Community Pharmacists Have Distinct Role in Fall Prevention for Patients

Falls can result in injuries that result in hospitalization and mortality. Fall-related injuries can cause long-term impacts on health outcomes and overall quality of life. Addressing health issues stemming from falls can be an expensive endeavor, constituting around 0.85% to 1.5% of a country's total health care spending.¹ Pharmacists can play a significant role in early identification, continuous monitoring, and interventions to minimize the risk of falls (ROF).

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Falls in older patients can be caused by a variety of factors, including poor strength, instability, visual impairment, cognitive decline, and medications. Certain medications, particularly those that impact blood pressure or induce central nervous system side effects, can significantly elevate the ROF, particularly in individuals with pre-existing clinical conditions associated with balance and mobility.

Fall risk-increasing drugs (FRIDs) refer to a group of medications associated with an increased ROF among older adults, including benzodiazepines, antipsychotics, antidepressants, opioids, and sedative antihistamines. A systematic review has reported that the prevalence of FRID use at the time of a fall-related injury among older adults ranged from 65% to 93%.² Hence, the active involvement of pharmacists in assessing and closely monitoring the use of FRIDs among older patients is crucial. This proactive engagement with pharmacists offers opportunities to enhance medication management and reduce the ROF in this population.

In the community setting, community pharmacists have a vital role in reducing the ROF among older adults. Serving as primary health care contacts, they provide comprehensive medication therapy management and identify those at risk through patient interactions and assessments. Through medication reviews, community pharmacists can identify potentially inappropriate medications, including FRIDs. Collaborating with other health care providers, they can recommend de-prescribing FRIDs, promoting safer medication use, and mitigating the ROF. Additionally, community pharmacists offer consultation and education to older patients, raising awareness of medication-related fall risks.

Further, community pharmacists should also identify and educate older adults with vitamin D deficiencies, emphasizing the importance of daily vitamin D supplementation for bone, muscle, and nerve strength. A previous study found that a daily intake of 800 to 2000 IU of vitamin D could reduce hip fractures by 30%.³ In addition to promoting vitamin D intake for nutritional enhancement, community pharmacists could also consider advising older adults to incorporate sufficient calcium (e.g., milk, yogurt, cheese) and protein-rich foods (e.g., dairy, eggs, oily fish) into their diets. This approach serves to optimize musculoskeletal health and acts as a proactive strategy to prevent falls and fractures.

Low-risk older patients should receive education about fall prevention and exercise.⁴ Community pharmacists can also advise engaging in moderate to high challenge balance exercises, including Tai Chi for at least 2 hours per week, as Tai Chi can enhance balance and strength. The effectiveness of well-designed exercises (e.g., group-based Tai Chi) in reducing falls among community-dwelling older individuals has been demonstrated. For older patients at high risk of falls requiring intensive exercise programs, community pharmacists may consider referring them to qualified professionals such as physiotherapists, exercise physiologists, or trained exercise instructors.

References

1. Heinrich, S., Rapp, K., Rissmann, U., Becker, C., & König, H. H. (2010). Cost of falls in old age: A systematic review. In Osteoporosis International (Vol. 21, Issue 6, pp. 891–902). https://doi.org/10.1007/s00198-009-1100-1
2. Hart, L. A., Phelan, E. A., Yi, J. Y., Marcum, Z. A., & Gray, S. L. (2020). Use of Fall Risk–Increasing Drugs Around a Fall-Related Injury in Older Adults: A Systematic Review. In Journal of the American Geriatrics Society (Vol. 68, Issue 6, pp. 1334–1343). Blackwell Publishing Inc. https://doi.org/10.1111/jgs.16369
3. Bischoff-Ferrari, H. A., Willett, W. C., Orav, E. J., Lips, P., Meunier, P. J., Lyons, R. A., Flicker, L., Wark, J., Jackson, R. D., Cauley, J. A., Meyer, H. E., Pfeifer, M., Sanders, K. M., Stähelin, H. B., Theiler, R., & Dawson-Hughes, B. (2012). A Pooled Analysis of Vitamin D Dose Requirements for Fracture Prevention. New England Journal of Medicine, 367(1), 40–49. https://doi.org/10.1056/nejmoa1109617
4. Montero-Odasso, M., van der Velde, N., Martin, F. C., Petrovic, M., Tan, M. P., Ryg, J., Aguilar-Navarro, S., Alexander, N. B., Becker, C., Blain, H., Bourke, R., Cameron, I. D., Camicioli, R., Clemson, L., Close, J., Delbaere, K., Duan, L., Duque, G., Dyer, S. M., … Masud, T. (2022). World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing, 51(9). https://doi.org/10.1093/ageing/afac205