Feet and eyes

Shoes that fit well protect and support the feet and can preserve and improve balance and stability. Poorly fitting shoes or slippers can cause trips and falls. Lace-up or Velcro fastening shoes give more support than slip-ons. Eyesight is an important factor in maintaining balance and co-ordination. The prevalence of some eye conditions such as macular degeneration, glaucoma and cataracts increases with age and highlights the importance of early detection. Eyes and glasses should be checked at least every two years. 

Medicines

Medicines that cause adverse effects on the central nervous system or that cause postural hypotension and can increase the risk of falls, include: 

• Sedatives
• Hypnotics
• Anxiolytics
• Diuretics
• Any drugs with antimuscarinic effects
• Antiarrhythmics
• Antinauseants
• Anticonvulsants
• Antidepressants
• Antihypertensives
• Antipsychotics.

Nutrition, frailty and falls

Poor nutrition is frequently associated with frailty and in turn this can lead to falls, particularly if muscles are wasted or weak. Appetite loss affects up to one in five older people living in the community. Many people perceive low body weight and unplanned weight loss (malnutrition) to be a normal part of ageing but these may be due to poor dietary intake.

In combination with exercise, older people need to eat enough protein foods to help prevent muscle loss (sarcopenia). Higher consumption of fruit and vegetables and lower consumption of highly processed foods are associated with lower frailty risk. 

Vitamin D deficiency has been associated with osteopenia (thin bones) and with muscle weakness, poor neuromuscular co-ordination, and falls. People are at risk of vitamin D deficiency if they are aged over 65 years, or are not exposed to much sunlight, usually because they are confined indoors for long periods, or because they wear clothes that cover the whole body. 

For a person with adequate calcium intake (700mg/day) but who is not exposed to much sunlight, 10mcg/400 international units of oral vitamin D daily (without calcium) is recommended. If calcium intake is inadequate the same dose of vitamin D with at least 1,000mg of calcium daily is recommended. For elderly people who are housebound or living in a nursing home, 20mcg/800 international units of vitamin D with at least 1,000mg of calcium daily is sometimes recommended. This dose has been shown to reduce falls and fractures in some studies although the evidence is of low quality.

Conclusions

Community pharmacy teams can contribute to reducing falls beyond monitoring medicines that are known to be associated with falls. Simple practical tips can help to build resilience and prevent or ameliorate the effects of frailty through encouraging physical activity, improving diet, enhanced safety in the home, and through the use of social networks.