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Age-old problem

Age is one of the simplest metrics for assessing the risk of falls among community pharmacy patients. Evidence suggests that adults aged 65 years and older have a three-fold higher risk of falling than those who are younger.

Learning objectives

After reading this feature, you should be able to: 

  • Recognise the risk factors for falls among older pharmacy patients and recommend preventative measures to help mitigate this risk
  • Understand the evidence supporting specific dementia risk-reducing strategies
  • Advise older customers on key steps to ensure they stay healthy and well this winter. 

As winter arrives and the weather becomes increasingly inclement, the risk of falls inevitably increases among older pharmacy patients. However, the elderly are not just at risk of falling outside on rainy pavements or icy streets — the home also contains a variety of avoidable trip and fall hazards. 

Most falls are multifactorial, so pharmacy teams need to consider various factors in order to pinpoint those patients at potentially increased risk. Characteristics of at-risk people may include:

  • Motor problems, particularly gait or balance impairment 
  • Sensory impairment
  • Cognitive or mood impairment
  • Orthostatic hypotension
  • Comorbid illnesses
  • Those older adults with impairment in their activities of daily living. 

In terms of sensory impairment, vision loss increases the risk of falls, so regular eye tests to assess for conditions such as cataracts and age-related macular degeneration are important, as well as to ensure current spectacles (or contact lens) prescriptions are up-to-date. It is also essential that older people get their hearing checked regularly as ear problems can contribute to dizziness, and combined sight and hearing impairment can make it more difficult to maintain proper balance. Peripheral neuropathy, for example caused by long-term type 2 diabetes, and vestibular dysfunction are other contributory comorbidities to consider.

Another area that can affect balance and lead to trips is unsuitable or inappropriate footwear. Older people should ensure shoes are well fitting and comfortable. Laces should be avoided if possible as these can be a trip hazard and also require bending to fasten. Sandals, high heels and backless slippers should be shunned in favour of more supportive footwear options with a good grip. Shoes or slippers should always be worn indoors as going bare foot or walking in socks or tights increases the risk of slipping.

Certain medications can also increase the risk of falls, particularly among elderly patients in whom polypharmacy is common. These include antihypertensives that lower blood pressure and CNS suppressives that may slow reactions and cause drowsiness or dizziness. 

Common culprits include anti-anxiety drugs, older antihistamines, tricyclic antidepressants, benzodiazepines, Z drugs, narcotics and anticholinergics. Alcohol consumption increases the risk of a fall – particularly when combined with certain medications. It also contributes to the likelihood of developing osteoporosis, which in turn raises the risk of bone fractures or breaks if a fall does occur. 

Pharmacy teams should ensure older customers are aware of all the above risk factors for falls and encourage them to take mitigating steps where possible. Aside from addressing risk factors, the main strategies for the prevention of falls centre on changes to the individual and also changes to the home. One of the most important practical steps older customers can take to reduce their risk of falling is building muscle strength and improving balance. 

Many community centres and local groups offer specific exercise programmes targeted at older people such as aqua aerobics, tai chi or chair-based exercises. Strengthening exercises can also be carried out at home. GPs can provide advice and refer patients to suitable exercise programmes for the elderly operating in the local area. Age UK also provides a searchable database of classes by postcode on its website. 

“One of the most important practical steps older patients can take to reduce their risk of falling is building muscle strength and improving balance”

Alongside muscle strengthening and balance exercises, weight bearing activity such as walking remains important to bolster overall bone health. Other measures which patients can take to keep their bones healthy include ensuring sufficient calcium intake, getting adequate exposure to vitamin D from sunlight, or taking necessary supplements as required. Strong bones are less likely to fracture under the weight of a fall and any breaks that do occur will be quicker to heal.

When outside in the winter months, older people should take extra care if the ground is slippery and consider clearing or gritting pathways (or asking a family member or neighbour to do this for them). It is important to check the weather forecast before setting out in case of wet or icy conditions that may increase the risk of falling. Older people should be particularly vigilant for Met Office cold weather alerts which signal the arrival of average temperatures below 2oC for 48 hours or longer, or periods of heavy snow or widespread ice.

The reality is, however, that many falls still take place within the relative safety of the home. Older patients should therefore be encouraged to undertake a full survey of their home to identify and remove any potential trip hazards. These include rugs, frayed or loose carpets (particularly at the top or bottom of the stairs), trailing wires and general clutter around the home. 

Use of non-slip mats and rugs is recommended, and older people should take care with loose-fitting trailing clothing such as dressing gowns. A night light near the bed is advisable to ensure nocturnal toilet visits can be navigated safety.
The rest of the house, particularly the stairs, should also be kept well lit, particularly in the darker winter months. 

Making joint health a priority

Research has consistently shown the great benefit of keeping active in later years, with one study concluding that physical activity is a key contributor to longevity, says optimal ageing expert Julie Robinson. Getting moving can help not only manage pain, but also improve strength and mobility, she says.

For those who are in the recovery stages of a fall, exercising should still be encouraged. “It may seem counter-intuitive, but it is important to keep exercising. This is because strong supporting muscles act as a brace to reduce the pressure on weakened joints, whilst increased blood flow delivers oxygen and nutrients to the effected tissues,” says Robinson.

“Pharmacists can play a pivotal role in steering people towards a prevention programme promoting lifestyle and diet changes, including recommendation of clinically proven joint- specific supplements, such as GOPO. Not only can a structured exercise programme help prevent falls by supporting strength and mobility, but clinically backed supplements can encourage customers to take up exercise in the first place by reducing the pains that accompany chronic joint conditions. 

“It is important to be aware of the evidence, as the most popular [supplements] may not be the most effective,” she warns.

Reducing dementia risk

Dementia is an important risk factor for falls as many of the associated symptoms increase the likelihood of falling. For example, people with dementia may have problems with mobility and balance, difficulty with memory and finding their way around (both outside and in the home setting) and slowed reaction speeds. 

Medications for dementia can also be associated with drowsiness, dizziness or low blood pressure. For pharmacy patients with diagnosed or suspected dementia and their families, offering effective advice on falls prevention is therefore particularly important.

Many healthy older patients may also have questions about strategies and interventions for boosting brain health with ageing. Pharmacy teams can help separate fact from fiction when it comes to dementia risk-reducing strategies, which are widely covered in the mainstream media.

Although getting older is inevitable and remains the biggest risk factor for developing dementia, there are proactive steps that individuals can take to reduce their own risk. Predictably, many of these are the linchpins of good health in general – physical activity (encompassing both aerobic and strength-building exercises), eating a healthy balanced diet, stopping smoking, drinking less alcohol and managing modifiable risk factors such as high blood pressure and type 2 diabetes. 

Recent evidence from the US indicates that reducing hypertension, obesity and physical inactivity by as little as 15 per cent could prevent over 400,000 cases of dementia. This highlights the important but often overlooked role of simple lifestyle measures and healthy behaviour changes in reducing future dementia risk.

To boost overall brain health and stave off – or even prevent – the development of dementia, staying mentally and socially active is also vital. The Alzheimer’s Society recommends regular activities that challenge the brain, such as crosswords, puzzles or quizzes, as well as things that engage the mind, require the processing of information and help to develop thinking skills. 

Examples include adult educational or learning activities, arts and crafts, playing a musical instrument or singing, playing cards or board games, reading books, creative writing or learning a new language. Apps and games available online or on smart devices are useful tools for providing mental stimulation and helping to boost overall brain health. 

Social interaction and conversation is also important as it draws on a number of key mental skills, as well as helping to improve overall mood, reduce the risk of loneliness and depression, and help promote general wellbeing. Findings from the first ever prospective randomised controlled trial (RCT) of its kind, carried out in Finland, have shown the power of brain healthy behaviours in reducing dementia risk.

 In this intriguingly titled FINGER study (the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability), patients in their 60s and 70s with mild cognitive deficits and underlying comorbidities who underwent a two-year brain health programme were compared to controls who received general health advice. 

The brain health programme included regular exercise (one hour ≥3 times per week), regular meetings with a nutritionist, effective management of vascular and metabolic conditions with physician consultations every few months, and a targeted cognitive training programme. The latter began with 10 group sessions and then evolved to self-administered computer-based brain training three times a week for 10-15 minutes a day. 

Overall, dementia risk was reduced by 30 per cent in study participants compared to controls who followed the general healthy living advice – better than any currently approved medication for treating dementia. Although this RCT involved a targeted programme, most of the interventions are readily extrapolatable to everyday life – eat healthily, exercise regularly, visit the GP frequently for control of underlying health conditions, and engage in specific brain training activities. 

From the UK, a recent 2022 observational study of over 290,000 people, the majority being women over the age of 60 years, has also identified a link between vitamin D deficiency and increased dementia risk. According to study findings, people with low vitamin D levels for a period spanning over a decade were 54 per cent more likely to develop dementia compared to those whose levels were normal. This underscores the importance of vitamin D supplementation for older customers – both for bone and brain health. 

Keeping well and warm

Beyond the specific area of falls, pharmacy teams have a wider role to play in ensuring elderly patients remain well – and warm – this winter, particularly as the cost of living crisis continues to bite. According to recent figures, an estimated 2.8 million older households will still be living in fuel poverty this year despite the freeze in the energy price cap.

Top of the list of winter priorities is to ensure all older customers have received their autumn Covid-19 booster and annual flu vaccine. This is particularly important as early signs out of Australia indicate that a particularly severe flu season may be making its way to the northern hemisphere this winter. Alongside the two main seasonal jabs, it is important to check that elderly patients are up-to-date with their pneumonia and shingles vaccines. 

Food and warmth are areas of particular concern this winter as, in the face of spiralling energy bills, older people may feel reluctant to turn on their heating or use their oven to prepare food. Remind older customers than eating is important to maintain their overall health and when it comes to food, ‘something is better than nothing’ – even a simple snack that does not require cooking. The British Dietetic Association provides some useful advice on meal planning on a budget on its website. Ideally, living rooms should be kept at a temperature of 21oC and bedrooms no lower than 18oC. 

It is also important for older people to keep warm when outdoors by wrapping up well and wearing extra layers. Regular hand washing, social distancing from those who are unwell and wearing face coverings in crowded indoor spaces are all useful infection prevention measures for winter. 

“An estimated 2.8 million older households will still be living in fuel poverty this year despite the freeze in the energy price cap”

Perhaps most importantly, pharmacies can act as a warm and welcome source of support and advice for elderly customers who may be trepidatious about any aspect of what this winter has in store. As Caroline Abrahams, charity director at Age UK, explains: “With the cost of food and energy soaring, and the universal Energy Price Guarantee set to end in April, pensioners on low and modest incomes are confronting the fact that basic goods and services are increasingly beyond their means. 

“They are looking ahead to the winter with great fear as a result. We have already heard from older people who are risking their health by switching off essential medical equipment, lights, heating and fridges – none of them luxuries – because they worry worse is to come.” 

Age UK provides a wealth of free online and telephone resources to help older people navigate the challenges that lay ahead. Pharmacy staff can signpost elderly customers to these key sources of help, as well as offering an understanding and sympathetic ear for those who simply wish to talk about their worries. From a practical perspective, pharmacists can help ensure elderly patients continue to take their prescribed medications by organising home delivery. 

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