Introduction and module overview

Community pharmacy teams see patients who are frail and at risk of falls every day. They also regularly dispense medicines that may contribute to falls, and others that are prescribed to treat and manage osteoporosis, which is associated with frailty and with fractures related to falling.

Understanding the bigger picture of how frailty develops during ageing and the contributory factors that increase the risk of falls is crucial in formulating practical advice for patients.

One in three people aged 65 years and over have a fall at least once each year, increasing to one in two of those aged 80 years and over. The result may be lacerations, brain injury or fractures. About 5 per cent of falls in older people who live in the community result in a fracture or hospitalisation and almost two-thirds of these admissions are in the over-80s. 

The aftermath of a fracture can be life-changing, and while some patients are able to regain their previous mobility, for many this is not the case and loss of independence may result. Worry about the possibility of future falls may restrict and even prevent a return to going outdoors and impact seriously on health and wellbeing. 

This module provides an overview of frailty and the risk of falls. It also provides simple guidance that pharmacists and their teams can offer to patients, alongside various helpful resources.

Contributory factors to falls

Pharmacists often think first about how medicines might be involved in falls. Indeed, many falls are associated with sedative drugs (e.g. benzodiazepines) and with drugs that can cause postural hypotension (e.g. antihypertensives) or may be associated with polypharmacy. However, the cause is usually multifactorial. 

Understanding the bigger picture of what happens during ageing, the development of frailty, and the contributory factors behind falls is crucial. In responding to symptoms presented by older people, it is important to be aware of those that may reflect the progressive development of frailty alongside those that predispose to falls. 

Frailty

‘Frailty’ is a term that is often misunderstood and refers to an older patient’s mental and physical resilience, and their capacity to recover and bounce back after illness or injury. A gradual decline in the musculoskeletal and endocrine systems, as well as immune system changes and long-standing inflammation, are all thought to contribute to frailty, which is now acknowledged as a health condition in its own right. 

Around 10 per cent of people aged over 65 years of age live with frailty, rising to 25-50 per cent in those 85 years of age and over. Although many older people have multiple chronic health conditions, frailty can also be present in someone with no other diagnosed health conditions. Older people who are living with frailty may not perceive themselves to be “frail” but often acknowledge that they have “slowed down” and often feel very tired. 

Key characteristics of frailty to bear in mind when an older person is asking for advice about symptoms are:

• Slow gait speed
• Weak grip strength and/or having difficulty in getting up from sitting down and in standing
• Low physical activity level
• Fatigue
• Low weight (unintended weight loss).

Since 2017 the GP contract in England has included a payment for identifying and managing patients over 65 years living with frailty. Similar initiatives are underway in Scotland and Wales. Many practices use a tool called the Electronic Frailty Index, which pulls information together on related clinical conditions and associated events from the GP clinical record. These systems are not foolproof and rely on accurate clinical records, so if a pharmacist suspects frailty with associated risk of falls, they may wish to advise the local GP practice of their concerns with the patient’s agreement.

Falls risk

Symptoms and signs that may indicate a risk of falls include:

• Urinary symptoms such as frequency, urgency, not getting to the toilet quickly enough, or having to get up at night to pass urine. Having to rush to the toilet can make a trip or fall more likely
• Dizzy spells or feeling faint.

Arthritis, diabetes, stroke, syncope and Parkinson’s disease can affect mobility and balance, so can contribute to the risk of falls. Depression and cognitive impairment are also associated with falls. Specific medicines that have been implicated include antihypertensives and benzodiazepines. Something that is frequently overlooked in older people is the role of alcohol in falls and the possibility of problem drinking may need to be tactfully explored.

Useful questions when frailty and increased risk of falls are suspected are:

• Have you fallen in the past year?
• Do you feel unsteady when standing or walking?
• Do you worry about falling?

Older people can help to protect themselves against the likelihood of falling by taking as many of the simple measures as they can. Explaining why each of these is beneficial is an important role for pharmacy teams as part of their healthy living work.