Patient Falls and Psychiatric Medications

Patient falls, some of which are fatal, were the subject of a sentinel event alert by The Joint Commission on Accreditation of Healthcare Organizations in 2000, and fall reduction was a 2014 Joint Commission national patient safety goal. In 2014, The Joint Commission’s Center for Transforming Healthcare reported that a pilot project to prevent falls was able to reduce both falls and injuries from falls at the 7 participating organizations.

Behavioral health facilities have not been rigorously studied, but a 2009 study in Pennsylvania found that falls in psychiatric hospitals were more frequent than in medical-surgical facilities (21.7% vs 15.4%), with patient harm as a result of falls also greater in psychiatric facilities (9.6% vs 3.7%). The association of medications with falls was significantly greater in behavioral health facilities than in non–behavioral health hospitals (70.3% vs 57.6%).

Behavioral health units have a number of risk factors for falls. Many of the patients are taking multiple psychiatric as well as medical medications that can cause sedation and orthostatic hypotension. Some of the patients may also be confused or agitated, while others may have gait impairment or extrapyramidal symptoms. Detoxification of alcohol-, opioid-, or benzodiazepine-dependent patients presents a fall risk, even in younger patients, because patients may be in a delirium from the intoxicating substance and/or be cognitively impaired from the medications commonly used in detox protocols. A study of psychiatric inpatients found that risk factors for falls included a diagnosis of depression and confusion or disorientation. The majority of falls occurred when patients were attempting to get out of bed, walk to the bathroom at night, or move from a sitting to standing position.

A retrospective analysis of 148 psychiatric inpatients found that those who fell were more likely to have an acute medical condition, complain of more physical symptoms, and be prescribed more medications than those who didn’t fall. Fallers were significantly more likely than nonfallers to be taking antihypertensive medications (19% vs 3%) and clonazepam (42% vs 18%). Benzodiazepines generally appear to add to fall risk. In a study of nursing home residents, patients taking benzodiazepines experienced a 44% greater rate of falls than nonusers. Additionally, imidazopyridine sleep aids (eg, zolpidem) have been associated with confusion, daytime somnolence, and dizziness in older inpatients, and falls may result. Antidepressants and antipsychotics also may increase the risk of falls via drowsiness, imbalance, confusion, orthostatic hypotension, and involuntary muscle contraction.

The Centers for Medicare & Medicaid Services has taken a strong stand on antipsychotic medication by setting a goal to reduce the use of these medications in nursing homes by 30% from 2012 to the end of 2016, with exclusion only for the diagnoses of schizophrenia, Tourette’s syndrome, and Huntington’s disease. More studies should be done to look at which antipsychotics and doses are most risky for falls and if any may be deemed as less risky to use. One nursing home study found that, while falls were more common among residents taking high doses of quetiapine (> 150 mg/d) or risperidone (> 2 mg/d) compared with residents not taking an antipsychotic, low doses of quetiapine or risperidone and any dose of olanzapine were not associated with a higher risk of falls.

Medical professionals, especially psychiatrists, need to become more educated, aware, and involved in fall prevention. The Institute for Clinical Systems Improvement protocol summary to prevent falls in inpatients recommends that a complete falls assessment should be made by the physician, nurse, and pharmacist. Unnecessary medications need to be discontinued. Medications with the side effects of sedation, confusion, and orthostatic hypotension need to be evaluated and altered appropriately.

Financial disclosure:Dr King had no relevant personal financial relationships to report.