Prevention of fall in elderly is an issue of concern because fall has a significant burden on the health care services. Fall in elderly is associated with physical injury which contributes to prolonged period of hospitalization and increased cost of treatment. As much as fall in elderly people occur in the community, a high incidence has been reported in the hospitalized adults (Merom et al., 2016). The situation of fall in the elderly is aggravated by the cognitive impairment (Sharma et al., 2018). It is indeed acknowledged by Williams et al. (2015) that the risk of falling in the hospitalized elderly suffering from mental illness is higher than those elderly people who do not suffer from cognitive impairment.  The occurrence of fall in the elderly patients in the psychiatry unit often goes unwitnessed as well as unreported (Sharma et al., 2018). Therefore, the need for close monitoring of the elderly patients in the psychiatry unit is paramount as one of the fall prevention strategies.

            Fall in the elderly patients in the psychiatry unit can be due to either intrinsic or extrinsic factors. Intrinsic factors include fall history, fear of falling, dementia, poor vision, gait problems, poor coordination as in the case of depression, and the use of drugs for  the treatment of mental illnesses (Wynaden, Tohotoa, Heslop, & Al Omari, 2016). Most of the drugs used for the management of mental illness such as the antipsychotics, anticonvulsants, antidepressants, and serotonin selective reuptake inhibitors are associated with dizziness, fainting episodes, and weakness of the muscles which interferes with an individual’s balance as well as mobility (Zhao & Kim, 2015). The extrinsic factors that predisposes the older adult in the psychiatry unit to fall include walk ways that are obstructed, poor lighting, floor as well as walk ways which are slippery, and lack of proper use of the assistive devises (Wynaden et al., 2016). Effective fall prevention strategies target the alleviation of the intrinsic and the extrinsic factors contributing to fall.

            In the psychiatry unit, fall is the greatest safety issue of concern. In the psychiatry unit, the incidence of fall is four times higher than the general inpatients setting of a hospital (Zhao & Kim, 2015). The estimated rate of fall in the psychiatry unit ranges from 13 to 25 per 1000 inpatient days (Wynaden et al., 2016). The main safety goal is to not only reduce the fall incidence but also reduce the harm emanating from the occurrences of fall (McMinn, Booth, Grist, & O’Brien, 2016). Even though several strategies have been implemented to alleviate the problem of inpatient fall in the psychiatry unit, the fall incidence remains high (Abraham, 2016). Therefore, the main purpose of this review of literature is to provide evidence based strategies that will help reduce the occurrence of fall among the elderly in the psychiatry unit.

Existing Knowledge, Research, and/or Views to a Process

            Fall in the elderly are frequently reported in the psychiatry unit. In the United Kingdom, the annual incidence of fall in the elderly in the psychiatry unit is about 36,000 cases (Abraham, 2016). Similar findings of annual incidence of about 36,000 falls per year have also been reported in countries such as Australia and United States (Du, Wolf, & Knopf, 2017). The elderly in the psychiatry unit are at increased risk of falling in comparison to other hospital inpatient settings because of conditions such as impaired mental status which is caused by dementia, episodes of depression, mania, as well as anxiety disorders (Williams et al., 2015). This situation of increased prevalence of fall is further aggravated by the psychotic drugs as well as the electroconvulsive therapy (Johnell et al., 2017).

            The holistic wellbeing of the elderly patient is impaired in the event that a fall incidence occur. Following a fall, the physical as well as the mental wellbeing of a patient is impaired (Mentis et al., 2017) and this may lead to an increased stay in the psychiatry unit which as a detriment effect on the cost of the treatment regimen. Tricco et al. (2017) is in agreement with Mentis et al. (2017) by affirming that fall in the elderly in the mental health unit has led to rehabilitation with some of the patients being discharged to a long term health care facility. Möhler, Nürnberger, Abraham, Köpke, and Meyer (2016) add that globally, the cost that has been linked with the management of fall in the elderly is increasing and that the greatest cost is due to management of fall in the elderly with mental illness. Strategies of fall prevention in the elderly the psychiatry unit is being directed at alleviating the common causes of fall.

            Most of the studies on fall prevention in the elderly have focused on dementia and ineffective cognition (Sharma et al., 2018). A fall risk assessment tool is used to screen the elderly prior to admission for the risk of dementia, and impaired mental wellbeing so that the fall prevention strategies are directed towards the identified risk factors (Wynaden et al., 2016). Other research studies have placed an emphasis on Alzheimer as it is a common condition among the elderly and the key manifestations are loss of memory and confusion (Zhao & Kim, 2015) and therefore the older adult is at an increased risk of falls. The fall prevention in elderly admitted at the psychiatry unit has also an emphasis on the number of medications that a patient is taking. A patient who is taking more than three drugs for treating the mental illness is at an increased risk of falling (Williams et al., 2015). The more the number of drugs a person is taking the higher the chances of drug interactions which further contributes to falls (Johnell et al., 2017).

            The probability of a fall is influenced by the mental illness of a patient. An elderly suffering from depression is likely to fall in comparison to another patient with mental illness who is not depressed (Harwood et al., 2018). Besides, the fall incidence among the elderly is common when an individual is either walking or moving from a chair to a bed and vice versa (Möhler, Nürnberger, Abraham, Köpke, & Meyer, 2016). In the psychiatry unit, the occurrence of fall is high because patients are encouraged to participate in psychotherapy activities such as exercises and occupational therapy (Jensen & Padilla, 2017). In light of the foregoing, the occurrence of fall is higher in the elderly in the psychiatry unit.

            The fall prevention strategies in the elderly in the psychiatry unit need to be addressed in a perspective that is multifaceted. From the moment an elderly is admitted in the psychiatry unit, the risk of fall should be established even though such an individual has never fallen before (Abraham, 2016). Situations such as the use of psychotic drugs, the state of confusion, the motivation to ambulate, and the increased age, makes the elderly vulnerable to falls (Merom et al., 2016). Vigilant monitoring of the elderly in the psychiatry unit by the health care providers has been found effective one of the fall prevention strategy (McMinn, Booth, Grist, & O’Brien, 2016). Sharma et al. (2018) add that the fall risk assessment should be a continuous process since the condition of the elderly in the psychiatry unit keeps on changing in response to the treatment regimen.

Design Process/Method

            A systematic review of the previously published literature was the methodology utilized. The databases used were Ebscohost, Medline, and google scholar. These databases were selected based on the fact that they have numerous peer reviewed articles in the medical and the nursing fields. The key words used for the search originated from the title of the study and they included fall, prevention, intervention, older adults, elderly, patients, inpatient, psychiatry unit, mental health facility, and setting. The key words were used to retrieve the most relevant articles for use in the systematic review.

The Boolean operator words that were used in the search included AND and OR. AND was used for joining words that were of different meaning. An example of a search using the AND includes Fall AND prevention AND elderly AND psychiatry unit. On the other hand, OR was used for joining synonyms. An example of search using the OR incudes Fall AND prevention AND elderly OR older adults. The use of Boolean operator helped to retrieve many relevant articles and thus the researcher had a variety of peer reviewed articles to choose the best that effectively addressed the issue under investigations.

            The search was limited to articles published in English since majority of the people can understand English and that the literature review is to be conducted in English. The year of publication was also limited to the last five years since these articles contained updated information. The inclusion criteria was randomized control trials, meta-analysis of randomized control trials, and cohort studies because these articles have a high level of evidence and thus the findings are valid and reliable and can be used for evidence based practice. The other inclusion criteria was research studies which focused on the fall prevention in the elderly who are suffering from mental illnesses such as the dementia, Alzheimer, depression, as well as psychosis. These studies were included because the problem under investigation is fall in the elderly in the psychiatry setting and thus the need for these patients to be suffering from mental illnesses. Although the major area of interest was the psychiatry setting, there were few studies and as a result researches conducted in other areas so long as the setting was inpatient and the focus was on elderly with mental illness was included in the review of literature. The primary outcome of interest was fall in the elderly as a single incidence or several fall occurrences. The secondary outcome of interest was the fall prevention strategies that were effective in reducing the number of fall in the elderly.

            The data extraction process involved a team of three reviewers. The inclusion of the reviewers was to help reduce the likelihood of researcher’s bias. The three reviewers worked independently and evaluated the titles as well as the abstracts of the study before selecting the studies to be used for the review of literature. The selected studies were put together and evaluated for similarities. The research studies were listed and those that were selected by the three or two reviewers were used for the review of literature.

The selected studies were critically appraised to establish whether they had methodological rigor. This means that the methodology utilized by each of the study was cautiously reviewed by the three reviewers. Studies with a high methodological rigor are credible and can thus be used for the review of literature. The research studies with the highest score in the review of methodologies were selected for the systematic review of literature. The content of the selected studies were assessed. Studies with similar interventions were grouped together for further analysis.

Analysis

The analysis of the selected literature revealed that there are several interventions for preventing fall in the elderly in the psychiatry unit with a variation depending on the diagnosis of the patient and the inpatient setting. Some of the fall interventions strategies that were found significant include exercises, increased physical activities, fall risk assessment, modification of the environment, training of the health care providers, increased supervision, and health education to the patients (Tricco et al., 2017). The aforementioned findings on fall reduction varied with some researches showing a statistically significant decrease in the number of fall while on the other hand other results displayed a clinically significant decrease in fall occurrences (Harwood et al., 2018). The variation in findings could be due to the choice of methodology but since the selected studies had methodological rigor, the presented results have been adopted for evidence based practice. Most of these studies had a focus on cognitive impairment, depression, as well as dementia while the other aspects of mental illness such as the schizophrenia did not form part of the study population (Burton et al., 2015). In addition, the study setting of most of the reviewed studies were the residential homes though the participants were elderly with mental illness. A difference in the area of research greatly interferes with the generalization of the findings.

A comparison can be drawn between the findings of the systematic review and the other previously published researches. It is indeed acknowledged that a fall prevention intervention should be multifactorial for it to be effective (Tricco et al., 2017). Among the elderly suffering from impaired cognition and depression, exercises have been found to have a statistically significant effect on the reduction of inpatient fall incidences (Jensen & Padilla, 2017). Those elderly suffering from dementia benefited from alterations in the social environment such as training the health care providers on the techniques of reducing agitation among these patients through activities such as the aromatherapy. Besides, enhancing the psychosocial care has been proved effective in reducing the falls episodes among the elderly with dementia (Harwood et al., 2018). Psychosocial care means that the nurse focuses on enhancing the psychological as well as the social wellbeing of the patient.

A review of the medication that the patient is taking has also been effective in reducing the falls prevalence among the elderly (Johnell et al., 2017). It is indeed evident that the strongest risk factor for fall in the elderly with mental illness is the use of psychotropic medication as well as polypharmacy (Du, Wolf, & Knopf, 2017). In order to reduce the fall episodes, there is need for either reducing the number of drugs that the patient is taking or withdraw the medications that have side effects such as confusion and drowsiness (Johnell et al., 2017). A confused person is likely to be disoriented to place and thus increased likelihood of fall while a drowsy person has a gait problem and can easily fall.

Other interventions that have been found effective in falls prevention include balance training, assessment of vision, and a continuous review of the drugs that the patient is taking (Merom et al., 2016). Balance training helps improve the gait. Vision assessment will help develop strategies that enhance vision such as increased lighting. A review of drugs will help stop or supplement drugs with drowsy effects. Besides, the health care providers working at the psychiatry unit need to be empowered with information on fall risk assessment and the prevention strategies that have been found effective (Jensen & Padilla, 2017).

Conclusion

            There are very few studies conducted in the psychiatry setting although the occurrence of fall in the elderly in the psychiatry unit is high. The evidence that have been presented for application to practice is not specific to a particular strategy but a number of multifactorial interventions. In addition, the available evidence for fall prevention has not focused on a variety of mental illness especially the psychotic disorders such as the schizophrenia. This means that it is difficult to implement the aforementioned interventions among patients with psychotic disorders.  A clear guideline has not been provided on the specific strategies that have been found useful in the reduction of fall in the elderly with mental illness. The recommended techniques for fall prevention have just been outlined and they include interventions such as muscular strength as well as balance training for the patients, environmental modification, assessment of vision, review of the medications, close monitoring of the patients, training of the health care providers on fall risk assessment and prevention strategies, and psychosocial care.

            Minimal evidence on the different fall prevention strategies in the elderly admitted in psychiatry unit exist. There is need for more research studies that focus on a specific falls prevention strategies as this will help provide credible findings for use in evidence based practice. The health care providers working with the elderly with mental illness need to access the available evidence and apply it in the clinical setting. This is imperative because a health care provider could be aware of the fall prevention strategies but is not knowledgeable on the specific strategy to apply to a particular patient, and thus the need for creating awareness among staff.

            It is worth noting that the psychiatry unit is a unique environment that has safety issues of concern for the mentally ill patients. In the absence of a clear evidence, the nurses may continue assessing and preventing fall among the elderly but the fall incidences keep on either increasing or remaining constant. There is need for more future researches to provide evidence for the fall prevention interventions which are specific to a particular group of psychiatry patients. Therefore, this systematic review of literature does not only add knowledge on the fall prevention strategies but also provide a basis for future research to help in comprehending the specific elements in the presented fall prevention strategies which are suitable for the elderly in the psychiatry unit.

Limitations and Implications

            The major limitations is that the reviewed studies had methodological issues which does not only interfere with the generalization of the finings but also the validity and reliability of the evidence. The major methodological issues was the setting of the selected studies. As much as the participants were the elderly with mental illness, the study setting was not a psychiatry unit and such findings can therefore not be generalized to a psychiatry setting which has a different structure and layout. The other methodological issue was that some of the findings were statistically significant while others were clinically significant yet the both findings were incorporated into the systematic review of literature, and this reduces the credibility of the provided evidence. The final limitation was that very few studies were found addressing the issue of fall in the elderly in the psychiatry unit due to the attributes of the elderly that limits the inclusion into research. For instance, an older adult is likely to be confused or experience memory loss and thus cannot be included in the research because a participant need to provide an informed consent before taking part in a research study.

            The major implication for clinical practice is that this systematic review has provided a variety of fall prevention interventions focusing on participants with different attributes and thus the application of the provided evidence to practice is compromised. Since several fall prevention strategies are captured in a single research study, the comparison process becomes difficult and thus the only chance available is for the health care providers to adopt all the propose interventions. The other implication for practice is that the elderly and especially those suffering from mental illness do not only present with signs and symptoms of the diseases but also with changes associated with old age which may further increase the susceptibility to fall. For instance, as a person ages, the muscles become weak, gait problem is experience, and the likelihood of suffering from chronic diseases such as hypertension is high. In order to reduce the risk of harm associated with fall in the elderly in the psychiatry unit, there is need for incorporating the changes associated with old age in the fall prevention strategies.

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