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

c o m / l o c a t e / c o l l Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population Dianne Wynaden, RN, MH

Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental

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j o u r n a l h o m e p a g e : w w w e l s e v i e r c o m / l o c a t e / c o l l

Recognising falls risk in older adult mental

health patients and acknowledging the

difference from the general older adult

population

Dianne Wynaden, RN, MHN, PhDa,

Jenny Tohotoa, BSc, MSc, PhDa , ∗,

Karen Heslop, RN, PhDb,

Omar Al Omari, PhD, RNc

aSchool of Nursing and Midwifery/Curtin Health Innovation Research Institute, Curtin University, Australia

bDepartment of Psychiatry, Royal Perth Hospital, Joint Position with Curtin University, Australia

cSchool of Nursing and Midwifery, Jerash University, Jordan

Received11April2014;receivedinrevisedform30September2014;accepted19December2014

KEYWORDS

Olderadult;

Mentalhealth;

Fallsrisk;

Fallriskmanagement

Summary Olderadultsadmittedtoinpatientmentalhealthunitspresentwithcomplex men-tal healthcareneedswhichareoften compoundedbythechallengesoflivingwithphysical co-morbidities.Theyareamobilepopulationandahighriskgroupforfallingduring hospitali-sation.Toaddressqualityandsafetyconcernsaroundtheincreasedriskforfalls,aqualitative researchstudywascompletedtoobtainanimprovedunderstandingofthefactorsthatincrease theriskoffallinginthispatientcohort

Focusgroupswere conductedwithmentalhealthprofessionalsworkingacrossolderadult mentalhealthservicesinmetropolitanWesternAustralia.Datawereanalysedusingcontent analysisandthreethemesemergedthatweresignificantconceptsrelevanttofallsriskinthis patient group.These themes were(1)limitationsofusing genericfallsrisk assessmentand managementtools,(2)assessmentoffallsrisknotcurrentlycapturedonstandardisedtools, and(3)populationspecificcausesoffalls

Thefindingsdemonstratethatolderadultmentalhealthpatientsareahighlymobilegroup thatexperiencefrequentchangesincognition,behaviourandmentalstate.Themixofpatients with organicor functionalpsychiatric disorderswithinthe same environmentalso presents complexanduniquecarechallengesandmulti-disciplinarycollaborationiscentraltoreduce theriskoffalls.Asthisgroupofpatientsarealsofrequentlyadmittedtobothgeneralinpatient

∗Correspondingauthor.Tel.:+61892662090.

E-mail address:j.tohotoa@curtin.edu.au (J Tohotoa).

http://dx.doi.org/10.1016/j.colegn.2014.12.002

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

Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental

andagedcaresettings,thefindingsarerelevanttotheassessmentandmanagementoffallsrisk acrossallhealthcaresettings

©2015AustralianCollegeofNursingLtd.PublishedbyElsevierLtd

1 Introduction and background

In2011,fallsclaimedthelivesof1530Australiansoverthe

ageof 75, which wasan increase from 365 in2002 (ABS,

2011),30%ofpeopleover65yearswholiveinthecommunity

falleach year(Gillespieetal.,2009).Fallsin olderadults

impose a substantial burden on health services and

con-tributesignificantcoststoanalreadyoverstretchedhealth

budget(AustralianInstituteofHealthandWelfare,2013).A

fallisdefinedasanyunexplainedeventthatresultsinthe

personinadvertentlycomingtorestonthefloor,ground,or

lowerlevel(Venes,2009).Whilethemajorityoffallsinolder

adultsoccurinthecommunity,theyarealsothemost

com-monadverse eventexperiencedduringhospitalisationand

themostreportedsafetyincidentoccurringacrossalladult

clinicalareas (Oliver& Healy,2009) Cognitivelyimpaired

older adults constitute a high-risk group for falling while

hospitalised(Harlein, Halfens, Dassen, & Lahmann, 2011)

andthefallsareoftenunwitnessedandcloseobservationof

patients,particularlythosepronetofalling,isakeyfactor

inpreventingfalls(Oliver,2002)

The causesof fallsaremulti-factorialwithboth

intrin-sic and extrinsic aetiologies (Lord, Sherrington, & Menz,

2001; Tzeng, 2010) Intrinsic factors include a history of

fallingandthefearoffallingagain(Fonad,Robins-Wahlin,

Winblad,Enami,&Sandmark,2008;Weber&Kelley,2010),

demographicfactorsofage(Edelman&Mandle,2010),and

chronicconditionslikediabetes,coronaryheartdiseaseand

dementia(Fonadetal.,2008;Mulley,2001;Schoenfelder&

Crowell,1999;Titler,Shever,Kanak,Picone,&Qin,2011)

Edelmanand Mandle (2010) established the link between

falls and problems with vision, hearing, blood pressure,

mobilityandgait.Additionally,alteredmobilityand

muscu-loskeletaldisorderscanresultindecreasedstrength,pain,

fatigue,anddifficultyambulating,resultinginanincreased

riskforfalls(Edelman&Mandle,2010).Changesinreaction

timeandcoordination thatis often experiencedwith

dis-orderslikedepressioncanalsoincreasefalls risk(Iaboni&

Flint,2013;Schoenfelder&Crowell,1999)

Medicationsprescribedtomanageprimaryorco-morbid

health problems can cause symptoms of dizziness,

syn-cope, and weakness, which also increases the risk for

falls by inhibiting balance and mobility (Weber & Kelley,

2010).The more medication takenby an older adult,the

greater their risk of falling (Mulley, 2001) Medications

with the strongest links to an increased risk of falling

arethosecommonlyusedwithmentalhealthpatientsand

includeserotonin reuptake inhibitorsand tricyclic

antide-pressants(Kerse, Flicker,Pfaff, Draper,& Lautenschlager,

2008), antipsychotic agents (Rigler et al., 2013),

benzo-diazepines, anticonvulsants (Lavsa,Fabian, Saul,Corman,

&Coley, 2010)and intheolder adultpopulation alsoanti

arrhythmics(Tinetti,2003)

Increased thirst, a common symptom in people

who have a mental illness, whether psychogenic or

medication-inducedcanleadtomorefrequentambulation andneedtourinatefurtherincreasingtheopportunityfor falls to occur (Tangman, Eriksson, Gustafson, & Lundin-Olsson, 2010) Extrinsic factors also increase falls risk (Fonadetal.,2008)andincludeenvironmentalissuessuch

asobstructedwalkways,inadequatelighting,slipperyfloors and surfaces, tripping andthe lack of or improper use of assistivedevices(Edelman&Mandle,2010)

Approximately 100,000 people over 65 years of age live in the health region where this research was con-ducted (AustralianBureau Statistics, 2011),and form the cohortthatmaybeadmittedtoolderadultmentalhealth inpatient units Fallsarea majorsafety concernin these healthsettingswithfallratesbeinguptofourtimeshigher than in general hospitalsettings (Blair & Gruman, 2005) One of the findings of a 12 month review of falls at two older adult mental health services in Western Australia, wastheidentified deficitsofgeneric falls assessment and managementtools(Heslopetal.,2012)whenusedforthis olderadultpopulation

Inrespondingtotheidentifiedhighfallsrisk,aqualitative studywasdesignedtoobtainamulti-disciplinary perspec-tiveonusinggenericfallsriskassessmentandmanagement toolsinthementalhealthsetting.Generictoolsare histori-cally targetedatassessingfalls riskin thesurgicaland/or medical general hospital setting and designed for assess-ment in acute or inpatient care where patients are less ambulantthanthoseadmittedtothementalhealthsetting Theyusuallyconsistoftwocomponents:fallsriskprediction

toidentifypatientswhoarelikelytofallandmanagement strategiestopreventthepatientfromfalling(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 onpatients 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 unsafewhen walking

or transferring,or (c)theyareconfused.Ifnone ofthese criteriaaremet,minimummanagementstandardsoutlined

on the tool must still be implemented for each patient These include, orientation to the hospital environment, ensuringacallbelliswithineasy reachandprovidingthe patientwithappropriatemobilityaids

2 Objectives of the study

Theobjectivesofthismulti-siteformativestudywitholder adultmentalhealthpatientswereto:

(1) Determinetheeffectiveness ofusinggeneric falls risk assessment and management tools with older adult mentalhealthpatients

(2) Identifymentalhealthspecifictriggersforfallsriskand theirmanagement

Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental

(3) Formulate multi-disciplinary assessment and

manage-mentstrategiestoreduce falls riskin thisolderadult

population

3 Methodology

The qualitative study reported on in this article formed

part of a larger study on falls in older adult

men-tal health patients This study aimed to address the

first objective: to determine the effectiveness of

cur-rent falls risk assessment tools and to explore expert

opinion around the perceived falls risk in this specific

population The researchwas deemed tobe minimal risk

and was registered as a quality improvement project at

each participating health service and ethicsapproval was

obtainedfromoneuniversityin WesternAustralia (SON&M

44-2010)

The initial phase of the research involved a review of

falls risk assessment and management tools usedin

clin-ical practice in Western Australia Following this review,

focusgroupswerethen conductedwithhealth

profession-alsfromarangeofdisciplinesbetweenJuneandNovember

2012 to explore the study objectives All mental health

nurses,occupationaltherapistsandphysiotherapists

work-ing in the older adult mental health units were invited

toparticipateinthesefocusgroups Interdisciplinary

par-ticipation reflectedthe importance of the strengthseach

discipline brought to falls risk prevention and

manage-ment 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 90min

and a facilitator guide was used to provide consistency

acrossgroups.Informationwasdigitallyrecordedand

tran-scribed Aftersixgroups, saturationof datawasachieved

and themes were well developed and expansive in their

descriptions

Data were analysed and transformed into

concep-tualmapswithaccompanyingillustrative quotations.Four

cognitive processes were integral to data analysis:

com-prehending,synthesising,theorisingandre-contextualising

(Field&Morse,1996).Thekeythemesweresignificant

con-ceptsthatlinkedsubstantialportionsofthedatatogether

Researcherchecksofdataanalysiswerecompletedbytwo

membersoftheteamandanalysiscontinueduntilconsensus

wasachievedacrossthemes

4 Results

Twenty-eight participants agreed to take part in the

research;21mentalhealthnurses(includingEN’s[enrolled

nurse], RN’s [registered nurse] and CN’s [clinical nurse])

four physiotherapists and three occupational therapists

Threethemesemergedfromthedata,namely‘‘limitations

of using generic falls risk assessment and management

tools’’; ‘‘assessment of falls risk not currently captured

onstandardisedtools’’,and‘‘populationspecificcausesof

falls’’

4.1 Theme 1: limitations of using generic falls risk assessment and management tools

Generally,participantswerecriticalofthegenericfallsrisk assessment tool currently used in the mental health set-tingas‘‘toomuchinformation[onthetool]istargetedat hospitalisedpatientsin thegeneralsetting andis not rel-evantto[mentalhealth] IVpoles, bedtables,wedon’t usethem,anditcannotbeindividualisedforeachpatient’’ (P21); ‘‘callbells,we don’t use them or bed rails, which areregardedasrestraints[inmentalhealth]’’(P12).Many

of‘‘theseitemsarecontraindicatedinmentalhealth’’(P9), andareviewedas‘‘clutterandobstaclesthatcouldincrease thefallsriskforamobilepatient’’(P7).Participantsspoke

of‘‘auditsdemonstratingproblemswiththeuseofgeneric tools in the mental health setting with a mobile older adultpopulation’’(P24);‘‘weauditthetoolonamonthly basis—andonthebasisoftheauditIwouldsaythat approxi-matelyhalfofwhatislistedisnotrelevant.Itisjustlistedas notapplicable’’(P28);Itisa‘‘tickboxmanagement strat-egyforassessingriskratherthanatoolthatisdirectiveof care’’(P10)

While meeting the minimum assessment and manage-mentstandardsoutlinedonthegeneric toolswasrelevant

in the mental health setting, additional information was oftenrequiredduetotheincreasedmobilityofthispatient cohortandtheirfluctuatingcognitive,behaviouraland men-tal state differences According to one participant ‘‘the minimumstandardsshouldalwaysbeincorporatedintothe initial falls assessment However, it can be difficult with somepatients to determine if theyare orientated tothe environment,especiallyiftheyareconfused’’(P23) Participants viewed the generic tool as limiting in

‘‘capturinginformation on sensoryimpairment’’ (P3) and

‘‘indefiningamanagementstrategyforthe[mentalhealth] patient’’(P1).Participantsexpressedthat‘‘thesetypesof assessmentswereverytickandflick’’(P14).Other partic-ipantscommentedonthelackofspaceandoptionsonthe currentgenerictool:‘‘Iwouldliketobeabletowriteabit morehere.Iwouldlike theformtobeabitmoreperson centred’’(P6)

4.2 Theme 2: assessment of falls risk not currently captured on standardised tools

Inassessingfallsrisksinolderadultmentalhealthpatients, participantsarticulatedthatitwascriticalto‘‘assessthe patient over a 24h period as things change according to the timeof the day, this means we [can then] do things with them when they are most functional and do less whentheyarenot managingsowell’’(P3) Observingthe patientcloselyover thefirst24h‘‘allowedthemtosettle intothe environment and for staffto obtain an accurate assessmentofthepatient’’(P5).Participantsviewed multi-disciplinarycollaborativeassessmentasfundamentaltothis process:‘‘nursesneedtoknowthemedicalco-morbidities thepatientpresentswithandthemedicationstheyare pre-scribedastheseimpactonrisk’’(P15);‘‘podiatryservices areimportant’’(P16);‘‘occupationaltherapistsassess cog-nitionaspartoftheirfunctionalassessment’’(P3);‘‘every patientshouldbeseenbythephysiotherapisttodetermine

Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental

iftheyneed aZimmerframeor iftheirfootwearis

appro-priate?’’(P22);‘‘youassesstheirgaitandeyecontact.Are

theywalkingon their own?Are they swinging theirarms?

Howis their balance?How did theyarrive at the ward?’’

(P1).Anotherparticipantcommentedonthevalueofa

phys-iotherapyassessment:

[Thephysio] usestheBerg balancetoolto assesstheir

levelofbalance:thehigherthescorethelowertheirrisk

offalling.Inassessingrisktheylookatfunctionaltasks

andobservethepatient.Forexample,theydropapen

andaskthem‘canyoupickthepenupofftheground?’

Theyassessifthepatienthasthecapacitytobenddown

andpickitup.Theyalsoobservethemgettingsomething

fromthe wardrobeasthisskillisan indicationof good

balance(P2)

Participants spoke of the importance of assessing the

patient’sstrengthsratherthantheirdeficits:‘‘genericforms

assessdeficitsratherthanfocusingonthepatient’sstrengths

and what they could do [to lessen their risk of falling]’’

(P10);‘‘formostofourpatientsthe[generic]formhas

lit-tlerelevance,forexample,thepatienttoday,theirfallsrisk

waspickedupquicklybythephysio[therapist]byassessing

thepatient’sstrengthsnotdeficits’’(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 courtyardswere

identifiedas high risk environmentsfor falls Participants

explainedthat patientswereat riskbecause:‘‘wedonot

haveensuites[so]mentendtourinateonthefloor[inthe

bedroom]andthenfall’’(P2);‘‘thesoil[inthegardenarea]

needstobebuiltupwhereitmeetsthecementasitisatrip

hazard’’(P13)

Frequent changes in cognition, behaviour and mental

statewerealsoidentifiedasspecificfallsriskfactorsinolder

adult mental health patients Restlessness, agitation and

disorientationwere commonly identifiedwith falls risk as

participantsexplained:‘‘justrecentlywehadtwopatients

whohavebeenveryproblematicatnight,withoneneeding

a‘‘special’’[onetoonenursingcare]topreventthem

wan-dering’’(P17); ‘‘you assess theirlevel of frailtyand then

disorientation, are they lost or confused? They will walk

arounduntiltheyarefatiguedandthenbemoreatriskofa

fall’’(P10)

Thepatientmixinmanyolderadultmentalhealthunits

was identified as a unique falls risk factor due to the

complexity and challenges in care requirements and

pre-sentationbetweenthosepatientswithdementiaandthose

withfunctionaldisorderssuchasschizophreniaandbi-polar

disorder ‘‘Whenyou have patients withorganic disorders

[e.g.dementia]andfunctional disorders[e.g

schizophre-nia]inthewardtogether,itisadifficultpatientmix’’(P18);

‘‘patientswithdementialackinsight,theyareintrusiveand

getintotroublewithotherpatients’’(P5)

Extrinsicfactorssuchasthe incorrectuseofor refusal

tousemobilityaidswereperceivedtoincreasetheriskof

falls:‘‘manypatients havewalkingframes butdonotuse

them,wehavealadywhodragsherframebehindher we

lookedatwaystoassisther,butwhensheisinthatframeof

mindit’shard.Sometimessheusesitappropriatelyand[at] othertimes[shedoes]not’’(P18);‘‘iftheyhaveamobility aid,aretheyusingitappropriately?Ihaveseenthemcarried overtheirshoulder orevencarrieditinfrontofthem’’ (P20)

Footwearwasalsoassociatedwithfallsriskinthispatient populationanddiscussedatlengthbyparticipants:‘‘many patientsarrivewithinappropriatefootwear’’(P21);‘‘they areadmittedandhavenoclotheswiththem sotheyend

up with foam slippers which are not appropriate’’(P22);

‘‘some people don’t have the money to buy appropriate footwear’’ (P13); ‘‘somepatients voidin their footwear’’ (P28)

Increasedfallsriskwasalsolinkedtomedicationuseas participants explained:‘‘the causes of falls include many factors,butoneofthemismedicationandthatisahuge fac-tor,oldermentalhealthpatientshavelotsofmedication’’ (P25); ‘‘the use of pro renata[when necessary] medica-tionstoaddressbehaviouralissuesfurtherimpactsonfalls risk’’(P24);‘‘iftheyareaverydisturbedpatientfromthe emergencydepartment,theymaybeoverlymedicatedand [onadmissionbecome]an immediatefallsrisk’’(P5) Par-ticipants spoke of the conundrum of medication use and theassociatedincreasedriskforfalls.‘‘Inaperfectworld

wewouldn’tputthem[olderadultpatients]onmedication becausetheyareafalls risk,but realisticallytheyhave a mentalillness,behaviouraldisturbancesandmedical condi-tionssothatisnotrealistic’’(P9);‘‘Whenusingmedication

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 fairlystickysituationtoget right asthefact isthereis a correlation between giving people these drugs [antipsy-chotics,benzodiazepines]andfalls’’(P24).Oneparticipant commentedonthespecificrisksidentifiedwiththeuseof antipsychotic medication where the patient was ‘‘being heavilysedated ‘‘andwiththeuse of aperients‘‘because with diarrhoea the patient may fall’’ (P8) The extra pyramidal side effectsof typical antipsychoticswere also seentoincreasefallsrisk:‘‘withthelastpatient,weknew

assoonashecamein[admittedtohospital]thathewould fall He was on prescribedantipsychotics and had a real shuffle—itaffectedhiswalkingandconsequentlyhefell’’ (P6).Medicalco-morbiditiesalsoincreasedtheriskoffalls:

‘‘it’saboutweighingupthatbalancebetweenmentalstate andmedicalhealth’’(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 func-tionaldisorderssuchasschizophreniaandbi-polardisorder (Heslop et al., 2012) The componentsof cognitive func-tion affected in dementia include memory and learning, attention,concentrationandorientation,problem-solving, calculation, language, and geographic orientation (Hsu, Nagamatsu, Davis, & Liu-Ambrose, 2012) Hence, these patients have frequently changing cognitive, behavioural andmentalstatesthatincreasetheirriskforfallingduring

Please cite this article in press as: Wynaden, D., et al Recognising falls risk in older adult mental

hospitalisation Whilethe use of generic falls risk

assess-ment andmanagement tools is commonpractice inmany

inpatients settings, the value of these tools with older

adult mentalhealth patientsappears limited.This finding

is supported byEstrin, Goetz, Hellerstein,Bennett-Staub,

and Seirmarco (2009) who claimedthat ‘‘there is a lack

of well-researched and validated fall risk models

specifi-callydevelopedforpopulationsofpsychiatricpatients’’(p

1245).Lee,MillsandWatts(2012)alsoidentifiedtheneedto

improvethesystemoffallsassessmentinpsychiatricolder

adultpopulations

Theincreasedfallsriskposedbythelevelofmobilityof

patientsisfurtherexacerbatedbythefactthatalmostevery

patientis ononeor moremedicationsthat alsoincreases

theirfallrisk(Estrinetal.,2009)andtherefore,allpatients

couldbeclassifiedasbeingathighriskforfalls.Thedebate

surroundingtheincreasedfallsriskwiththeuseof

antipsy-choticmedicationversusimprovedmentalhealthoutcomes

continues.Olderadultsmaybeprescribedanumberof

med-icationsandtakingtwoormorepsychotropicmedicationsis

associatedwithatwofoldtoninefoldincreaseinthe

num-ber offalls (Gustafsson, Sandman,Karlsson, Gustafson, &

Lovheim,2013;Lim,Ng,Ng,&Ng,2001)

Many of these prescriptions are linked to

control-ling behavioural and psychological symptoms of dementia

(Richter,Mann,Meyer,Haastert,&Kopke,2011;Seitzetal.,

2013)yetwithdrawalofpsychotropicmedicationshasbeen

associated with a reduction in falls and improved

cogni-tion (Iyer, Naganathan, McLachlan, & Le Couteur, 2008;

Ruths,Straand,Nygaard,& Aarsland, 2008).Selbaeck and

Engedalfoundatypicalantipsychoticshadamodesteffect

onthebehaviouralandpsychologicalsymptomsof

demen-tiaandpotentiallyserioussideeffectsandthatconventional

antipsychoticsappeartohaveevenlessfavourableeffects

andadverseeventprofiles(Selbaek&Engedal,2008).The

dilemma of appropriate prescribing for behavioural

man-agement in an older adult mental health unitagainst the

increasedriskoffallingremainsanongoingissue for

clini-ciansandresearchers

To capture thecomplexity ofthefalls risk intheolder

adult mental health population, a comprehensive mental

healthassessmentandmanagementtoolneedstobe

devel-oped 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 importanceidentified in this

qualitative study for the assessment and management of

fallsriskinthispatientcohortinclude:cognition,functional

ability,mobility,mentalstateandbehaviour,environmental

concerns,medicalco-morbidityandmedication.Addressing

each of these criteria withan assessment and correlated

management strategy could decrease the fall risk and

increasetheclinicalskillsofstaffwhoworkwiththisgroup

ofolderadults

Whilenursesplayalargeroleintheassessmentand

man-agementoffallsriskinhospitalisedpatientsinthegeneral

healthcaresetting,amultidisciplinaryapproachto

assess-mentandmanagementoffallsriskispromotedinthemental

health setting The findingsdemonstrate the uniqueskills

eachprofessioncontributestoimprovedfallsriskprevention

in olderadultsandthe transferabilityof findingstoother

hospitalsettingsarerelevant

6 Limitations

Thestudywaslimitedtotheonegeographicallocationand thehealthprofessionalswhoparticipatedonlyworkedwith olderadultsexperiencingmentalhealthproblemsinpublic hospitals.Additionalintrinsicandextrinsicfactorsmayadd

tothe falls risk for older adult mental health patients in otherhealthcaresettings

7 Conclusion

The findings of this study highlight that generic falls risk assessmentandmanagementtoolsidentifyrisksassociated primarilywithimmobilepatientsandhavelimitedusewith

apatient population who aremobile and experience fre-quentfluctuationsincognitive,behaviourandmentalstate Thesepatientsduetotheirmobilityareconstantlyexposed

tomanyoftheextrinsicriskfactorsforfallssuchastripping andslipping.Thepatientmixaddsfurthertothecomplexity and challenges of preventing falls in this patient popula-tion.Antipsychotic,antidepressantandhypnoticmedication alladd to the sedatingand hypotensive side effects that furtherincreasetheriskforfalls.Manypatientshave mul-tiple co-morbidities and the combination of medications usedtotreattheirprimarypresentingillnessandtheir co-morbiditiesisaspecificfallsrisksfactorinthispopulation The importance of multidisciplinary collaboration in reducingfallsriskinthispatientcohortisessentialforbest practiceinfallsriskassessmentandmanagement.Asmental healthpatientsarenowcommonlyfoundinallhealthcare settingsthefindingsandidentifiedqualityandsafetyissues arerelevantinallsettings

Acknowledgement

ThisresearchwasfundedbyaQualityandSafetyGrantfrom theWesternAustralianDepartmentofHealth

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