News feature: Pharmacists can play an important role in preventing falls in older people

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The Pharmaceutical Journal Vol 267 No 7167 p421-422
29 September 2001

News feature

Pharmacists can play an important role in preventing falls in older people

Reducing falls among older people is a key aim of the National Service Framework for Older People. Clare Bellingham finds out how pharmacists in Barnet, Enfield and Haringey have been getting involved

Pharmacists can play an important role in reducing falls among older people. Falls are a major cause of disability and mortality in people aged over 75 years in the United Kingdom. Data indicate that every year, 400,000 older people in the UK have to go to hospital following a fall. The actual number of falls is much higher because of older people not attending hospital, or the fact that many older people do not admit to falling because of a perceived fear of getting old.

The National Service Framework (NSF) for Older People, published in March this year, identifies reducing the number of falls as one of its key priorities. It states that action has to be taken to:

Prevent falls. This should be tackled by public health strategies to reduce the incidence of falls and to identify those most at risk of falls and take appropriate preventative measures.
Prevent and treat osteoporosis. Osteoporosis occurs in one in three women and one in 12 men aged over 50 years and increases the risk of fracture when a person falls. Preventing and treating osteoporosis reduces both the number and severity of falls.
Set up new integrated falls services. These will aim to improve care and treatment of people who have had a fall.

Pharmacists’ role in preventing falls is in two areas: providing health promotion about falls and conducting reviews of medicines that precipitate falls.

Role for pharmacists in the NSF: the view from the top

Professor Ian Philp, national director for older people’s services, is responsible for overseeing the implementation of the NSF for Older People.

“Pharmacists have a really big role in implementing the NSF in a whole variety of areas, particularly in those highlighted in the medicines management booklet,” he told The Journal. “We are a long way from optimal management now but if we manage to implement the guidance in the medicines management booklet we will transform older people’s health experiences.”

Professor Philp said that pharmacists have a role to play in preventing falls. “As a doctor, the first thing I look at when patients are referred to me is their drugs as a potential cause of falls,” he said. Pharmacists can identify drugs that may increase a patient’s risk of falls.

Conducting medication reviews is a role that pharmacists can take on, and in many cases, have done so already. Professor Philp said that, in his own experience with clinical pharmacists on ward rounds in hospitals, he has found that the pharmacist’s input adds a lot of extra value. “Pharmacists’ input is useful because they pay attention to the details of patients’ medication. Pharmacists think about drugs all the time, not just in the current situation but also about what will happen in the future when patients are discharged. Therefore, pharmacists address issues of concordance.”

Within the area of medication reviews, some of the issues that pharmacists can address are:

Inadequate dosing instructions
Under-use of medicines
Unnecessary prescribing
Changes in medication when the patient moves from hospital to community care
Provision of information about medicines
Detection of adverse drug reactions
Checking repeat medicines
The need for compliance aids

Professor Philp said that these issues provided a significant role for pharmacists that they should undertake in partnership with other members of the health care team. He stressed the importance of health professionals working together and highlighted the fact that many of the multidisciplinary teams recommended to improve care for older people described in the NSF had a pharmacist as a core member of the team. He added: “Intermediate care is a high priority. I would like to see pharmacists engaging in making intermediate care work in terms of managing drugs prior to discharge and easing the transition from hospital to home.”

Pharmacists also have a role to play in providing health promotion advice because of the accessibility of pharmacies. Specific areas of health promotion for older people include stroke and fall prevention, nutrition, mental health and influenza.

Professor Philp said that the NSF provided a clear sense of direction but that a real challenge exists in terms of its implementation. “The plan is for the next few years. It is a marathon not a sprint,” he said. Issues that needed to be addressed included managing the workforce, implementing change, research and development, measuring performance indicators and financial investment. “There is some urgency to get going but it will be a long haul,” he said.

Ensuring that patients are being prescribed appropriate medicines and are using them effectively is a key part of preventing falls. Certain medicines can increase the likelihood of falls. These include those that cause hypotension, hypnotics (including sedative antihistamines) and drugs that cause dehydration (eg, diuretics and laxatives). In addition, pharmacists should take note of older people taking oral corticosteroids that increase the risk of osteoporosis.

The NSF has set the target that, by April 2002, all people aged over 75 years should have their medicines reviewed at least annually, and that for those taking four or more medicines reviews should be conducted every six months. In addition, by 2004, every primary care group/trust should have schemes in place to ensure that older people get more help from pharmacists in using their medicines.

These targets provide an opportunity for pharmacists to set up locally funded projects to conduct medication reviews to reduce falls among older people.

Pharmacy-based project

Pharmacists in Barnet, Enfield and Haringey Health Authority, for example, have been involved in a project that aimed to reduce falls among older people. Health Promotion England has selected the project as an example of good practice and will be holding a series of regional briefings at which the project will be discussed.

Kostakis Christodoulou, health development service programme manager, and Georgie Herskovits, senior pharmaceutical adviser, Barnet, Enfield and Haringey Health Authority, say that the pharmacy intervention project has reinforced the value of pharmacists undertaking health promotion work and strengthened the role of pharmacists in multidisciplinary teams. They say that pharmacists can reduce the risk of falls among older people by:

Identifying older people at risk of falls
Ensuring medicines are prescribed appropriately and used effectively
Providing a home safety checklist to identify potential hazards for falls
Referring those at high risk of falls to physical activity classes
Promoting falls prevention programmes as part of a multidisciplinary team
Promoting good nutrition, particularly increasing intake of vitamin D and calcium

The project took place over a four-week period earlier this year, in which 18 community pharmacists identified older people visiting the pharmacy who were potentially at risk of falls. They asked the patients to complete a questionnaire and provided advice about preventing falls and their medication. All pharmacists participating in the scheme attended a training course on using medicines effectively and were paid Ł65 for taking part.

A total of 843 older people took part in the project: 28 per cent were over 75 years, 41 per cent were over 70 years and the rest below 70 years. The majority were women (72 per cent). The proportion of participants who had had a fall in the previous six months was 18 per cent and 36 per cent knew someone who had fallen in that time.

The questionnaire results indicated that health promotion was needed about the importance of not moving someone who had fallen and that having a less cluttered, well-lit, warm home reduced the risk of falls. Pharmacists also provided advice on the importance of physical activity which has been shown to reduce the incidence of falls.

One of the pharmacists involved in the project, Mahesh Pabari, explains that at the point of dispensing, medicines that could potentially cause falls were identified. These included hypnotics, tranquillisers and antihypertensives. Patients taking these medicines were counselled about the possibility of their medicines increasing the risk of falls. In particular, pharmacists warned patients about the risk of consuming alcohol at the same time as taking certain medicines, where appropriate.

In some cases, if the pharmacist was particularly concerned about a patient’s risk of falling as a result of their medicine, a referral note was sent to the patient’s general practitioner suggesting that the patient’s medicines needed to be reviewed.

Mr Pabari says that patients had been glad to receive the information about their medicines. Some patients had been told about the risk of falls in the past but when the medicines had been prescribed for a long time, the patients felt that it was useful to be reminded. Carers had also found the information useful. GPs in the area had been told about the project before it began and feedback from the GPs had been appreciative, he added.

Following the project, an evaluation questionnaire revealed that the vast majority of patients were in favour of the campaign. Only 10 per cent of patient responses were unfavourable, mainly because they felt that the campaign was not relevant rather than being against the intervention. Pharmacists felt that most patients were interested to learn about ways to improve safety and reduce the risk of falls.

In order to achieve the standards set in the NSF, primary care groups/trusts need pharmacists to conduct medication reviews and get involved in preventing falls. So the opportunity is there to provide this important service — pharmacists need to grab it.

Clare Bellingham is on the staff of The Pharmaceutical Journal