The context of interventions

The literature describes a range of interventions including medication review which have been examined for their ability to reduce the risk, rate or incidence of falls in older people.

There is heterogeneity in the definition of medication review, and in most cases medication review is included as part of a multi-factorial intervention or multi-component intervention. Note: a multifactorial intervention can be defined as interventions from two or more categories, linked to each individual’s risk profile. People in the same programme can receive different combinations. For example, one person receives supervised exercise and home-hazard modification, whereas another home-hazard modification and medication modification. A multiple component intervention can be defined as two or more main categories of intervention for everyone receiving the falls prevention programme. For example, everyone received supervised exercise and medication (vitamin D and calcium supplementation), or supervised exercise and environmental assessment of their home.

Many studies have tested, and guidelines mention, specific tools to improve consistency of medication review. These include STOPP/START, STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) or STEADI (Stopping Elderly Accidents, Deaths and Injuries) as explicit criteria to identify those at risk of falls. This guidance has updated case finding indicators that will support identification of appropriate cohorts. These indicators can be found in Case finding indicators for CDS available on STU.

Interventions have been studied in care settings including hospitals, care homes, and in people living in the community. Most reviews identify people at risk of falling or having fallen as the main focus for intervention including medication modification/ withdrawal. The timing of medication reviews varies. Other opportunities identified for medication review were: transfer of care (admission, transfer, discharge), after a fall, when there is a significant change in condition, and when new medicines are prescribed. Some evidence-based guidelines recommend specific monitoring on an ongoing basis for medicines with side effects known to contribute to falls risk, such as sedation or postural hypotension, or monthly reviews for specific medicines such as psychoactive medication. Once the individuals have been identified, then a medication review should be undertaken using the 7-Steps person-centred approach.

The variation in studies makes interpretation of the literature difficult, however some broad recommendations can be drawn. Based on two SRs of high quality^115,116 and eight guidelines of mixed quality,^{6,65,117,118,119,120,121,122}we make the following recommendations on medication review, which should be undertaken using the 7-Steps process.

Recommendations on medication review for those people at risk of falls or have fallen

1 - Strong recommendation

A medication review should be considered for those who experience or are at risk of falls. This may include modification/ reduction/ withdrawal, as part of a multifactorial prevention strategy. People on psychotropic medications should have their medication discontinued where appropriate to reduce risk of falling.

2 - Strong recommendation

Medication reviews to reduce risk of falls should be conducted by a healthcare provider with the appropriate knowledge and skills, such as a pharmacist, prescriber, or specialist.

3 - Conditional recommendation

Medication reviews should be part of multifactorial risk assessment and individual care plan.

4 - Conditional recommendation

A medication review should be undertaken during transitions of care (admission, transfer, discharge), after a fall, when there is a significant change in condition; and when new medications are prescribed, with the aim to monitor medications with side effects known to contribute to risk of falls.