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International Journal of Mental Health Nursing (2016) 25, 3–11
doi: 10.1111/inm.12164
Feature Article
Impact of falls on mental health outcomes for older adult mental health patients: An Australian study Karen Ruth Heslop, PhD 1,2 and Dianne Gaye Wynaden, PhD 2,3 1
Royal Perth Hospital, 2School of Nursing and Midwifery, Curtin University, and 3Fremantle Mental Health Services Perth, Western Australia, Australia
ABSTRACT: 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. KEY WORDS: falls, Health of the Nation Outcome Scale scores, mental health outcomes, National Outcome Casemix Collection, older adult mental health service.
INTRODUCTION AND BACKGROUND The health-care cost associated with falls in people 65 years and older is estimated by the World Health Organization at A$4913 per fall (World Health Organization 2007). Falls add substantially to already stretched health budgets (Bradley 2013) and claim the lives of many older adults each year (Australian Bureau of Statistics 2012). A fall is ‘any unexplained event that results in the patient inadvertently coming to rest on the floor, ground, or lower level’ (Venes 2013, p.884). Approximately 30% of people over 65 years who live in the community fall each year (Gillespie et al. 2012), and falling is the most commonly-reported safety incident during hospitalization across all adult clinical areas (Oliver & Healy 2009). Correspondence: Karen Heslop, School of Nursing and Midwifery, Curtin University, Kent Street, Bentley U 1987, Perth, WA 6845, Australia. Email: [email protected] Karen Ruth Heslop, PhD. Dianne Gaye Wynaden, PhD. accepted August 2 2015; published online November 24 2015.
© 2015 Australian College of Mental Health Nurses Inc.
Falls are of particular concern in older adult mental health inpatient services, where fall rates are reported to be up to four times higher than in other hospital settings (Blair & Gruman 2005). Older adult mental health patients are an ambulant population, and this increases their risk for falling (Heslop et al. 2012), with many of these falls being unwitnessed (Oliver & Healy 2009). In addition, many of the medications used to manage primary or comorbid presenting health problems in this patient population can cause dizziness, syncope, and weakness (Weber & Kelley 2009). For example, serotonin reuptake inhibitors and tricyclic antidepressants (Kerse et al. 2008), antipsychotic agents (Rigler et al. 2013), benzodiazepines, anticonvulsants (Lavsa et al. 2010), and anti-arrhythmics (Tinetti 2003) are all linked to increased risk for falling. Older adult mental health inpatient populations are comprised of patients who primarily have a neurocognitive disorder or those with a mental illness, as outlined in the Diagnostic and Statistical Manual of Mental Health Disorders,
4
5th Edition (DSM-V) (American Psychiatric Association 2013), and the International Classification of Disorders–10th Revision (ICD-10) (World Health Organization 1992). The DSM-V term ‘neurocognitive disorder’, covers disorders, such as ‘dementias, delirium, amnesic disorders and disorders previously defined as other cognitive disorders’ (p. 591–643). Cognitive deficits are the primary indicator of neurocognitive disorders, but not for mental illnesses which include ‘schizophrenia, depression and bipolar disorder’ (p. 87–188). Chapter 5 of the ICD-10, ‘Mental and behavioural disorders – (F00–F99)’ include those of psychological development, with the exception being those listed (F00–F10) ‘neurocognitive, including symptomatic, mental disorders’ (p. 312–320). The disorders covered in Chapter 6 ‘Diseases of the nervous system – (G00-G99)’ include inflammatory, systemic, or degenerative diseases of the central nervous system. All of these ICD-10 codes are represented in older adult mental health populations, and while it is well known that cognitively-impaired older adults constitute a high-risk group for accidental falls (Harlein et al. 2011), older adults with a primary mental illness also regularly fall (Heslop et al. 2012). A history of falling is a risk factor for future falls (Australian Commission on Safety and Quality in Health Care 2009), and sustaining a fall during hospitalization reduces a patient’s ability to return home on discharge (Karmel et al. 2007). Alteration in balance, functional mobility, muscle strength, and the fear of falling are all factors that impact on the ongoing quality of life of elderly people following a fall (Ozcan et al. 2005). However, the impact of falls on mental health outcomes in older adult mental health patients remains relatively unexplored. The present article reports on research utilizing Health of the Nation Outcome Scale for people over the age of 65 (HoNOS65+) scores recorded in Australian National Outcome Casemix Collection (NOCC) data that examined the mental health outcomes of a cohort of 65 patients who sustained a fall and 73 non-fallers admitted to an older adult mental health service (OAMHS), and with state and national HoNOS65+ data. NOCC data were introduced in Australia under the National Mental Health Strategy, which commenced in 1992, and its importance has been reinforced in all subsequent national mental health plans (Commonwealth of Australia 2009). NOCC data provide a framework for the national assessment of outcomes of services provided to people with mental illness, and an assessment of whether these services meet national outcome standards. The NOCC data comprise clinician- and consumer-rated measures, allowing individuals to map their mental health journey over time. The information collected can
K. R. HESLOP AND D. G. WYNADEN
also be used to help mental health services plan for improvements in service delivery (Mental Health Information Development 2003). The HoNOS65+ is one scale used in NOCC data. The HoNOS65+ was developed to rate mental health improvement over time (Burns et al. 1999). It consists of 12 items and covers problems that might be experienced by people with a significant mental illness. Each item is rated on a five-point scale (0 = no problem, 1–4 = minor problem, 5 = very severe problem). The clinician rates each item, usually over a period of the previous 2 weeks (or, in Australia, the 3 days prior to discharge in acute inpatient settings (Pirkis et al. 2005)), and in doing so, draws on all relevant, available information about the patient from a variety of sources. The HoNOS65+ takes approximately 5 min to complete, and is done when the patient is admitted and discharged from hospital and every 3 months while they are being case managed and living in the community. This repeated assessment captures the person’s mental health journey and any changes occurring over time (Mental Health Information Development 2003). The HoNOS65+ has good demonstrated concurrent validity, good interrater reliability, and adequate sensitivity to change and feasibility and utility (Pirkis et al. 2005).
METHOD Admission and discharge HoNOS65+ scores at four OAMHS were collected for all patients who sustained falls during hospitalization, and for a group of age-, sex-, and diagnosis-matched non-fallers who were admitted to the same OAMHS when the falls occurred. Data were collected between 1 July 2012 and 28 February 2014 as part of a larger study funded through a quality and safety grant from the Western Australian Department of Health, Australia. Ethics approval was obtained from the health service and one university to conduct the research. The admission and discharge HoNOS65+ scores of fallers and non-fallers were analysed to compare the mental health outcomes, and comparisons were then made with state and national discharge data for this patient population. All data were analysed using IBM SPSS Statistics 22 package (IBM Software Group, Chicago, IL, USA). Descriptive statistics were used to compare sex, age, ICD-10 diagnoses, and length of stay. One-way analysis of variance (ANOVA) was conducted with groups (fallers or non-fallers) as the dependent variable to determine differences in admission HoNOS65+ scores between fallers and non-fallers. Local HoNOS65+ data were compared to aggregated state and national data taken from the Australian Mental Health Outcomes and Classification Networks © 2015 Australian College of Mental Health Nurses Inc.
IMPACT OF FALLS ON MENTAL HEALTH OUTCOMES
data portal (Australian Mental Health Outcomes and Classification Network 2015). Independent samples t-tests were used to test the hypothesis that there was an improvement in mean HoNOS65+ between admission and discharge scores in the local, state, and national older adult inpatient populations:
5 TABLE 1: Demographics (n = 65) Total
%
45 20
69.2 30.8
3 14 32 16
4.6 21.5 49.2 24.7
54 11
83.1 16.9
43 11 3 7 1
66.2 16.9 4.6 10.8 1.5
4 10 17 7 19 8 65
6.2 15.4 26.1 10.8 29.2 12.3
Sex
where x1 and x2 are the means of the two samples, Δ is the hypothesized difference between the population means, s1 and s2 are the standard deviations of the two samples, and n 1and n 2 are the sizes of the two samples. To determine statistically-significant differences, the null hypothesis (that is there is no difference between mean admission and discharge HoNOS65+ scores) was tested. The null hypothesis was mathematically expressed as: μ1 – μ2 = 0, where μ1 represents admission HoNOS65+ scores, and μ2 represents discharge HoNOS65+ scores. An observed difference in mean HoNOS65+ scores between admission and discharge is mathematically expressed as: μd = μ1 – μ2. The null hypothesis was rejected when μ1 – μ2 = 0 at the 0.05 level of significance using a two-tail test of significance.
Male Female Age (years) 50–59 60–69 70–79 >80 Mental Health Act Status Voluntary Involuntary Place of birth Australia/NZ UK Asia Europe Middle East Length of stay (days) 1–14 15–28 29–56 57–84 85–168 ≥169 Total
RESULTS
TABLE 2: Number of falls sustained per patient (n = 65)
t ¼ x1 x2 Δ=ðs1 =n1 Þ þ ðs2 =n2 Þ;
At the four OAMHS, 122 falls were sustained by 65 patients between 1 July 2012 and 28 February 2014, representing 19.3% of the 633 admissions to the four OAMHS over this period. The demographic details and admission status under the 1996 Western Australian Mental Health Act (Government of Western Australia 1996) of those who sustained a fall are outlined in Table 1. Forty patients (61.5%) who fell sustained a single fall, while 25 (38.5%) sustained multiple falls. Of note were two patients who sustained eight falls, and one patient who sustained 10 falls (see Table 2). The highest number of falls occurred in patients who had ‘organic mental disorders’ (ICD-10 diagnostic groups F00–F09), with seven patients who had ‘unspecified dementia’ (F03) sustaining 21 falls. One patient with an ICD-10 diagnosis of ‘other degenerative disorder of the nervous system – (G31.8)’ experienced 10 falls while hospitalized, and was the study group’s highest faller (see Table 3 for other diagnoses assigned to patients who fell during hospitalization). The 65 patients sustained 122 falls across all stages of their hospital stay (Table 4). This reinforces the high falls risk of this population and the need for close supervision of patients at all times. © 2015 Australian College of Mental Health Nurses Inc.
Falls (n) 1 2 3 4 5 6 8 10 Total
Frequency
Total falls
40 13 5 1 1 1 2 1
40 26 15 4 5 6 16 10 122
HoNOS65+ When data were analysed by patients, it was noted that there were less fallers than non-fallers (65 compared with 73). This variation in non-fallers occurred because several patients sustained multiple falls, and on eight occasions, their previously-matched non-faller control had been discharged, and so the patient on a subsequent fall had to be matched with an additional non-faller. A one-way ANOVA was conducted with group (fallers or non-fallers) as the dependent variable to determine if there were any group differences in admission HoNOS65+ scores between fallers and non-fallers. At the time of admission, there were significant statistical between-group
6
K. R. HESLOP AND D. G. WYNADEN
TABLE 3: Primary ICD-10 diagnoses on discharge of the 65 patients who experienced 122 falls ICD-10 code F00–F09
Organic, including symptomatic mental disorders
F10–F19 F20–F29
Mental & behavioural disorders due to psychoactive substance use Schizophrenia, schizotypal and delusional disorders
F30–F39
Mood (Affective) disorders
F40–F49 F80–F89
Neurotic, stress related and somatoform disorders Disorders of psychological development
F90–F99
Behavioural syndromes associated with onset usually occurring in the childhood and adolescence Inflammatory diseases if the central nervous system Extrapyramidal and movement disorders Systemic atrophies primarily affecting the central nervous system
G10–G19 G20–26 G30–G39
G90–G99 J10–J19 J20–J29 J60–J69 N17–N19 R40–R46
Other disorders of the nervous system Influenza and pneumonia Other acute lower respiratory infections Lung diseases due to external agents Renal failure Symptoms and signs involving cognition, perception, emotional state and behaviour
Total
Patients
Frequency
Totals
F00.0 F00.9 F01.9 F02.3 F03 F05.1 F05.9 F06 F06.8 F10.6
1 2 4 1 7 1 1 1 1 1
3 6 9 2 21 3 1 1 2 1
48 1
F20.0 F20.9 F25.0 F25.9 F31.1 F31.5 F31.6 F31.9 F32.20 F32.30 F32.9 F33.1 F33.3 F41.9 F84.0 F84.1 F91.9
3 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1
4 4 1 1 1 1 1 1 2 2 2 1 3 1 2 2 3
G10 G20 G30.9 G31.0 G31.8 G31.9 G93.8 J18.9 J22 J69.0 N17.9 R41.8
1 2 11 1 1 1 1 1 2 1 1 1
1 2 15 2 10 3 1 2 2 1 1 1
10
14 1 4 3 1 2
30 1 2 2 1 1 1 122
ICD-10, International Classification of Disorders–10th Revision.
differences in item 5: physical illness or disability problems (fallers’ mean score = 1.44, standard deviation (SD) = 1.6; non-fallers mean score = 1.58, SD = 1.7 (f = 8.38 (df1), P = 0.005)). Although non-fallers had higher mean scores suggesting greater disability, neither score was considered ‘clinically significant’, that is greater than 2 (Philip Burgess et al. 2009). Significant differences were observed on the admission ‘impairment subscale’ (fallers’ mean score = 4.43, SD =2.1; non-fallers’ mean score = 3.53, SD = 2.1 (f = 6.18 (df1), P = 0.014)), suggesting fallers had greater
‘impairment’. However, it is likely that this difference reflects the differences in admission scores noted in item 4: ‘cognitive problems’. These data are difficult to interpret, as there were no significant differences in other item or subscale scores at admission, suggesting that fallers and non-fallers were generally homogenous in their symptom profile. When admission HoNOS65+ scores were compared with discharge scores, fallers showed less improvement across most items (as reflected in total scores). The non© 2015 Australian College of Mental Health Nurses Inc.
IMPACT OF FALLS ON MENTAL HEALTH OUTCOMES TABLE 4: Number of days from admission to fall event sustained (n = 122) Days
Total
0–6 7–13 14–20 21–27 28–55 56–90 >91 Total
22 22 15 11 26 13 13 122
faller group made significant improvements in behavioural disturbances, non-accidental self-injury, problem drinking and drug taking, hallucinations and delusions, other mental problems, and problems with relationships, and on both the behavioural problems and social problems subscales. Fallers only made improvements on one item scale, ‘depressive symptoms’, where both fallers and non-fallers experienced significant improvement, and on one subscale, ‘symptomatic problems’ (see Table 5).
Comparing population means In order to determine whether older adults admitted to a mental health unit experience an improvement in their mental health outcome mean total HoNOS65+ scores and subscale scores (social problem, behavioural problem, symptomatic problem, and impairment subscales) on admission, we compared mean total HoNOS65+ discharge scores and subscale discharge scores using a t-test for two independent samples. It can be seen from Table 6 that national and state HoNOS65+ scores indicate that patients admitted to OAMHS generally experience an improvement in their mental health from admission to discharge (as indicated by rejection of the null hypothesis). However, it is also noted that older adults who sustained a fall in this sample did not experience improvements in total HoNOS65+ scores or in social, behavioural, or symptomatic problem subscales compared to non-fallers who were matched for age, sex, diagnoses and admission date.
DISCUSSION It is widely acknowledged that, as a group, people with a severe mental illness have poorer levels of physical health and die earlier than people of the same age in the general population (Colton & Manderscheid 2006). The findings of this research also highlight the complex interactions that adverse events, such as falls, have on the mental health outcomes of hospitalized older adults diagnosed with © 2015 Australian College of Mental Health Nurses Inc.
7
neurocognitive disorders or mental illnesses. Generally, HONOS65+ scores improve with routine mental health care (Cheung & Strachan 2007; Veerbeek et al. 2014). While Australian state and national HoNOS65+ data demonstrate that older adults generally experience improved HoNOS65+ discharge scores, the 65 patients in the present study who fell did not follow this trend. These patients demonstrated poorer outcomes on three of the four HoNOS65+ subscale ratings (social, behavioural, and symptomatic problems). While it is difficult to determine the exact reasons for this outcome, it is important to examine the difference within the context of care provision in OAMHS. Falls happen throughout all stages of hospitalization, and close observation, along with assessment using a standardized falls risk-management tool that measures changes in falls risk over time is identified as best practice (Chang et al. 2004). Such assessment is recommended on admission, following a fall and when there is a change in medication or in the patient’s level of agitation and symptom psychopathology (Van Leuven 2010). Because many of the drugs used with this patient population can cause dizziness and weakness (Glab et al. 2014), and are linked to increased falls risk, routine monitoring of lying and standing blood pressure is an essential part of an effective falls management programme, as well as a routine assessment of sedation and medication-induced movement disorders (Iaboni & Flint 2013). The lack of improvement in the patients who fell across HoNOS65+ subscales of social, behavioural, or symptomatic problems could have occurred for a variety of reasons. Pain, stiffness, and unresolved injuries associated with the fall, which were not accurately identified and treated, could lead to behaviours that could be misinterpreted by clinicians as associated with mental health deterioration. For example, these unresolved injuries could lead to delirium that remains undiagnosed in patients with existing cognitive decline (Hare et al. 2008; Speed et al. 2007). In the extreme, these could result in the patient not returning home on discharge and could have a resulting continued impact on quality of life outcomes (Speed et al. 2007). This hidden impact of falls Sequelae highlights the need for the clinician completing the discharge HoNOS65+ to be familiar with the patient over the preceding 3-day period being rated. A lack of knowledge and awareness in staff of the ongoing impact associated with falling on changes in mental state is also suggested as accounting for some of the differences in mental health outcomes between the fallers and non-fallers in this study. The use of validated scales, such as the Mini Mental State Examination
8
K. R. HESLOP AND D. G. WYNADEN
TABLE 5: HoNOS 65+ scores at admission and discharge in fallers (n = 65) and non-fallers (n = 73) Fallers Item scores
Adx/Dis
1. Behavioural disturbance 2. Non-accidental self-injury 3. Problem drinking or drug taking 4. Cognitive problems 5. Physical illness or disability problems 6. Hallucinations and delusions 7. Depressive symptoms 8. Other mental problems 9. Problems with relationships 10.Problems in activity of daily living 11. Problems with living conditions 12. Problems with occupation or activity Subscales Behavioural problems Impairment Social problems Symptomatic problems Total score
Non-fallers
Mean
SD
d.f.
F
P-value
Mean
SD
d.f.
F
Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis
1.8 1.49 0.67 0.26 0.42 0.25 2.4 2.23 2.05 1.92 1.44 0.98 1.78 1.09 1.73 1.32 1.56 1.06 2.25 2.21 1.27 0.92 1.6 1.4
1.41 1.09 1.54 0.84 1.46 1.34 1.27 1.45 1.31 1.33 1.62 1.15 1.58 0.97 1.68 1.3 2.12 1.61 1.28 1.5 1.91 1.62 2.4 1.9
1
1.611
0.207
10.094
2.905
0.091
1
14.3
1
0.409
0.524
1
0.439
0.509
1
0.262
0.61
1
2.817
0.096
1
7.352
0.008*
1
1.966
0.164
1
1.944
0.166
1
0.031
0.861
1
1.043
0.309
1
0.239
0.626
1.44 1.14 0.95 0.24 0.72 0.17 1.35 1.57 1.22 1.29 1.72 1.57 1.78 1.33 1.36 1.122 1.9 1.53 1.39 1.49 1.6 1.19 1.29 1.32
1
1
1.85 1.12 0.52 0.06 0.29 0.03 2.05 1.94 1.38 1.25 1.58 0.97 1.68 0.74 1.57 0.92 1.75 0.95 1.89 1.55 1.15 0.74 1.05 0.82
Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis
2.64 1.88 4.43 4.16 5.24 5.3 4.69 3.56 17.07 14.89
2.34 1.76 2.05 2.24 3.9 4.3 2.644 2.5 7.629 8.478
1
3.872
0.052
1
0.464
0.497
1
0.006
0.941
1
5.525
0.02*
1
2.091
0.151
2.61 1.27 3.52 3.17 5.25 3.93 4.95 3.44 16.37 10.99
2.11 1.28 2.13 2.44 3.88 3.88 2.98 8.06 7.43 7.96
P-value 0.002*
International Journal of Mental Health Nursing (2016) 25, 3–11
doi: 10.1111/inm.12164
Feature Article
Impact of falls on mental health outcomes for older adult mental health patients: An Australian study Karen Ruth Heslop, PhD 1,2 and Dianne Gaye Wynaden, PhD 2,3 1
Royal Perth Hospital, 2School of Nursing and Midwifery, Curtin University, and 3Fremantle Mental Health Services Perth, Western Australia, Australia
ABSTRACT: 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. KEY WORDS: falls, Health of the Nation Outcome Scale scores, mental health outcomes, National Outcome Casemix Collection, older adult mental health service.
INTRODUCTION AND BACKGROUND The health-care cost associated with falls in people 65 years and older is estimated by the World Health Organization at A$4913 per fall (World Health Organization 2007). Falls add substantially to already stretched health budgets (Bradley 2013) and claim the lives of many older adults each year (Australian Bureau of Statistics 2012). A fall is ‘any unexplained event that results in the patient inadvertently coming to rest on the floor, ground, or lower level’ (Venes 2013, p.884). Approximately 30% of people over 65 years who live in the community fall each year (Gillespie et al. 2012), and falling is the most commonly-reported safety incident during hospitalization across all adult clinical areas (Oliver & Healy 2009). Correspondence: Karen Heslop, School of Nursing and Midwifery, Curtin University, Kent Street, Bentley U 1987, Perth, WA 6845, Australia. Email: [email protected] Karen Ruth Heslop, PhD. Dianne Gaye Wynaden, PhD. accepted August 2 2015; published online November 24 2015.
© 2015 Australian College of Mental Health Nurses Inc.
Falls are of particular concern in older adult mental health inpatient services, where fall rates are reported to be up to four times higher than in other hospital settings (Blair & Gruman 2005). Older adult mental health patients are an ambulant population, and this increases their risk for falling (Heslop et al. 2012), with many of these falls being unwitnessed (Oliver & Healy 2009). In addition, many of the medications used to manage primary or comorbid presenting health problems in this patient population can cause dizziness, syncope, and weakness (Weber & Kelley 2009). For example, serotonin reuptake inhibitors and tricyclic antidepressants (Kerse et al. 2008), antipsychotic agents (Rigler et al. 2013), benzodiazepines, anticonvulsants (Lavsa et al. 2010), and anti-arrhythmics (Tinetti 2003) are all linked to increased risk for falling. Older adult mental health inpatient populations are comprised of patients who primarily have a neurocognitive disorder or those with a mental illness, as outlined in the Diagnostic and Statistical Manual of Mental Health Disorders,
4
5th Edition (DSM-V) (American Psychiatric Association 2013), and the International Classification of Disorders–10th Revision (ICD-10) (World Health Organization 1992). The DSM-V term ‘neurocognitive disorder’, covers disorders, such as ‘dementias, delirium, amnesic disorders and disorders previously defined as other cognitive disorders’ (p. 591–643). Cognitive deficits are the primary indicator of neurocognitive disorders, but not for mental illnesses which include ‘schizophrenia, depression and bipolar disorder’ (p. 87–188). Chapter 5 of the ICD-10, ‘Mental and behavioural disorders – (F00–F99)’ include those of psychological development, with the exception being those listed (F00–F10) ‘neurocognitive, including symptomatic, mental disorders’ (p. 312–320). The disorders covered in Chapter 6 ‘Diseases of the nervous system – (G00-G99)’ include inflammatory, systemic, or degenerative diseases of the central nervous system. All of these ICD-10 codes are represented in older adult mental health populations, and while it is well known that cognitively-impaired older adults constitute a high-risk group for accidental falls (Harlein et al. 2011), older adults with a primary mental illness also regularly fall (Heslop et al. 2012). A history of falling is a risk factor for future falls (Australian Commission on Safety and Quality in Health Care 2009), and sustaining a fall during hospitalization reduces a patient’s ability to return home on discharge (Karmel et al. 2007). Alteration in balance, functional mobility, muscle strength, and the fear of falling are all factors that impact on the ongoing quality of life of elderly people following a fall (Ozcan et al. 2005). However, the impact of falls on mental health outcomes in older adult mental health patients remains relatively unexplored. The present article reports on research utilizing Health of the Nation Outcome Scale for people over the age of 65 (HoNOS65+) scores recorded in Australian National Outcome Casemix Collection (NOCC) data that examined the mental health outcomes of a cohort of 65 patients who sustained a fall and 73 non-fallers admitted to an older adult mental health service (OAMHS), and with state and national HoNOS65+ data. NOCC data were introduced in Australia under the National Mental Health Strategy, which commenced in 1992, and its importance has been reinforced in all subsequent national mental health plans (Commonwealth of Australia 2009). NOCC data provide a framework for the national assessment of outcomes of services provided to people with mental illness, and an assessment of whether these services meet national outcome standards. The NOCC data comprise clinician- and consumer-rated measures, allowing individuals to map their mental health journey over time. The information collected can
K. R. HESLOP AND D. G. WYNADEN
also be used to help mental health services plan for improvements in service delivery (Mental Health Information Development 2003). The HoNOS65+ is one scale used in NOCC data. The HoNOS65+ was developed to rate mental health improvement over time (Burns et al. 1999). It consists of 12 items and covers problems that might be experienced by people with a significant mental illness. Each item is rated on a five-point scale (0 = no problem, 1–4 = minor problem, 5 = very severe problem). The clinician rates each item, usually over a period of the previous 2 weeks (or, in Australia, the 3 days prior to discharge in acute inpatient settings (Pirkis et al. 2005)), and in doing so, draws on all relevant, available information about the patient from a variety of sources. The HoNOS65+ takes approximately 5 min to complete, and is done when the patient is admitted and discharged from hospital and every 3 months while they are being case managed and living in the community. This repeated assessment captures the person’s mental health journey and any changes occurring over time (Mental Health Information Development 2003). The HoNOS65+ has good demonstrated concurrent validity, good interrater reliability, and adequate sensitivity to change and feasibility and utility (Pirkis et al. 2005).
METHOD Admission and discharge HoNOS65+ scores at four OAMHS were collected for all patients who sustained falls during hospitalization, and for a group of age-, sex-, and diagnosis-matched non-fallers who were admitted to the same OAMHS when the falls occurred. Data were collected between 1 July 2012 and 28 February 2014 as part of a larger study funded through a quality and safety grant from the Western Australian Department of Health, Australia. Ethics approval was obtained from the health service and one university to conduct the research. The admission and discharge HoNOS65+ scores of fallers and non-fallers were analysed to compare the mental health outcomes, and comparisons were then made with state and national discharge data for this patient population. All data were analysed using IBM SPSS Statistics 22 package (IBM Software Group, Chicago, IL, USA). Descriptive statistics were used to compare sex, age, ICD-10 diagnoses, and length of stay. One-way analysis of variance (ANOVA) was conducted with groups (fallers or non-fallers) as the dependent variable to determine differences in admission HoNOS65+ scores between fallers and non-fallers. Local HoNOS65+ data were compared to aggregated state and national data taken from the Australian Mental Health Outcomes and Classification Networks © 2015 Australian College of Mental Health Nurses Inc.
IMPACT OF FALLS ON MENTAL HEALTH OUTCOMES
data portal (Australian Mental Health Outcomes and Classification Network 2015). Independent samples t-tests were used to test the hypothesis that there was an improvement in mean HoNOS65+ between admission and discharge scores in the local, state, and national older adult inpatient populations:
5 TABLE 1: Demographics (n = 65) Total
%
45 20
69.2 30.8
3 14 32 16
4.6 21.5 49.2 24.7
54 11
83.1 16.9
43 11 3 7 1
66.2 16.9 4.6 10.8 1.5
4 10 17 7 19 8 65
6.2 15.4 26.1 10.8 29.2 12.3
Sex
where x1 and x2 are the means of the two samples, Δ is the hypothesized difference between the population means, s1 and s2 are the standard deviations of the two samples, and n 1and n 2 are the sizes of the two samples. To determine statistically-significant differences, the null hypothesis (that is there is no difference between mean admission and discharge HoNOS65+ scores) was tested. The null hypothesis was mathematically expressed as: μ1 – μ2 = 0, where μ1 represents admission HoNOS65+ scores, and μ2 represents discharge HoNOS65+ scores. An observed difference in mean HoNOS65+ scores between admission and discharge is mathematically expressed as: μd = μ1 – μ2. The null hypothesis was rejected when μ1 – μ2 = 0 at the 0.05 level of significance using a two-tail test of significance.
Male Female Age (years) 50–59 60–69 70–79 >80 Mental Health Act Status Voluntary Involuntary Place of birth Australia/NZ UK Asia Europe Middle East Length of stay (days) 1–14 15–28 29–56 57–84 85–168 ≥169 Total
RESULTS
TABLE 2: Number of falls sustained per patient (n = 65)
t ¼ x1 x2 Δ=ðs1 =n1 Þ þ ðs2 =n2 Þ;
At the four OAMHS, 122 falls were sustained by 65 patients between 1 July 2012 and 28 February 2014, representing 19.3% of the 633 admissions to the four OAMHS over this period. The demographic details and admission status under the 1996 Western Australian Mental Health Act (Government of Western Australia 1996) of those who sustained a fall are outlined in Table 1. Forty patients (61.5%) who fell sustained a single fall, while 25 (38.5%) sustained multiple falls. Of note were two patients who sustained eight falls, and one patient who sustained 10 falls (see Table 2). The highest number of falls occurred in patients who had ‘organic mental disorders’ (ICD-10 diagnostic groups F00–F09), with seven patients who had ‘unspecified dementia’ (F03) sustaining 21 falls. One patient with an ICD-10 diagnosis of ‘other degenerative disorder of the nervous system – (G31.8)’ experienced 10 falls while hospitalized, and was the study group’s highest faller (see Table 3 for other diagnoses assigned to patients who fell during hospitalization). The 65 patients sustained 122 falls across all stages of their hospital stay (Table 4). This reinforces the high falls risk of this population and the need for close supervision of patients at all times. © 2015 Australian College of Mental Health Nurses Inc.
Falls (n) 1 2 3 4 5 6 8 10 Total
Frequency
Total falls
40 13 5 1 1 1 2 1
40 26 15 4 5 6 16 10 122
HoNOS65+ When data were analysed by patients, it was noted that there were less fallers than non-fallers (65 compared with 73). This variation in non-fallers occurred because several patients sustained multiple falls, and on eight occasions, their previously-matched non-faller control had been discharged, and so the patient on a subsequent fall had to be matched with an additional non-faller. A one-way ANOVA was conducted with group (fallers or non-fallers) as the dependent variable to determine if there were any group differences in admission HoNOS65+ scores between fallers and non-fallers. At the time of admission, there were significant statistical between-group
6
K. R. HESLOP AND D. G. WYNADEN
TABLE 3: Primary ICD-10 diagnoses on discharge of the 65 patients who experienced 122 falls ICD-10 code F00–F09
Organic, including symptomatic mental disorders
F10–F19 F20–F29
Mental & behavioural disorders due to psychoactive substance use Schizophrenia, schizotypal and delusional disorders
F30–F39
Mood (Affective) disorders
F40–F49 F80–F89
Neurotic, stress related and somatoform disorders Disorders of psychological development
F90–F99
Behavioural syndromes associated with onset usually occurring in the childhood and adolescence Inflammatory diseases if the central nervous system Extrapyramidal and movement disorders Systemic atrophies primarily affecting the central nervous system
G10–G19 G20–26 G30–G39
G90–G99 J10–J19 J20–J29 J60–J69 N17–N19 R40–R46
Other disorders of the nervous system Influenza and pneumonia Other acute lower respiratory infections Lung diseases due to external agents Renal failure Symptoms and signs involving cognition, perception, emotional state and behaviour
Total
Patients
Frequency
Totals
F00.0 F00.9 F01.9 F02.3 F03 F05.1 F05.9 F06 F06.8 F10.6
1 2 4 1 7 1 1 1 1 1
3 6 9 2 21 3 1 1 2 1
48 1
F20.0 F20.9 F25.0 F25.9 F31.1 F31.5 F31.6 F31.9 F32.20 F32.30 F32.9 F33.1 F33.3 F41.9 F84.0 F84.1 F91.9
3 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1
4 4 1 1 1 1 1 1 2 2 2 1 3 1 2 2 3
G10 G20 G30.9 G31.0 G31.8 G31.9 G93.8 J18.9 J22 J69.0 N17.9 R41.8
1 2 11 1 1 1 1 1 2 1 1 1
1 2 15 2 10 3 1 2 2 1 1 1
10
14 1 4 3 1 2
30 1 2 2 1 1 1 122
ICD-10, International Classification of Disorders–10th Revision.
differences in item 5: physical illness or disability problems (fallers’ mean score = 1.44, standard deviation (SD) = 1.6; non-fallers mean score = 1.58, SD = 1.7 (f = 8.38 (df1), P = 0.005)). Although non-fallers had higher mean scores suggesting greater disability, neither score was considered ‘clinically significant’, that is greater than 2 (Philip Burgess et al. 2009). Significant differences were observed on the admission ‘impairment subscale’ (fallers’ mean score = 4.43, SD =2.1; non-fallers’ mean score = 3.53, SD = 2.1 (f = 6.18 (df1), P = 0.014)), suggesting fallers had greater
‘impairment’. However, it is likely that this difference reflects the differences in admission scores noted in item 4: ‘cognitive problems’. These data are difficult to interpret, as there were no significant differences in other item or subscale scores at admission, suggesting that fallers and non-fallers were generally homogenous in their symptom profile. When admission HoNOS65+ scores were compared with discharge scores, fallers showed less improvement across most items (as reflected in total scores). The non© 2015 Australian College of Mental Health Nurses Inc.
IMPACT OF FALLS ON MENTAL HEALTH OUTCOMES TABLE 4: Number of days from admission to fall event sustained (n = 122) Days
Total
0–6 7–13 14–20 21–27 28–55 56–90 >91 Total
22 22 15 11 26 13 13 122
faller group made significant improvements in behavioural disturbances, non-accidental self-injury, problem drinking and drug taking, hallucinations and delusions, other mental problems, and problems with relationships, and on both the behavioural problems and social problems subscales. Fallers only made improvements on one item scale, ‘depressive symptoms’, where both fallers and non-fallers experienced significant improvement, and on one subscale, ‘symptomatic problems’ (see Table 5).
Comparing population means In order to determine whether older adults admitted to a mental health unit experience an improvement in their mental health outcome mean total HoNOS65+ scores and subscale scores (social problem, behavioural problem, symptomatic problem, and impairment subscales) on admission, we compared mean total HoNOS65+ discharge scores and subscale discharge scores using a t-test for two independent samples. It can be seen from Table 6 that national and state HoNOS65+ scores indicate that patients admitted to OAMHS generally experience an improvement in their mental health from admission to discharge (as indicated by rejection of the null hypothesis). However, it is also noted that older adults who sustained a fall in this sample did not experience improvements in total HoNOS65+ scores or in social, behavioural, or symptomatic problem subscales compared to non-fallers who were matched for age, sex, diagnoses and admission date.
DISCUSSION It is widely acknowledged that, as a group, people with a severe mental illness have poorer levels of physical health and die earlier than people of the same age in the general population (Colton & Manderscheid 2006). The findings of this research also highlight the complex interactions that adverse events, such as falls, have on the mental health outcomes of hospitalized older adults diagnosed with © 2015 Australian College of Mental Health Nurses Inc.
7
neurocognitive disorders or mental illnesses. Generally, HONOS65+ scores improve with routine mental health care (Cheung & Strachan 2007; Veerbeek et al. 2014). While Australian state and national HoNOS65+ data demonstrate that older adults generally experience improved HoNOS65+ discharge scores, the 65 patients in the present study who fell did not follow this trend. These patients demonstrated poorer outcomes on three of the four HoNOS65+ subscale ratings (social, behavioural, and symptomatic problems). While it is difficult to determine the exact reasons for this outcome, it is important to examine the difference within the context of care provision in OAMHS. Falls happen throughout all stages of hospitalization, and close observation, along with assessment using a standardized falls risk-management tool that measures changes in falls risk over time is identified as best practice (Chang et al. 2004). Such assessment is recommended on admission, following a fall and when there is a change in medication or in the patient’s level of agitation and symptom psychopathology (Van Leuven 2010). Because many of the drugs used with this patient population can cause dizziness and weakness (Glab et al. 2014), and are linked to increased falls risk, routine monitoring of lying and standing blood pressure is an essential part of an effective falls management programme, as well as a routine assessment of sedation and medication-induced movement disorders (Iaboni & Flint 2013). The lack of improvement in the patients who fell across HoNOS65+ subscales of social, behavioural, or symptomatic problems could have occurred for a variety of reasons. Pain, stiffness, and unresolved injuries associated with the fall, which were not accurately identified and treated, could lead to behaviours that could be misinterpreted by clinicians as associated with mental health deterioration. For example, these unresolved injuries could lead to delirium that remains undiagnosed in patients with existing cognitive decline (Hare et al. 2008; Speed et al. 2007). In the extreme, these could result in the patient not returning home on discharge and could have a resulting continued impact on quality of life outcomes (Speed et al. 2007). This hidden impact of falls Sequelae highlights the need for the clinician completing the discharge HoNOS65+ to be familiar with the patient over the preceding 3-day period being rated. A lack of knowledge and awareness in staff of the ongoing impact associated with falling on changes in mental state is also suggested as accounting for some of the differences in mental health outcomes between the fallers and non-fallers in this study. The use of validated scales, such as the Mini Mental State Examination
8
K. R. HESLOP AND D. G. WYNADEN
TABLE 5: HoNOS 65+ scores at admission and discharge in fallers (n = 65) and non-fallers (n = 73) Fallers Item scores
Adx/Dis
1. Behavioural disturbance 2. Non-accidental self-injury 3. Problem drinking or drug taking 4. Cognitive problems 5. Physical illness or disability problems 6. Hallucinations and delusions 7. Depressive symptoms 8. Other mental problems 9. Problems with relationships 10.Problems in activity of daily living 11. Problems with living conditions 12. Problems with occupation or activity Subscales Behavioural problems Impairment Social problems Symptomatic problems Total score
Non-fallers
Mean
SD
d.f.
F
P-value
Mean
SD
d.f.
F
Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis
1.8 1.49 0.67 0.26 0.42 0.25 2.4 2.23 2.05 1.92 1.44 0.98 1.78 1.09 1.73 1.32 1.56 1.06 2.25 2.21 1.27 0.92 1.6 1.4
1.41 1.09 1.54 0.84 1.46 1.34 1.27 1.45 1.31 1.33 1.62 1.15 1.58 0.97 1.68 1.3 2.12 1.61 1.28 1.5 1.91 1.62 2.4 1.9
1
1.611
0.207
10.094
2.905
0.091
1
14.3
1
0.409
0.524
1
0.439
0.509
1
0.262
0.61
1
2.817
0.096
1
7.352
0.008*
1
1.966
0.164
1
1.944
0.166
1
0.031
0.861
1
1.043
0.309
1
0.239
0.626
1.44 1.14 0.95 0.24 0.72 0.17 1.35 1.57 1.22 1.29 1.72 1.57 1.78 1.33 1.36 1.122 1.9 1.53 1.39 1.49 1.6 1.19 1.29 1.32
1
1
1.85 1.12 0.52 0.06 0.29 0.03 2.05 1.94 1.38 1.25 1.58 0.97 1.68 0.74 1.57 0.92 1.75 0.95 1.89 1.55 1.15 0.74 1.05 0.82
Adx Dis Adx Dis Adx Dis Adx Dis Adx Dis
2.64 1.88 4.43 4.16 5.24 5.3 4.69 3.56 17.07 14.89
2.34 1.76 2.05 2.24 3.9 4.3 2.644 2.5 7.629 8.478
1
3.872
0.052
1
0.464
0.497
1
0.006
0.941
1
5.525
0.02*
1
2.091
0.151
2.61 1.27 3.52 3.17 5.25 3.93 4.95 3.44 16.37 10.99
2.11 1.28 2.13 2.44 3.88 3.88 2.98 8.06 7.43 7.96
P-value 0.002*
