Learn how to identify and help patients at risk
rxPassport Pharmacy Newsletter
November 2014
Falls in the Elderly: Risk Factors and Prevention
Meet Our Patient – Mrs. FP
Mrs. FP (71 yo) presents at the pharmacy counter with a box of diphenhydramine and asks if she can take them to help her sleep.
You have known her for a long time and know that she is recently widowed and lives by herself with some family living in the same city. Her chronic conditions include hypertension and since her husband passed away she has been suffering with insomnia.
Her current medications include:
Hydrochlorothiazide 25 mg daily
Oxazepam 10 mg qhs prn (started a month ago - she takes about 1 tablet 3 nights a week)
She has run out of oxazepam and wanted to know if she could take diphenhydramine prn for now as her family doctor is not in office for another 4 days.
What would you recommend?
Prevalence and Consequences of Falls in the Elderly
Each year, more than one third of seniors aged 65 or older experience a fall.1 Why is this important?
Falls are the leading cause of hospitalizations due to injury in seniors1
Around 20-30% of seniors who fall will experience moderate to severe injury, with hip fractures being the most common fall related injury2
About one fifth of all injury-related deaths in seniors can be traced back to a fall incident3
Falls can also lead to profound social, psychological and economic consequences1
This is unfortunate, as falls are preventable! Pharmacists can play an active role in fall prevention and can reduce the number of patient injuries and deaths secondary to falls.
Risk factors
Falls in the elderly are often due to a combination of multiple risk factors.
Table 1. Risk Factors in the Elderly1,4,5,6
Major Risk Factors
Cognitive impairment
Medications (see table 2)
Mobility impairment
Older age (≥65 years old)
Previous falls
Using more than 4 medications
Other Risk Factors
Alcohol intake
Arthritis and Pain
Cardiovascular disease
Fear of falling
Female gender
Home and environmental hazards
Living alone
Parkinson’s disease
Urinary incontinence or nocturia
Visual or hearing impairment
Side effects of medications also play a major role in fall risk. Side effects such as, dizziness, sedation, confusion, visual disturbances, and hypotension can increase the risk of falls.7 The highest medication risk associations occur in patients on complex regimens and psychoactive medications (eg. sedatives, antipsychotics, and antidepressants).6
Table 2. Medication Classes That Increase Fall Risk7
1st generation Antihistamines
Anti-Parkinson Agents
Sulfonylureas, meglitinides or insulin
Fall Risk Assessment in the Elderly
When gathering information and assessing for major risk factors, think HELP5:
Has previously fallen
Elderly patient
Loss of mobility and/or cognition
Also consider asking the following questions4,7:
Do you exercise throughout the week? If so, how often and what types of exercises?
Are you afraid of falling or slipping?
Do you live by yourself?
Have you had any changes in vision or hearing?
Do you drink alcoholic beverages? If so, how many within a week?
Do you feel any dizziness when standing up? Throughout the day?
On a scale from 1 to 10, how healthy would you say you eat?
Clinical Practice Tip
Most patients will not voluntarily tell healthcare professionals about their history of falls.1 Therefore, it is important to remember to prompt for fall history when you encounter an elderly patient.
Refer patients with any of the following for a more in depth fall risk assessment:6
1. Previous acute fall (fall resulting in an injury)
2. Two falls (with no injury) within the last 12 months
3. Any gait or balance impairments
Revisit Mrs. FP
After speaking to Mrs. FP, you obtain the following information:
No history of previous falls, but she reports that she almost fell once when going to the bathroom in the middle of the night
No recent changes in memory, vision, hearing, or medical conditions (besides insomnia)
No trouble when walking; she walks outside 15 minutes a day for exercise
She indicates that she feels groggy some mornings, and this has started about 3-4 weeks ago
Fall Prevention Interventions
Following a patient’s fall assessment, their specific risk factors will guide the fall interventions for the individual patient.
Medication Reviews
The more medication a patient is taking, the higher the patient’s risk for falling, regardless of the medication type.8 Therefore, it is important to conduct a thorough medication review to ensure that medications are appropriate, safe, and effective. If possible, consider discontinuation or dose reduction of medications.6
Clinical Practice Tip
Conduct medication reviews with your patients at least once a year, or when they are prescribed a new fall risk enhancing medication (see table 2).
Vitamin D
Vitamin D’s role in the prevention of falls has been shown to be effective in elderly patients that reside in long-term care homes taking 800 IU of vitamin D daily.6 There has been inconsistent results for vitamin D in other populations, however, there is some evidence that vitamin D supplementation of 800 IU daily may decrease fall risk in studies that had adequate determination of falls.9 For further information see the 2010 Vitamin D guideline statement from Osteoporosis Canada.
Reminder: Irrespective of fall prevention, vitamin D should still be recommended for the elderly population. The recommended amount of vitamin D for patients who are older than 50 years old is 800-1000 IU.9
Non-Pharmacological Interventions6,10,1,11
Interventions Examples
Customized Exercise Program
Exercise regimens should include strength training, balance, gait, and coordination training
Eg. Tai Chi and physical therapy
Guides for general physical activity for seniors: Canada’s Physical Activity Guide to Healthy Active Living for Older Adults and Physical Activity Tips for Older Adults
Home modifications
Anti-slip floor mats for the tub/shower
Reduction of clutter
Adequate lighting
Items that are used often should be stored in easy to access areas
Night lights along the hallways, especially near washrooms
Sturdy handrails on stairs
Grab bars in the bathroom
Mobility Aids and Assistive Devices
Should be properly maintained and used correctly
Ensure that they are within easy reach
Foot ware and clothing
Proper fitting foot ware and clothing
Opt for foot ware with high surface contact area
During winter and icy conditions wear anti-slip shoes outdoors
Vision related
Cataract surgery should be expedited on the first affected eye
Avoid using multifocal lenses while walking or using stairs
Choose healthy choices to help with strength
Don’t skip meals
Postural/Orthostatic Hypotension Management
Compression stockings
Head should be elevated by 4 inches when sleeping
Keep hydrated
Counseling Mrs. FP
Diphenhydramine can cause drowsiness throughout the day and increase Mrs. FP’s risk for falling, therefore diphenhydramine is not recommended
Initiate/reiterate sleep hygiene techniques to maximize ability to sleep at night and reduce need for oxazepam
Avoid fluid intake and caffeine close to bedtime to avoid her having to get up frequently at night to urinate
Ensure the pathway from bedroom to washroom is clear of clutter
Place night lights in the washroom and in hallways
Recommend balance exercises such as Tai Chi
By Margaret Noriel, PharmD Candidate
With appreciation to Mike Boivin
In this issue
Meet our Patient
Prevalence and Consequences
Risk Factors
Fall Risk Assessment
Fall Prevention Interventions
Interactive Poll
Pharmacy Student Blog
Interactive Poll
Q: How often do you ask elderly patients about previous falls?
Every 6 months
Every year
When prescribed medications that increase their risk of falling
During medication reviews
When prescribed medications that increase their risk of falling AND during medication reviews
I don’t remember when I last asked a patient
Osteoporosis, Fractures and Fall Risk
If a patient has osteoporosis they are at increased risk of obtaining a fracture due to a fall. There are tools which can be used to assess a patient’s risk of fractures within 10 years: CAROC and FRAX. Results from a 10-year fracture risk assessment will help guide potential pharmacotherapy for your patient.
» Get more information
Health Canada
Public Health Agency of Canada: Seniors’ Falls in Canada: Second Report: View Resource
AGS/BGS Clinical Practice Guideline for Prevention of Falls in Older Persons – 2011 Updated Summary
1. Al-Aama T. (2011). Falls in the elderly: spectrum and prevention. Canadian Family Physician, 57(7), 771-776.
2. World Health Organization. (2012). Falls. Retrieved November 14, 2014. View source.
3. Public Health Agency of Canada. (2011). The Facts: Seniors and Injury in Canada. Retrieved November 14, 2014. View source.
4. Public Health Agency of Canada. (2014). Seniors’ Falls in Canada: Second Report. Retrieved November 10, 2014. View source.
5. de Jong MR, et al. (2013). Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Therapeutic Advances in Drug Safety, 4(4), 147-154
6. Panel on prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148-157.
7. Safer Healthcare Now!. (2014). Reducing Falls and Injuries From Falls: Getting Started Kit. Retrieved November 10, 2014. View source.
8. Tinetti ME, et al. (2010). The Patient who falls: “It’s always a trade-off”. The Journal of the American Medical Association, 303(3), 258-266.
9. Hanley DA, et al. (2010). Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada. Canadian Medical Association Journal, 182(12), E610-E618.
10. Health Canada. (2006). Seniors and Aging – Preventing Falls in and around Your Home. Retrieved November 14, 2014. View source.
11. Figueroa JJ, et al. (2010). Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleveland Clinical Journal of Medicine, 77(5), 298-306.
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