Polypharmacy prescribing guidance - draft: consultation

5. Medication and the frail older adult

5.1 Frailty

5.1.1 What is Frailty?

‘Frailty is the inability to withstand illness without the loss of function.’ (K. Rockwood)93

Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. A person living with frailty is vulnerable to significant, and often sudden, changes in health and function, in response to what would usually be a minor stressor event or change, such as a simple infection or an alteration in medication.

People living with frailty are more likely to suffer from adverse effects of medication.^[97] This group also has a shorter life expectancy to gain benefit from medication compared to those not living with frailty. It is important to focus on reducing medication related harm in this group of adults in particular, to avoid physical and cognitive impairment.

It is important to remember that frailty:

• while associated with ageing is not an inevitable outcome of ageing
• varies in degree from mild to very severe
• is not static and that people can become more or less frail, and reversable causes for increasing frailty should be considered
• is associated with increased morbidity and mortality, and adverse outcomes such as falls, delirium, hospital admission, and the need for long-term institutional care
• considerably impacts a person’s quality of life
• increases the use of primary care and unplanned secondary care services

5.1.2 When should frailty be considered?

Any interaction between a health or social care professional and an older person, aged over 65, should include an assessment of frailty. However, it is important to acknowledge that multimorbidity can occur earlier in those from more deprived backgrounds. Assessment of frailty should be considered when individuals are taking 10 or more multiple medications or have two or more long-term conditions. There is a clear association between frailty and polypharmacy. Assessment of clinical frailty can indicate how a person may respond to treatment, or about their future healthcare needs. It may highlight reversable causes of frailty.

5.1.3 Why assess frailty?

Identifying people living with frailty, allows them to have interventions that can reduce their level of frailty, and enable them to live longer with less disability. Early targeted preventative actions can also support decisions regarding appropriateness of interventions.

5.1.4 Why assess frailty when prescribing?

Considering frailty can be helpful when making decisions regarding appropriateness of treatment. Those with frailty are more susceptible to adverse effects of medication and have a reduced life expectancy to gain benefit from medication compared to adults without frailty. The assessment of frailty, and level of frailty can therefore help guide decision-making when starting new medication or reviewing current medication. The principles of Realistic Medicine with a person-centred approach should be considered with a focus on reducing harm, personalising the treatment, and wherever possible, involving the individual in decision-making. This can be achieved by following the 7-Steps process when making decisions about medication. The table below sets out the recommendations on reviewing the evidence, and a considered judgment process (see Appendix G for methodology).

Table 7: Recommendations on when to screen for frailty when undertaking 10 or more multiple medications or have two or more long-term conditions

No.	Our recommendations	Strength of recommendation
1	Healthcare professionals might want to consider screening for frailty in the following groups of people: Older adults (over 65 years) Anyone with reported change in mobility, presence of falls, and noticeable decrease in Activities of Daily Living after discharge from a hospital Anyone with continual fatigue People with multimorbidity	Conditional recommendation
2	Healthcare professionals should look for the following indicators of frailty: Falls, incontinence, immobility and/or confusion Any underlying medical problems that might cause frailty Polypharmacy and adverse effects of medications. Acute illness presenting as functional deterioration e.g. mobility, difficulty with self-care and toileting Reduced cognition and delirium Slowness, weakness, low physical activity, exhaustion, and shrinking	Conditional recommendation
3	Assessment can take place in the following settings: ambulatory setting primary care hospital outpatient community care	Conditional recommendation
4	Assessment might be appropriate at the following points in time: At baseline and then at least annually As part of Comprehensive Geriatric Assessment (CGA) to determine a person’s medical, psychosocial, and functional capabilities	Conditional recommendation

5.1.5 How to measure frailty

A range of tools for assessing frailty are available and following a review of these, the Clinical Frailty Score (Rockwood) and the Electronic Frailty Index are recommended.

Clinical Frailty Score (Rockwood):

• Is a simple, accessible, ordinal scale which stratifies frailty and each level has a pictorial description, and is based on the clinical judgment of the practitioner
• It stratifies the person into nine levels from fit, to living with mild, moderate or severe frailty or terminally ill
• It is validated in older adults over the age of 65 years but not in younger people with stable long-term disabilities
• It has been shown to indicate adverse outcomes in older people in hospital

• A level of 5 or more is seen as frail

Clinical Frailty Scale

1: Very Fit

People who are robust, active, energetic and motivated. They tend to exercise regularly and are among the fittest for their age.

2: Fit

People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g., seasonally.

3: Managing Well

People whose medical problems are well controlled, even if occasionally symptomatic, but often not regularly active beyond routine walking.

4: Living With Very Mild Frailty

Previously “vulnerable,” this category marks early transition from complete independence. While notdependent on others for daily help, often symptomslimit activities. A common complaint is being “slowed up”and/or being tired during the day.

5: Living With Mild Frailty

People who often have more evident slowing, and need help with high order instrumental activities of daily living (finances, transportation, heavy housework). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation, medications and begins to restrict light housework.

6: Living With Moderate Frailty

People who need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.

7: Living With Severe Frailty

Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months).

8: Living With Very Severe Frailty

Completely dependent for personal care and approaching end of life. Typically, they could not recover even from a minor illness.

9: Terminally Ill

Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise living with severe frailty. Many terminally ill people can still exercise until very close to death.

Scoring frailty in people with dementia

The degree of frailty generally corresponds to the degree of dementia. Common symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/ story and social withdrawal.

In moderate dementia, recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting.

In severe dementia, they cannot do personal care without help.

In very severe dementia they are often bedfast. Many are virtually mute.

Clinical Frailty Scale ©2005–2020 Rockwood, Version 2.0 (EN). All rights reserved. For permission: www.geriatricmedicineresearch.ca Rockwood K et al. A global clinical measure of fitness and frailty in elderly people.93

Electronic Frailty Index (eFI):

• is based on coding and not on individual patient assessment. It therefore should be used to identify those at risk of frailty and followed with an individual assessment
• is a population risk stratification tool which uses routine electronic data already collected and coded within general practice. It is not a diagnostic tool but it can identify those who may be living with mild, moderate and severe frailty. It can also be used to identify those who are becoming increasingly frail over a short period of time
• uses a cumulative deficit model to identify and score frailty based on routine interactions with their GP practice. As individuals interact with the practice team a list of read codes accumulates in their records
• uses a subset of these read codes to interpret any number of up to 36 potential deficits to produce a score. This score determines whether a person is considered fit, mildly frail, moderately frail, or severely frail and nearing the end of their life. This can be calculated for an individual or for a whole GP practice population over 65 years of age.
• is strongly predictive of adverse outcomes and has been validated in around 900,000 patient records94

5.1.6 Prescribing decisions when someone is frail

As people become increasingly frail, their life expectancy reduces and the time to accumulate benefit from medication reduces. An individual’s priorities of treatment can often change from prolonging life and reducing major events, to symptom control and reducing harm. There can be additional challenges with administration, and adherence to medication. In this section the key areas where prescribing decisions may be influenced by the level of frailty are considered. It is recognised that this is an area with only limited evidence as few clinical trials focus on frail subgroups.

There is limited evidence regarding prescribing according to different levels of frailty (mild, moderate, severe). Due to this, the strength of recommendations are good practice points based on expert clinical opinion. Prescribers and patients may be helped by the use of NNT charts or gates plots to help visualise potential magnitude of benefit of medication for this intervention, to support shared decision-making.

5.1.7 Frailty and Type 2 Diabetes (T2DM)

This section concentrates on prescribing in older people living with frailty who have T2DM, with a particular focus on:

• whether intensive blood glucose control (aimed at a target HbA1c less than 48mmol/mol / <6.5%) reduces the risk of mortality, cardiovascular events, and diabetes related end points
• the risks of intensive blood glucose control and potential increase in adverse events

The mixed quality and limited evidence indicates:[98]^,[99]

• In those with frailty, higher HbA1c (>69mmol/mol, >8.5%) is associated with poor muscle quality and sarcopenia.
• In older adults with T2DM and CKD, tight glycaemic control (<42mmol/mol, <6%) increases the risk of hypoglycaemia, further deterioration in function and cessation of disability-free living. Therefore, acceptable glycaemic targets are:
  • 53-64 mmol/mol (7-8%) generally
  • 59-69 mmol/mol (7.5-8.5%) for frail older adults with CKD
  • Avoid tight glycaemic control (<42mmol/mol, <6%)
• Higher levels acceptable in those with limited life expectancy (whilst minimising symptomatic hyperglycaemia or hypoglycaemia).
• Assess HbA1c readings from the previous 6-12 months to set goals for discharge regarding glycaemic control. Previous targets could be revisited and goals individualised to take account of comorbid medical conditions or functional and cognitive status. In people with moderate to severe frailty, a higher glucose range was acceptable.
• If a person is admitted to hospital, it is necessary to immediately review the therapy regimen on admission, and then every 24 hours, to ensure a satisfactory level of glycaemia, avoiding overtreatment and minimising adjustments.
• It is important to be aware that insulin doses at hospital discharge can be very different to those needed in the community. Any medication changes need to be communicated clearly in the discharge summary to the primary and community care team and family members/carers. There should be a rapid review post discharge.

The table below sets out the recommendations based on the evidence, and a considered judgment process.

Table 8: Recommendations to manage frailty and T2D

No.	Our recommendations	Strength of recommendation
1	Healthcare professionals (HCP) and older people with frailty might want to discuss the following regarding diabetes medication: Strict avoidance of both hypoglycaemia (defined as <4.0 mmol/L) and osmotic symptoms (usually seen when glucose levels are greater than 15 mmol/L) should be a major goal of care for the frail older inpatient.	Good practice point
2	A higher glucose range should be considered by the care team in people with moderate to severe frailty or those with limited life expectancy.	Good practice point
3	The need for glycaemic control to be less rigid for frail older adults with chronic kidney disease: an HbA1c range of 59-69mmol/mol (7.5-8.5%), due to an increased risk of hypoglycaemia. Avoid tight glycaemic control (Hba1c <42mmol/mol (6%)).	Good practice point
4	Higher HbA1c of >69 mmol/mol (>8.5%) has been shown to be independently associated with poor muscle quality, which may lead to sarcopenia.	Good practice point
5	To review medication regimen post discharge, at home, or in a care facility.	Good practice point

5.1.8 Frailty and hypertension

The aim to control blood pressure to lower than 140/90mmHg is associated with a significant reduction in composite cardiovascular outcomes. [100]^{, [101]} The evidence was reviewed for tight blood pressure control in older adults living with frailty and hypertension, considering if treatment aimed at reducing BP to less than 140/90mmHg will:

• reduce the risk of mortality?
• reduce the risk of cardiovascular outcomes?

• increase adverse events?

From the review of guidelines available, (one of mixed quality and one of high quality), there is advice regarding detection, monitoring, and treatment of hypertension, however levels of frailty were not considered.100^,101 Independence, frailty, and comorbidities will all influence treatment decisions, especially in older (>65 years) and very old (>80 years) people.

Lowering systolic blood pressure to less than 140mmHg in older people with primary hypertension without T2DM, is associated with both benefits and harms. While reducing mortality and cardiovascular events, a systolic blood pressure below 120mmHg is associated with greater risk of harms, including injury from falls and acute kidney injury, particularly for those with frailty.

There is a lack of evidence for intensive blood pressure targets in people with frailty and for those over the age of 80 years. It is noted that people who are frail have increased risk of adverse events and less time to gain benefits from long-term rigid BP control. The table below sets out the recommendations on reviewing the evidence, and a considered judgment process.

Table 9: Recommendation when managing frailty and hypertension

No.	Our recommendations	Strength of recommendation
1	Antihypertensive medications can reduce the risk of mortality, stroke, and heart failure in older adults. Because biological rather than chronological age can determine tolerability of, and likely benefit from medications, these individuals should not be denied treatment, or have it withdrawn simply on the basis of their chronological age. A person-centred approach should be considered.	Good Practice Point
2	Prescribers and people over 65 years of age with frailty might want to discuss the tolerability of, and benefits from, antihypertensive medication taking into consideration a person’s level of frailty, and independence.	Good Practice Point
3	A general treatment target of systolic blood pressure (SBP) below 140 mmHg, and diastolic blood pressure (DBP) below 80 mmHg is recommended for adults under 80 years with or without T2DM. For those over 65 years of age with frailty, this might not be achievable. While a higher target is acceptable, if lower blood pressure is sought, a slower timeline for reductions will be required in frail old or very old patients; it is important to recognise that this might not be achievable.	Conditional recommendation
4	BP targets should be balanced with the greater risk of harms, falls and acute kidney injury.	Good Practice Point

5.1.9 Frailty and Statins

There is limited evidence on whether statins prescribed for primary or secondary prevention were associated with reduced Major Adverse Cardiovascular Events (MACE) among adults older than 65 years living with frailty.

Based on one SR judged to be acceptable in quality and of partial relevance,^[102] it is not possible to determine:

• If a statin prescribed for the purpose of primary or secondary prevention reduces the risk of mortality/MACE among older adults with frailty.
• If statin prescribing will change the frequency of admission to long-term care or reduce frequency of admission to hospital.
• What impact statins have on the treatment burden or quality of life of people with frailty.

Nevertheless, some evidence within the same SR is less unequivocal, and so the following should be noted:

• That people more often stop statins when prescribed for the purpose of primary prevention than for secondary prevention.
• That the likelihood of deprescribing a statin increases with severity of frailty.

The table below sets out the recommendations on reviewing the evidence, and a considered judgment process.

Table 10: Recommendations when managing frailty and statins

No.	Our recommendations	Strength of recommendation
1	Prescribers and older people with frailty might want to discuss reducing or stopping a statin because the evidence does not indicate: Reduction in morbidity/mortality in primary prevention A change in the frequency of admission to long-term care, or reduced frequency of admission to hospital	Good practice point
2	Prescribers and older people with frailty may wish to discuss what effect taking a statin has on treatment burden, or quality of life. Within the polypharmacy manage medicines app, prescribers and patients may wish to use shared decision-making tools, such as NNT charts or gates plots to help visualise potential magnitude of benefit of medication for this intervention.	Good practice point

5.1.10 Frailty and medication for mental health

One guideline ^[103] and one SR [104] focused on frailty and mental health medication. These reviewed antidepressant use in frail, older adults and the efficacy and safety of medication for those with Alzheimer’s disease and associated behavioural and psychological symptoms of dementia.

Frailty and antidepressants:

There is no significant evidence that individuals with depression and frailty benefit from antidepressants.103 One SR also found no evidence of benefits for people with frailty taking antidepressants (fluoxetine, clomipramine).104

The evidence is poor regarding benefits and harm, therefore prescribers and people over 65 years with frailty should discuss the use of antidepressants, considering the lowest effective dose and the duration of treatment. Due to poor efficacy, these should be reviewed after two to four weeks to assess the benefits and side effects. ^[105]

Trials of different types of antidepressants were examined in older adults with depression, or with neuropsychiatric symptoms of dementia. They reviewed the benefit in relation to the adverse effects, which include more frequent fatigue, nausea, constipation, dizziness, and diarrhoea, and proposed that a reduction in antidepressants in frail older adults could decrease the risk of polypharmacy and medication side effects.

Frailty and Acetylcholinesterase Inhibitors (AChEI) for Alzheimer’s dementia

One SR found significantly fewer deaths among people taking AChEI compared to placebo.104 People taking AChEI (galantamine, donepezil) suffered significantly more neurological adverse effects (agitation, tremor, confusion, depression, abnormal gait, and dizziness), than people taking placebo. There was little difference in functional status between placebo and AChEI. There was no significant difference in adherence to treatment.

For cognitive function, measured by Severe Impairment Battery (SIB), one trial reported a significant difference, in favour of galantamine over placebo. When Mini Mental State Examination (MMSE) was used to measure cognitive function, another trial reported significant superiority of donepezil compared with placebo at 8,16 and 20 weeks.104

Therefore, prescribers and people over 65 years with frailty, should discuss the benefits of taking AChEIs, (including fewer deaths and cognitive benefits) compared to the risk of adverse GI and neurological effects (e.g. agitation, tremor, confusion, depression, aggression, vertigo, abnormal gait, and dizziness). Stopping established treatment with AChEIs for Alzheimer’s dementia may lead to loss of cognition or function which may not be regained if the medication is restarted, so the risks and benefits of deprescribing should be considered carefully.

Frailty and anticonvulsants in the treatment of symptoms of dementia

The efficacy and safety of anticonvulsants (carbamazepine, valproate) was compared with placebo in frail older patients with Alzheimer’s disease and aggressive / agitated behaviour,104 and the evidence is limited. Prescribers and people over 65 years with frailty (and/or their proxy) should balance the limited benefits of prescribing anticonvulsants against the considerable neurological adverse effects (agitation, tremor, confusion, depression, aggression, vertigo, abnormal gait, dizziness).

Frailty and antipsychotics in the treatment of symptoms of dementia

The efficacy and safety of a range of antipsychotics (including risperidone, haloperidol, quetiapine, fluvoxamine) was reviewed in frail older adults with Alzheimer’s Disease and psychotic symptoms.104 The evidence for effectiveness was limited for improving agitation, anergia and some behavioural and psychological symptoms. Overall, there was little evidence of benefit for a range of outcomes, e.g. cognitive function, treatment of thought disturbance, dementia outcomes, reduction in deaths.

The evidence highlighted that antipsychotics have adverse effects, including a significant worsening in extrapyramidal symptoms. There was some evidence that people with frailty treated with antipsychotics had significantly more neurological adverse events (e.g. somnolence, agitation, abnormal gait, insomnia and convulsions).

Antipsychotics are frequently prescribed to reduce symptoms of stress and distress in people with dementia. However, these drugs have limited benefits, and older patients are particularly vulnerable to their adverse effects.^[106] Antipsychotics are also associated with an adverse cardiovascular profile and an increased risk of metabolic disorders, and these may need additional electrocardiogram (ECG) and biochemistry monitoring. Long-term use is associated with cerebrovascular events and death in people with dementia.32 They should only be used when alternative non-pharmacological measures have failed, and their use should be re-evaluated on a regular basis. Evidence suggests that discontinuation may not cause significant deterioration in symptoms.

The table below sets out the recommendations on reviewing the evidence, and a considered judgment process.

Table 11: Recommendations when managing frailty and depression or dementia

No.	Our recommendations	Strength of recommendation
1	Antidepressants should only be started if non-pharmacological interventions are insufficient due to lack of evidence of benefit and increased side effects.	Conditional recommendation
2	If antidepressants are started for frail older adults over 65 years, the person should be reassessed after 8-12 weeks due to lack of evidence of benefit and increased risk of side effects.	Conditional recommendation
3	Prescribers and people over 65 years with frailty and Alzheimer’s dementia should discuss the benefits of taking AChEIs (fewer deaths and cognitive benefits), compared to the risk of adverse GI and neurological effects (agitation, tremor, confusion, depression, aggression, vertigo, abnormal gait, dizziness).	Conditional recommendation
4	The risks and benefits of deprescribing AChEIs for Alzheimer’s dementia should be considered carefully. Stopping established treatment with may lead to loss of cognition or function which may not be regained if the medication is restarted.	Conditional recommendation
5	Prescribers and people over 65 years with frailty should balance the limited benefits of prescribing anticonvulsants for agitation and aggressive behaviour in people with Alzheimer’s disease against the considerable neurological adverse effects (agitation, tremor, confusion, depression, aggression, vertigo, abnormal gait, dizziness). The evidence for the use of anticonvulsants to reduce agitation and aggressive behaviour in people with Alzheimer’s disease is limited.	Conditional recommendation
6	Prescribers and people over 65 years with frailty should be cautious when considering the prescription of antipsychotic medication for stress and distress in dementia. They have a considerable number of adverse effects, particularly neurological, cardiovascular and metabolic. There is an increased risk of death for those over 65 years on these medications. The evidence for the use of antipsychotic medication in stress and distress in dementia is limited.	Conditional recommendation
7	People taking antidepressants, anticonvulsants or antipsychotics should have the prescribing of these medicines reviewed regularly.	Conditional recommendation

5.2 Medication and the risk of falling

5.2.1 Falls

A fall is “an unexpected event in which an individual comes to rest on the ground, floor, or a lower level”.^[107]

Although most people experience a fall at some point in their life, the impact of a fall for older or frailer people can be critical. Loss of confidence due to fear of a further fall may lead to reduced mobility, increased isolation, reduced muscle mass, increased joint pain and loss of independence, whether or not an injury is sustained from the fall. Falls are a major cause of emergency hospital admission for older people in the UK and can have long-term consequences.

Around one third of adults over 65 and around half of adults over 80 will fall at least once a year. Around one in 10 falls will result in a fracture.^[108]

Fractures increase morbidity, and people who have hip or vertebral fractures have a decreased life expectancy. ^[109]

People who fall may have a number of physical and environmental factors which contribute to future risk of falling. A multi-factorial falls assessment will include areas such as:

• lighting
• walking surfaces/ trip hazards
• eyesight
• health conditions including balance
• intake of alcohol and other substances
• medication

5.2.2 Which medicines should be considered?

Various medicines have been identified as being associated with an increased risk of falling in older people. In systematic reviews medicines associated with falls are those acting on: the central nervous system (e.g. benzodiazepines, opioids, sedatives), the cardiovascular system (e.g. antihypertensives), medicines for diabetes, and many others have been associated with falls. Evidence on the outcome of reducing medicines associated with falls is limited. It is recognised that reducing or stopping many of these medicines can be challenging, and future studies are required in this area.

The table below sets out the recommendations on reviewing the evidence, and a considered judgment process.

Table 12: Recommendations for medication reviews to reduce falls (Based on five SRs of varying quality, which reported mixed evidence of the risk of prescribing potentially inappropriate medication)84^{,[110],[111],[112],[113]}

Our recommendations

Prescribers and medicine users should discuss the benefits and harms of taking medication associated with increased falls as part of a person-centred medication review.

(Benzodiazepines, opioids, sedatives, diabetes medication, psychotropics, and antihypertensives are associated with risk of falls).

Strength of recommendation

Conditional recommendation

5.2.3 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 or STEADI 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 Appendix D1.

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[114]^,[115] and eight guidelines of mixed quality,6^,64^{,[116],[117],[118],[119],[120],[121]} we make the following recommendations on medication review, which should be undertaken using the 7-Steps process.

Table 13: Recommendations on medication review for those people at risk of falls or have fallen

No.	Our recommendations	Strength of recommendation
1	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 if possible to reduce risk of falling.	Strong recommendation
2	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.	Strong recommendation
3	Medication reviews should be part of multifactorial risk assessment and individual care plan.	Conditional recommendation
4	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.	Conditional recommendation

5.2.4 Who should conduct medication reviews?

In the UK, legislation allows a range of appropriately trained, registered professionals to prescribe and review medication. It is anticipated that relevant prescribing professionals will develop confidence and competence in reviewing medication for older people at risk of falls. To date the evidence has focused on GPs and pharmacists.

5.2.5 General Practice interventions as part of a multidisciplinary approach

A systematic review and meta-analysis looked at the involvement of general practices in falls prevention as part of a multidisciplinary approach. As with other literature around falls and falls prevention, the content of the intervention varied leading to difficulties pooling results. While overall the literature shows no effect of interventions to reduce the proportion of those who fell more than once, six studies showed a significant reduction in the number of people who experienced an injurious fall. Medication review was part of the suite of interventions studied but their effect could not be isolated from the rest of the multidisciplinary approach. The table below sets out the recommendations on reviewing the evidence, and a considered judgment process.

Table 14: Recommendations to show the impact of polypharmacy reviews on falls prevention (based on one low quality SR)

Our recommendations

General practice-based MDT polypharmacy interventions may contribute to falls prevention.

Strength of recommendation

Conditional recommendation

5.2.6 Pharmacist interventions

Some reviews looked at pharmacist interventions aimed at a broader effect than falls risk alone, such as reduction of adverse drug effects, some of which include falls. Studies looking at pharmacist-led interventions to reduce adverse drug effects showed either positive outcomes, no difference, or mixed results. For those studies looking specifically at falls as an adverse drug effect, pharmacist interventions were effective. The heterogeneity of the studies leads to caution in the interpretation of the results. The table below sets out the recommendations on reviewing the evidence, and a considered judgment process.

Table 15: Recommendations regarding pharmacist led medication reviews on impact of falls (based on one SR of acceptable quality)

No.	Our recommendations	Strength of recommendation
1	A medicine review undertaken by a pharmacist can have a significant reduction on adverse drug events.	Strong recommendation
2	A medicine review undertaken by a pharmacist may help reduce the risk of falls.	Conditional recommendation