In the United States, the older adult population—defined as those 65 and older—is projected to grow to 83.7 million by 2050 (Ortman, Velkoff, & Hogan, 2014). Within this population, one in four older adults falls annually and one dies every 19 minutes as a result of falling (National Council on Aging, 2017). Older adults who fall contribute to an estimated 2.8 million emergency department visits, 800,000 hospitalizations, and more than 27,000 deaths annually (National Council on Aging, 2017). In 2015, in terms of direct medical costs to the U.S. health care system, fatal falls cost $637.2 million and non-fatal falls cost $31.3 billion (Burns, Stevens, & Lee, 2016). These costs are striking increases from 2000, when costs were approximately $200 million and $19 billion for fatal and non-fatal falls, respectively (Stevens, Corso, Finkelstein, & Miller, 2006). Indirect costs related to falls are more difficult to measure, with few studies assessing their societal consequences, including productivity losses from caregivers (Fu, n.d.; Henrich, Rapp, Rissmann, Becker, & König, 2010). Moreover, the physical and mental consequences of falls are often detrimental. In addition to increased mortality, older adults may experience a decrease in activities of daily living associated with physical decline, and a loss of independence as a result (Centers for Disease Control and Prevention [CDC], n.d.a; National Council on Aging, 2017). The psychological and emotional burden stemming from falls—including depression and social isolation—may further contribute to a cycle of diminished quality of life (Burns et al., 2016; National Council on Aging, 2017).
Medication-Related Risk Factors
Falls are associated with myriad risk factors, including intrinsic and extrinsic influences (Ambrose, Paul, & Hausdorff, 2013; O'Loughlin, Robitaille, Boivin, & Suissa, 1993). In addition to medical conditions and environmental hazards, certain medications are known to have a role in increasing fall risk (CDC, 2015; Tinetti, Speechley, & Ginter, 1988). These medications, collectively known as falls risk increasing drugs (FRIDs), include but are not limited to: psychotropic, opioid, antihypertensive, hypoglycemic, and anticholinergic agents, and are recognized by the American Geriatrics Society (AGS; AGS 2015 Beers Criteria Update Expert Panel, 2015) as potentially inappropriate for use in older adults (Table 1). These medications are potentially inappropriate for the older adult population, as their side effects may include orthostatic hypotension, blurred vision, dizziness, sedation, impaired psychomotor function, and increased cognitive impairment—all of which are associated with increased risk of falling (AGS 2015 Beers Criteria Update Expert Panel, 2015). Especially in the older adult population, where multiple FRIDs may be prescribed for various medical conditions, compounded side effects may pose a significant fall risk (AGS 2015 Beers Criteria Update Expert Panel, 2015). Moreover, the use of multiple FRIDs may contribute to polypharmacy—another risk factor for falls (O'Loughlin et al., 1993). Attention must be given to the collective drug burden aspect, not just one class of medication.
Medication Classes Associated With Falls and Fractures (FRIDs)
Role of Interdisciplinary Collaboration
Health care providers play a vital role in falls prevention. Studies have demonstrated the importance of an interdisciplinary or multidisciplinary approach in reducing fall rates and building trust among those involved in providing care (Baxter & Markle-Reid, 2009; Choi & Hector, 2012; Close et al., 1999). Choi and Hector (2012) conducted a meta-analysis of randomized controlled trials to assess the effectiveness of falls prevention initiatives and demonstrated that these programs reduced fall rates by 9% to 12% depending on the type of program. Hanley, Silke, and Murphy (2010) further established that such programs were cost-effective in reducing costs associated with falls in countries including Australia and New Zealand. In contrast, studies conducted by Hendriks, Bleijlevens, et al. (2008) and Hendriks, Evers, et al. (2008) in the Netherlands have concluded that multidisciplinary programs are ineffective and failed to demonstrate a reduction in falls, as well as decrease falls-associated costs. However, the majority of studies reviewed provided overwhelming support for an interdisciplinary approach to falls prevention, with evidence suggesting a decrease in fall rates (Baxter & Markle-Reid, 2009; Choi & Hector, 2012; Close et al., 1999; Hanley et al., 2010).
Although many of the above studies evaluated an interdisciplinary or multidisciplinary approach, few exist that evaluate the specific role of the pharmacist in falls prevention programs. Recommendations made by U.S. agencies, including the CDC and National Institute on Aging (NIA), state that medication reviews and management may reduce falls risk; however, the U.S. Preventive Services Task Force is hesitant to recommend medication discontinuations, based on insufficient evidence (Moyer, 2012). The few studies that investigated such practices had moderate or inclusive findings. For example, Royal, Smeaton, Avery, Hurwitz, and Sheikh (2006) conducted a meta-analysis of medication-related hospital admissions and found evidence to suggest that pharmacist-led medication reviews were moderately effective in reducing hospital admissions. In addition, research by Casteel, Blalock, Ferreri, Roth, and Demby (2011) demonstrated that the lack of coordination of care and communication between community pharmacists and prescribers impedes the potential benefits of a medication-centered interdisciplinary falls initiative.
A recent exploratory study by Turner, Brandt, Whittaker, Huang, and Simoni-Wastila (2017) examined the impact of a falls prevention education seminar for pharmacists and found that pharmacists were more likely to consider the feasibility of implementing a falls prevention initiative in their practice site after learning pertinent skills and tools. Research by Mott et al. (2014) further details the ongoing development of community-based, pharmacist-led falls prevention initiatives, and the efforts required to create an effective program. In an environment that encourages care coordination between health care professionals, pharmacists may provide an additional channel of care for older adults. For example, community pharmacists are optimally situated in practice settings that encourage communication and collaboration with patients. They can bridge gaps in care coordination between primary care providers and patients regarding polypharmacy, medication adherence and compliance, and inappropriate use of medicines. In addition, pharmacists can provide medication reconciliation, screen for FRIDs, and optimize medication use through medication therapy management. Furthermore, they can provide point-of-care services, such as falls prevention education and blood pressure monitoring. Providing such services to patients is a screening process that identifies those at risk for falls and brings potential concerns to the forefront for other providers.
International, federal, and nonprofit organizations have increasingly recognized the potential positive impact that pharmacists may have on falls prevention. Globally, the World Health Organization has recognized the need for interdisciplinary cooperation in falls prevention and notes that expanding the role of pharmacists to target medications taken by older adults may be a viable preventive measure (Scott, 2007). The CDC (n.d.b) recently released the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit, with a section dedicated to medication review. This toolkit focuses on a team-based approach, including all members involved—patients, caregivers, pharmacists, nurses, physical therapists, and other providers of the health care delivery team.
Collaboration, particularly between nurses and pharmacists, has the potential to reduce medication-related falls. Nurses practice in a wide range of settings and hold various responsibilities providing direct patient care, as well as having prescriptive authority. Readily accessible to patients, nurses have established patient–provider relationships and can assess for falls risk using materials provided by the CDC STEADI toolkit, National Council on Aging, and NIA (Table 2). For example, nurses can tailor the medications they prescribe to minimize FRIDs use. In collaboration with pharmacists, nurses can attain a comprehensive patient medication history to minimize polypharmacy and FRIDs use.
Falls Prevention Resources for Health Care Providers
Concurrently with falls prevention, promoting mobility is an area that has the potential to maximize the quality of life for falls patients (Growdon, Shorr, & Inouye, 2017). In this aspect, physical therapists can deliver valuable services, such as assessing mobility through a variety of measurements, including the Timed Up & Go, 30-Second Chair Stand, and 4-Stage Balance tests (CDC, n.d.c; Stevens, 2013). In addition to assessing patient risk through physical examinations that evaluate gait and balance, physical therapists may deliver services that improve muscle tone, strength, and flexibility to minimize the potential for future falls (Stevens, 2013).
Falls are often fatal for older adults (National Council on Aging, 2017). In addition to increased mortality, falls can contribute to diminished quality of life and activities of daily living (National Council on Aging, 2017). Immobility and physical dependence are consequences that may have long-lasting effects (CDC, n.d.a). Along with patients, caregivers may also be affected emotionally and financially (Fu, n.d.; Henrich et al., 2010). Thus, risk of falls poses a challenge to all facets of society, and efforts for prevention span across caregivers, health care providers, and policymakers. With efforts to raise awareness among health care providers of the growing, but latent, concern of falls, pharmacists and nurses are uniquely positioned to provide care to community-dwelling older adults. The need for care coordination among providers is essential in transitions of care, particularly for this vulnerable population.
- Ambrose, A.F., Paul, G. & Hausdorff, J.M. (2013). Risk factors for falls among older adults: A review of the literature. Maturitas, 75, 51–61. doi:10.1016/j.maturitas.2013.02.009 [CrossRef]
- American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 Updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63, 2227–2246. doi:10.1111/jgs.13702 [CrossRef]
- Baxter, P. & Markle-Reid, M. (2009). An interprofessional team approach to fall prevention for older home care clients ‘at risk’ of falling: Health care providers share their experiences. International Journal of Integrated Care, 9(2). doi:10.5334/ijic.317 [CrossRef]
- Burns, E.R., Stevens, J.A. & Lee, R. (2016). The direct costs of fatal and non-fatal falls among older adults—United States. Journal of Safety Research, 58, 99–103. doi:10.1016/j.jsr.2016.05.001 [CrossRef]
- Casteel, C., Blalock, S.J., Ferreri, S., Roth, M.T. & Demby, K.B. (2011). Implementation of a community pharmacy-based falls prevention program. American Journal of Geriatric Pharmacotherapy, 9, 310–319. doi:10.1016/j.amjopharm.2011.08.002 [CrossRef]
- Centers for Disease Control and Prevention. (n.d.a). Falls are leading cause of injury and death in older Americans. Retrieved from https://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html
- Centers for Disease Control and Prevention. (n.d.b). SAFE medication review framework: A team-based approach. Retrieved from https://www.cdc.gov/steadi
- Centers for Disease Control and Prevention. (n.d.c). Timed up & go. Retrieved from https://www.cdc.gov/steadi/pdf/STEADI-Assessment-TUG-508.pdf
- Centers for Disease Control and Prevention. (2015). Preventing falls: A guide to implementing effective community-based fall prevention programs. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/fallpreventionguide-2015-a.pdf
- Choi, M. & Hector, M. (2012). Effectiveness of intervention programs in preventing falls: A systematic review of recent 10 years and meta-analysis. Journal of the American Medical Directors Association, 13, 188e13–21. doi:10.1016/j.jamda.2011.04.022 [CrossRef]
- Close, J., Ellis, M., Hooper, R., Glucksman, E., Jackson, S. & Swift, C. (1999). Prevention of falls in the elderly trial (PROFET): A randomised controlled trial. The Lancet, 353, 93–97. doi:10.1016/S0140-6736(98)06119-4 [CrossRef]
- Fu, D. (n.d.). Health service impacts and costs of falls in older age. Retrieved from http://www.who.int/ageing/projects/4%20Health%20service%20impacts%20and%20costs%20of%20falls2.pdf
- Growdon, M.E., Shorr, R.I. & Inouye, S.K. (2017). The tension between promoting mobility and preventing falls in the hospital. JAMA Internal Medicine, 177, 759–760. doi:10.1001/jamainternmed.2017.0840 [CrossRef]
- Hanley, A., Silke, C. & Murphy, J. (2010). Community-based health efforts for the prevention of falls in the elderly. Clinical Interventions in Aging, 6, 19–25. doi:10.2147/CIA.S9489 [CrossRef]
- Hendriks, M.R., Bleijlevens, M.H., van Haastregt, J.C., Crebolder, H.F., Diederiks, J.P., Evers, S.M. & van Eijk, J.T. (2008). Lack of effectiveness of a multidisciplinary fall-prevention program in elderly people at risk: A randomized, controlled trial. Journal of the American Geriatrics Society, 56, 1390–1397. doi:10.1111/j.1532-5415.2008.01803.x [CrossRef]
- Hendriks, M.R., Evers, S.M., Bleijlevens, M.H., van Haastregt, J.C., Crebolder, H.F. & van Eijk, J.T. (2008). Cost-effectiveness of a multidisciplinary fall prevention program in community-dwelling elderly people: A randomized controlled trial (ISRCTN 64716113). International Journal of Technology Assessment in Health Care, 24, 193–202. doi:10.1017/S0266462308080276 [CrossRef]
- Henrich, S.K., Rapp, K., Rissmann, U., Becker, C. & König, H.H. (2010). Cost of falls in old age: A systematic review. Osteoporosis International, 21, 891–902. doi:10.1007/s00198-009-1100-1 [CrossRef]
- Mott, D.A., Martin, B., Breslow, R., Michaels, B., Kirchner, J., Mahoney, J. & Margolis, A. (2014). The development of a community-based, pharmacist-provided falls prevention MTM intervention for older adults: Relationship building, methods, and rationale. Innovations in Pharmacy, 5, 140. doi:10.24926/iip.v5i1.322 [CrossRef]
- Moyer, V.A. (2012). Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 157, 197–204. doi:10.7326/0003-4819-157-3-201208070-00462 [CrossRef]
- National Council on Aging. (2017, August16). Falls prevention facts. Retrieved from https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts
- O'Loughlin, J.L., Robitaille, Y., Boivin, J.F. & Suissa, S. (1993). Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. American Journal of Epidemiology, 137, 342–354. doi:10.1093/oxfordjournals.aje.a116681 [CrossRef]
- Ortman, J.M., Velkoff, V.A. & Hogan, H. (2014, May). An aging nation: The older population in the United States. Retrieved from https://www.census.gov/prod/2014pubs/p25-1140.pdf
- Royal, S., Smeaton, L., Avery, A.J., Hurwitz, B. & Sheikh, A. (2006). Interventions in primary care to reduce medication related adverse events and hospital admissions: Systematic review and meta-analysis. Quality and Safety in Health Care, 15, 23–31. doi:10.1136/qshc.2004.012153 [CrossRef]
- Scott, V. (2007, April3). World Health Organization report: Prevention of falls in older age. Retrieved from http://www.who.int/ageing/projects/5.Intervention,%20policies%20and%20sustainability%20of%20falls%20prevention.pdf
- Stevens, J.A. (2013). The STEADI Tool Kit: A fall prevention resource for health care providers. The IHS Primary Care Provider, 39, 162–166.
- Stevens, J.A., Corso, P.S., Finkelstein, E.A. & Miller, T.R. (2006). The costs of fatal and non-fatal falls among older adults. Injury Prevention, 12, 290–295. doi:10.1136/ip.2005.011015 [CrossRef]
- Tinetti, M.E., Speechley, M. & Ginter, S.F. (1988). Risk factors for falls among elderly persons living in the community. New England Journal of Medicine, 319, 1701–1707. doi:10.1056/NEJM198812293192604 [CrossRef]
- Turner, J., Brandt, N., Whittaker, C., Huang, L. & Simoni-Wastila, L. (2017, November4). Improving knowledge, skills, and attitudes (KSA) of community pharmacists in implementing falls prevention initiatives in older adults. Poster presented at the American Society of Consultant Pharmacists Annual Meeting & Exhibition. , Kissimmee, FL. .
Medication Classes Associated With Falls and Fractures (FRIDs)
|Geriatric Syndrome||Medication Class||Rationale|
|History of falls or fractures|
Antidepressant (e.g., SSRI, TCA, SNRI)
Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics
|May cause ataxia, impaired psychomotor function, syncope, additional falls; shorter-acting benzodiazepine agents are not safer than long-acting ones|
Falls Prevention Resources for Health Care Providers
|Centers for Disease Control and Prevention Stopping Elderly Accidents, Deaths, and Injuries (STEADI) Toolkit||A toolkit that includes printable case studies, pocket guides, brochures, assessment tests, fact sheets, and educational handouts about falls prevention. It also offers free accredited Continuing Education training for providers. Educational materials for patients are also available.||https://www.cdc.gov/steadi/index.html|
|National Council on Aging||Provides resources on healthy aging, including falls prevention, chronic disease management, nutritional assistance, and financial security for older adults.||https://www.ncoa.org|
|National Institute on Aging||Provides free publications regarding older adult health. These may include exercise guides, and brochures on safe medication use, dietary supplements, aging and eye health, and other resources. Publications are also available in Spanish.||https://www.nia.nih.gov|