In general medicine, falls among older adults and the consequences of such falls have been the focus of a plethora of empirical and scholarly research efforts. This is for good reason since falls are the leading cause of accidental death in older adults and are a major cause of morbidity and mortality (Currie, Reference Currie and Hughes2006). It is estimated that between a third and a half of adults aged over 65 years fall each year (Lim et al., Reference Lim, Ng, Ng and Ng2001). The cost to healthcare systems is significant; for example, in the U.S.A. non-fatal falls cost between $16 billion and $19 billion per annum (Stevens et al., Reference Stevens2006). Despite advances in general medicine, there is a relative dearth of empirical data on the incidence of falls in older adults. However, older adults with mental illness are an “at risk” group and those at particular risk are individuals residing in institutions (Lim et al., Reference Lim, Ng, Ng and Ng2001; Stubbs, Reference Stubbs2010). Older adults with mental illness are at elevated risk of falls due to a complex mix of coexisting medical, surgical and degenerative conditions (Lim et al., Reference Lim, Ng, Ng and Ng2001). In addition, such older adults may be taking a number of different medications, including psychotropic medication. Taking two or more psychotropics is associated with a two- to nine-fold increase in the number of falls (Lim et al., Reference Lim, Ng, Ng and Ng2001).
Older adults with mental illness are also at elevated risk of osteoporosis (Stubbs, Reference Stubbs2010). One particularly serious sequalae of falls in this patient group is osteoporotic fracture (Stubbs, Reference Stubbs2010). Osteoporotic fractures can have a devastating effect on an individual's physical and psychological health and also lead to a decrease in the ability to complete activities of daily living and therefore negatively influence a person's quality of life. Hip fractures occurring following a fall are particularly troublesome; indeed, some will die and less than a third will return to their pre-fracture level of independence and functioning. Thus, it is suggested that any interventions to reduce the risk of both falls and subsequent osteoporotic fractures should be a research priority. Lim and colleagues (Reference Lim, Ng, Ng and Ng2001) have provided a general profile of institutionalized older adults with mental illness who are most at risk of falls: they are aged older than 75 years, take three or more medications, have undergone a recent change in mental state and/or medication, have lower limb and balance problems, and have been diagnosed with depression and/or anxiety. It is clear that many older adults with mental illness residing in intuitions worldwide meet some of these criteria and are therefore at risk of falls and subsequent fractures.
It is well established that in order to prevent falls a multidisciplinary team approach is required (Currie, Reference Currie and Hughes2006). Nurses and their assistants can play a key role in preventing falls since they are employed in large numbers to provide care for older adults residing in institutions. Thus, they are well placed to monitor some of the purported risk factors for falls as outlined by Lim et al. (Reference Lim, Ng, Ng and Ng2001) above. Nurses can play an immediate role in reducing falls and through monitoring the aforementioned risk factors may be able to spot potential “fallers” early. This may result in a reduction in falls among institutionalized older adults in both the long and short term.
Some research has demonstrated that a member of the nursing staff was present when a patient fell in over 40% of instances (Khalaf and Morris, Reference Khalaf and Morris1996). In such cases, nurses who are aware of the risk factors for falls could intervene immediately prior to a fall occurring. In the longer term, nurses who are aware of changes in an older adult's mental state should inform the multidisciplinary team and, in particular, the responsible psychiatrist. Coincidentally, the staff who are most often on duty are typically those who are non-qualified, such as healthcare assistants. This group in general do not have the level of academic knowledge that qualified nurses possess and will be less aware of the risk factors for falls. However, this group is arguably best placed to monitor changes in a person's mental state. In addition, healthcare assistants are typically poorly represented at multidisciplinary ward rounds when falls risk factors should be fed back to the team. Changes in medication are a risk factor for falls and should the team decide to alter a person's medication, it is imperative that this information is cascaded to healthcare assistants as, once again, they are the most obvious members of staff to monitor this risk factor for falls. Balance and/or gait difficulties can be observed while an older adult is conducting his/her activities of daily living. Nurses and their assistants should monitor the person's performance of tasks such as walking, using the toilet, getting out of bed and rising from a chair, all of which are particularly associated with falls (Lim et al., Reference Lim, Ng, Ng and Ng2001).
In order to take a proactive approach to falls prevention, it may be beneficial for institutions providing care for older adults with mental illness to update their staff induction programs. Non-qualified nurses need to be empowered with knowledge about the risk factors for falls, and their role in monitoring and preventing falls should not be underestimated. Another strategy that may help is the routine attendance of non-qualified nurses on ward rounds. This is because they frequently possess relevant and up-to-date information regarding an older adult's mental state, response to medication changes and performance of activities of daily living, all of which are frequently implicated as risk factors for falls (Lim et al., Reference Lim, Ng, Ng and Ng2001).
