2009). This would typically include a review of medication; environmental falls risk assessments, the provision of walking aids and strength and balance training (Gillespie et al., 2009).

Physiotherapists have a central role in preventing falls in this population. Individually tailored strength and balance exercises are beneficial and may be directed under the provision of a chartered physiotherapist (Gillespie et al., 2009). As part of their treatment approach, physiotherapists may provide the patient at risk of falls with a walking aid such as a zimmer frame or walking sticks. Within the general older adult population, the physiotherapist has little cause for concern when issuing such walking aids. However, among certain older adult psychiatric inpatients, such as those presenting with challenging and aggressive behavior, much greater care and consideration must be taken before doing so. This is because aggressive older adult psychiatric patients may use such a walking aid as a weapon to attack other staff and patients, with the potential to cause serious injury. This is a population that may express high and severe levels of aggressive and challenging behaviors (Stewart et al., 2008), yet the consequences of falls in this group of people who are at elevated risk of osteoporosis may be serious and long lasting.

So what is the clinical team to do when working with the aggressive older adult who may well be osteoporotic and who has been identified as a high falls risk? Should one issue the walking aid and leave the patient with a potentially serious weapon? This would put others at considerable risk. Alternatively, the physiotherapist under the direction of the wider clinical team could withhold the use of such a walking aid. The Townsend Division of St Andrews Healthcare deals with this scenario on a reasonably frequent basis. Our experience is that there is no general “rule of thumb”. The model we have developed involves the physiotherapist working with the aggressive older adult to quantify their balance impairment through standardized outcome measures. If this confirms that the patient is a high falls risk; the physiotherapist reports back to the clinical team at a meeting to discuss the pros and cons of issuing such a walking aid. This is a process that cannot be rushed, since the consequences of the patient falling or using the walking aid as a weapon may be equally serious. In most cases, the clinical team has tended to favor not issuing the aggressive older adult with a walking aid. This leaves the aggressive older adult at an increased risk of falling. To make provision for this the team seeks to increase observations on such patients to minimize the risk of falls. Clearly this still leaves the patient at risk of falls, but we have found that quick intervention by the observing staff helps to reduce the risk of falls. This has initial cost implications, but should such an aggressive patient be admitted to a local general hospital with a fractured femur, for example, staff will have to be deployed whilst this patient undergoes rehabilitation. This is in addition to the costs of the hospital admission to treat the patient. Should such situations arise, clear documentation of the clinical reasoning processes behind the team's decision is essential.

In summary, aggressive older adults may have impaired balance, be at elevated risk of falls and of osteoporosis (Stubbs et al., 2009). The consequences of this can be life threatening and may leave the patient with permanent disability. Physiotherapists routinely issue walking aids to reduce the risk of falls in general older adult settings. Great care and consideration needs to take place before a walking aid is issued to the aggressive older adult psychiatric inpatient. Should a balance deficit be identified, the physiotherapist ought to work with the clinical team to agree a consensus on the safest option. Clear and logical documentation is key.