Falls are the most common cause of emergency hospital admission for people aged 65 and over in England, accounting for more than 250,000 admissions each year according to NHS Digital. The consequences are severe: hip fracture carries a 30-day mortality rate of approximately 8 per cent, and many patients who survive never regain their previous level of independence. Community pharmacists, through medication review and proactive advice, are one of the most cost-effective interventions available.

Why medicines matter

Medication is a modifiable risk factor in approximately 40 per cent of falls in older adults, according to research published in Age and Ageing. The mechanism is straightforward: medicines that cause sedation, dizziness, postural hypotension or impaired balance increase the likelihood of falling. The risk compounds with polypharmacy — patients taking five or more medicines are at significantly higher risk than those on fewer.

NICE Clinical Guideline 161 (Falls in older people: assessing risk and prevention) explicitly recommends medication review as part of a multifactorial falls risk assessment.

High-risk medicines: the pharmacist's checklist

Pharmacists reviewing medication in the context of falls prevention should scrutinise the following drug classes:

The cumulative effect matters more than any single medicine. A patient on a benzodiazepine, an alpha-blocker and a diuretic faces a substantially higher falls risk than any one of those medicines would suggest alone.

Conducting a falls-focused medication review

Pharmacists performing structured medication reviews (SMRs) or New Medicine Service (NMS) consultations can integrate falls risk assessment with relatively simple additions:

Step 1: Identify the patient. Target patients aged 65 and over, particularly those with a history of falls, those recently discharged from hospital, and those on four or more medicines.

Step 2: Review the medication list. Cross-reference against the high-risk classes above. Count the number of fall-risk medicines. Calculate the anticholinergic burden score (a cumulative ACB score ≥3 is associated with increased falls risk and cognitive impairment).

Step 3: Ask about symptoms. "Do you ever feel dizzy when you stand up?" "Have you had any near-misses or actual falls recently?" "Are you sleeping well, or do you feel drowsy during the day?" Patients often normalise these symptoms and do not volunteer them.

Step 4: Measure lying and standing blood pressure. Postural hypotension — defined as a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing — is present in up to 30 per cent of community-dwelling older adults. It is treatable, often by adjusting antihypertensive doses or timing.

Step 5: Recommend changes. Pharmacists cannot unilaterally stop prescribed medicines, but they can:

• Recommend dose reduction or deprescribing to the GP with specific suggestions (e.g., "consider reducing doxazosin from 4mg to 2mg given postural drop of 25 mmHg")
• Switch sedating antihistamines to non-sedating alternatives (cetirizine, loratadine)
• Recommend taking diuretics in the morning rather than evening to reduce nocturia (a falls risk in itself)
• Suggest gradual benzodiazepine withdrawal programmes where appropriate
• Flag anticholinergic medicines for review

Beyond medicines: what pharmacists can advise

Falls prevention is multifactorial. While medication review is the pharmacist's primary contribution, broader advice reinforces the intervention:

Vitamin D: NICE recommends vitamin D supplementation (10µg/400 IU daily) for all adults over 65 in the UK, and higher doses (up to 25µg/1,000 IU or more) for those identified as deficient. Vitamin D supports muscle function and bone density. Pharmacists should check that patients are actually taking it — adherence to preventive supplements is notoriously poor.

Footwear: Loose slippers, worn soles and high heels all increase falls risk. Pharmacists can briefly mention the importance of well-fitting, low-heeled shoes with non-slip soles — it takes seconds and can prevent fractures.

Vision: Outdated prescriptions for glasses are a modifiable falls risk. Pharmacists can ask when the patient last had an eye test and recommend a visit to the optician.

Home hazards: Loose rugs, poor lighting, trailing cables and clutter on stairs are common fall triggers. Pharmacists can signpost to local authority home safety assessments, which are free for older adults in many areas.

Exercise: Strength and balance programmes (such as tai chi, Otago exercise programme, or FaME — Falls Management Exercise) have the strongest evidence base for falls prevention outside of medication review. Pharmacists can signpost to local programmes or Age UK resources.

The economic case

Falls cost the NHS more than £2.3 billion per year, according to Public Health England. A single hip fracture costs approximately £30,000 in acute care, rehabilitation and social support. A community pharmacy medication review costs a fraction of that — and evidence from NHS England pilot programmes suggests that pharmacist-led medication review reduces falls-related hospital admissions by 15–25 per cent.

For pharmacy owners, falls prevention services also represent a business opportunity. The Community Pharmacy Contractual Framework funds structured medication reviews, and some local authorities commission dedicated falls prevention screening programmes through community pharmacies.

Signposting and referral

Pharmacists should refer patients to their GP or local falls service when:

• A patient reports two or more falls in the past 12 months
• A patient presents after a fall with any injury
• Postural hypotension is identified and requires medication adjustment
• There are gait or balance abnormalities that may benefit from physiotherapy
• Cognitive impairment is suspected (which both increases falls risk and complicates medication management)

The PharmSee pharmacy finder helps patients locate community pharmacies offering clinical services including medication review. For pharmacists developing expertise in older adult care, the job board lists roles in care home pharmacy, PCN clinical pharmacy and community settings where falls prevention is a core activity. Salary benchmarks for these roles are available in the PharmSee salary guide.

Sources: NHS Digital Hospital Episode Statistics (falls admissions); NICE CG161 Falls in older people: assessing risk and prevention (2013, reviewed 2024); Public Health England falls prevention cost data; Age and Ageing journal (medication and falls risk); NHSBSA dispensing contractor records; PharmSee vacancy tracker (April 2026, n=1,715 active listings).