Falls prevention support

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Supriya Kapas, specialist clinical pharmacist, Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust

Module overview

Falls and fractures are common and are serious health issues affecting older people in the UK. People aged 65 years and older have the highest risk of falling. Around a third of people aged 65 and over – and half of people aged 80 and over – fall at least once a year.

Falling can cause distress, pain, injury, loss of confidence and independence, and mortality. The consequences may include a person moving into residential or nursing care and being unable to return home. For the person and their family, life may never be the same again. Falls also have a major impact on health and social care, costing the NHS and local authorities more than £5bn each year.

In this module, we highlight current NICE guideline recommendations and explain how these principles apply to community pharmacy practice across the UK. NICE guideline NG249, ‘Falls: assessment and prevention in older people and in people 50 and over at higher risk’, replaced CG161 in April 2025. It reflects the potential for pharmacists in the community to extend their role in identifying and assessing people at risk of falls.

The updated guideline is broader and more detailed. It gives community pharmacists clear opportunities to identify people at risk, recognise contributory factors including falls risk increasing drugs (FRIDs), and collaborate with GPs, practice-based pharmacists, home care nurses and physiotherapists. It also places greater emphasis on patient education and shared decision-making as part of multifactorial falls evaluation in older patients.

NICE also recognises that healthcare professionals’ knowledge of their patients can inform clinical assessment, and that community settings provide further opportunities for falls assessment and prevention.

Identifying people at risk

Current NICE guidance covers people aged 50 to 64 years with conditions that increase falls risk, such as Parkinson’s disease, dementia, stroke, frailty or learning disability. Community pharmacists can help to recognise medical conditions linked to falls. In people aged over 65 years, additional higher-risk conditions include diabetes, visual impairment, arthritis, neuropathy and osteoporosis.

Community pharmacists and their teams often see mobility changes before other clinicians do. Warning signs include:

• Difficulty standing from a chair
• Shuffling gait
• Using furniture for support
• Slowed walking
• Tremor or rigidity
• Visible frailty
• Poor footwear
• Bruising suggestive of previous falls
• Confusion or cognitive decline.

Even brief observations and conversations with patients can be valuable. NG249 highlights the psychological aspects of falls prevention. A brief dialogue at the medicines counter, for example, may reveal a patient’s increased avoidance of leaving home, reduced confidence, reluctance to walk outside, or increasing dependence on carers.

Asking a few simple, targeted screening questions can quickly obtain relevant information. Examples include:

• “Have you fallen in the last year?”
• “Do you feel unsteady when walking?”
• “Have you had any near falls?”
• “Do you ever feel dizzy when standing up?”
• “Are you worried about falling?”
• “Have you become less active because of a fear of falling?”

A history of two or more falls in a year, fall-related injury, inability to get up after a fall, blackouts, syncope or increasing frailty should all trigger referral for fuller assessment.

Recognising contributing factors

Falls in older people often have multiple causes. These can be intrinsic, such as person-specific health factors; or extrinsic, such as environmental factors. Risk increases with age and accumulating comorbidity, and can be affected by gait, balance, cognition, vision and dizziness. Falls risk increasing drugs (FRIDs) are an important and modifiable contributor in older people and others at higher risk of falling.

Existing community pharmacy services can be used opportunistically to identify falls risk. For instance, falls risk screening can be integrated into the New Medicine Service, the Discharge Medicines Service and vaccination appointments, helping to identify risk earlier. Structured medication reviews are usually provided by GP practice-based pharmacists, either in the surgery, in care homes or in the patient’s own home.

Triggers for referral include frequent hospital admissions, patient or carer concerns, medicines adherence problems, requests for compliance aids or alternative formulations, the return of large quantities of unused medicines, and polypharmacy. Most pharmacies offer blood pressure checks, creating an opportunity to screen for symptoms of postural hypotension. Ask about dizziness on standing, feeling faint, blurred vision or weakness after getting up. Pharmacists providing hypertension services may identify excessive BP lowering, dehydration or orthostatic symptoms.

Identify high-risk medicines (FRIDs)

Medicines commonly associated with falls include:

• Benzodiazepines
• Z-drugs
• Opioids
• Antidepressants
• Antipsychotics
• Anticholinergics
• Antihypertensives (postural hypotension)
• Diuretics
• Hypoglycaemics (hypo episodes).

In community pharmacy practice, examples of commonly prescribed medicines to review include diazepam, zopiclone, amitriptyline and quetiapine (see Table 1 for a more comprehensive list of FRIDs).

Structured medication reviews are specifically mentioned in NG249. Patients can be asked whether they feel they are benefiting from their medicines, if they have any adherence difficulties and whether they are experiencing, or are at risk of, adverse drug reactions. Suspected ADRs should be reported through the Yellow Card scheme where appropriate.

Pharmacists should particularly look out for:

• Polypharmacy and recent medication changes
• Duplicate sedatives
• High anticholinergic burden
• Medicines causing dizziness or sedation
• Medicines that increase the risk of fracture such as antiepileptics, levothyroxine, PPIs and steroids (see Table 2).

Supporting patients

Older patients vary in their individual values, preferences and care goals. This provides a useful starting point for discussing what matters most to those with comorbidities. Generally, people place greater importance on maintaining independence and improving quality of life than on quantity of life alone. Social history is also important, as deprivation and ethnic minority backgrounds may be associated with health inequalities.

Community pharmacists can support patients at risk of falls to make decisions about interventions by using a shared decision-making approach that balances clinical benefit, patient preferences, confidence, independence and practical barriers. Explore what matters to a patient by asking questions such as:

• “What worries you most about falling?”
• “What changes would feel manageable for you?”
• “What would help you feel safer when moving around?”

Key interventions recommended by NICE include exercise, medication optimisation, home safety interventions, vision and hearing review, footwear advice and referral to specialist services. However, the guidance does not recommend walking aids as a universal falls prevention intervention on their own.

Resistance to using a walking aid is common and may arise for several reasons, including concern that it is a visible sign of ageing, illness, disability or loss of autonomy, or worry about how others may react.

When discussing a broader falls prevention plan, remember that the goal is safer mobility, not reduced mobility. NG249 places stronger emphasis on exercise, balance, strength and functional mobility alongside any equipment choice, rather than replacing activity with equipment alone.

Community pharmacists can make a significant contribution to falls prevention and patient outcomes by integrating the Discharge Medicines Service (DMS) and BP checks into routine practice, especially for older adults.

The period immediately after hospital discharge is particularly high-risk, making the DMS an important opportunity to identify and address falls risk. Patients identified through the DMS or BP checks can be signposted or referred to appropriate local services.

An effective approach is to use every DMS referral as a falls risk screening opportunity.

By combining medication reconciliation, identification of FRIDs, patient education and BP checks, pharmacists can help prevent avoidable falls, reduce hospital readmissions, and improve quality of life for older and vulnerable patients.

Table 3 (below) summarises practical ways in which community pharmacists can support shared decision-making with patients.

Conclusion

For many people, the first conversation about falls prevention – or whether they may be at risk of falling – takes place not in a clinic but across the counter in a community pharmacy. That moment can be important. Falls can cause distress, pain, injury, loss of confidence and independence, and even death. They should not be dismissed as an inevitable part of ageing, particularly when concerns continue or worsen over time.

While community pharmacists are not in the main expected to use falls risk prediction tools, they are well placed to identify patients at increasing risk of falling and recognise factors that commonly contribute to this risk. A helpful consultation that asks the right questions, listens to how symptoms affect daily life and remains alert to red flag events can make an important difference to patient outcomes.

By combining clinical awareness with clear communication, appropriate reassurance and confident referral, pharmacists and their teams can make a meaningful contribution to preventing falls in higher-risk patients. In doing so, they can support patients to make informed choices about interventions that balance clinical effectiveness with personal preferences, confidence, independence and practical considerations.