Pharmacy fall prevention services for the community-dwelling elderly:Patient engagement and expectations

Medication use is an important risk factor for falls. Community pharmacists should therefore organise fall prevention care; however, little is known about patients' expectations of such services. This qualitative study aims to explore the expectations of community-dwelling older patients regarding fall prevention services provided by community pharmacies. Telephone intakes, followed by three focus groups, were conducted with 17 patients, who were aged ≥75 years, used at least one fall risk-increasing drug (FRID) and were registered at a community pharmacy in Amsterdam, the Netherlands. Some time of the focus groups was spent on playing a game involving knowledge questions and activities to stimulate discussion of topics related to falling. Data were collected between January 2020 and April 2020, and all focus groups were audiotaped and transcribed verbatim. The precaution adoption process model (PAPM) was applied during data analysis. Patients who had already experienced a fall more often mentioned that they took precautions to prevent falling. In general, patients were unaware that their medication use could increase their fall risk. Therefore, they did not expect pharmacists to play a role in fall prevention. However, many patients were interested in deprescribing. Patients also wanted to be informed about which medication could increase fall risk. In conclusion, although patients initially did not see a role for pharmacists in fall prevention, their perception changed when they were informed about the potential fall risk-increasing effects of some medications. Patients expected pharmacists to focus on drug-related interventions to reduce fall risk, such as deprescribing

Community pharmacists' perceptions on providing fall prevention services:A mixed-methods study

Background Pharmacists may contribute to fall prevention particularly by identifying and deprescribing fall risk-increasing drugs (FRIDs) in patients with high fall risk. Objective To assess community pharmacists’ perceptions on providing fall prevention services, and to identify their barriers and facilitators in offering these fall prevention services including deprescribing of FRIDs. Setting A mixed-methods study was conducted with Dutch pharmacists. Method Quantitative (ranking statements on a Likert scale, survey) and qualitative data (semi-structured interviews) were collected. Out of 466 pharmacists who were invited to participate, 313 Dutch pharmacists ranked statements, about providing fall prevention, that were presented during a lecture, and 205 completed a survey. To explore pharmacists’ perceptions in-depth, 16 were interviewed. Quantitative data were analysed using descriptive statistics. All interviews were audiotaped and transcribed verbatim. The capability opportunity motivation-behaviour model was applied to interpret and analyse the findings of qualitative data. Main outcome measure Community pharmacists’ views on providing fall prevention. Results Pharmacists stated that they were motivated to provide fall prevention. They believed they were capable of providing fall prevention by FRID deprescribing. They perceived limited opportunities to contribute. Major barriers included insufficient multidisciplinary collaboration, patient unwillingness to deprescribe FRIDs, and lack of time. Facilitators included goal-setting behaviour, financial compensation, and skilled communication. Conclusion Despite the complex decision-making process in medication-related fall prevention, community pharmacists are motivated and feel capable of providing fall prevention. Opportunities for pharmacists to provide fall prevention services should be enhanced, for example by implementing multidisciplinary agreements. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11096-021-01277-4

Perspectives of primary care providers on multidisciplinary collaboration to prevent medication-related falls

Background: The causes of falls are often multifactorial. The prevention of falls benefits from a multidisciplinary approach. As people who fall are generally older and users of polypharmacy who frequently visit pharmacies, pharmacists may contribute to fall prevention. Objectives: This study aims to explore the perceptions of primary care providers on multidisciplinary collaboration in fall prevention especially with pharmacists. Methods: Two focus groups were held with each of the following health disciplines: physiotherapists, home care nurses, and practice nurses. A topic list was developed based on the capability opportunity motivation - behaviour (COM-B) model and the theoretical domains framework (TDF). Focus groups were audiotaped and transcribed verbatim. Data were collected in the Netherlands between March and June 2021. Results: Six online focus groups were held with 17 physiotherapists, 14 home care nurses, and 15 practice nurses. Participants reported to collaborate multidisciplinary to prevent falls, but they had very limited collaboration with community pharmacists regarding fall prevention. Participants had limited knowledge on drugs that increase the risk of falls. This contributed to their low awareness of the potential role of pharmacists in fall prevention. Other reasons for poor collaboration in fall prevention were lack of agreements with pharmacists, limited coordination and communication. Participants were open to more collaboration with pharmacists and believed this could potentially improve patient outcomes. Conclusions: Multidisciplinary agreements among health care providers, including community pharmacists, about referral criteria, roles and responsibilities, communication and coordination, could stimulate further collaboration in fall prevention

Establishing a community pharmacy-based fall prevention service - An implementation study

Background: Community pharmacists are in the position to contribute to fall prevention, but this is not yet common practice. Objective: The aim of this study was to evaluate the implementation of a community pharmacy-based fall prevention service. Methods: A fall prevention service, consisting of a fall risk screening and assessment including a medication review, was implemented in pharmacies during three months. A preparative online training was provided to the pharmacy team to enhance adoption of the service. Included patients were aged ≥70 years, using ≥5 drugs of which ≥1 fall risk-increasing drug. The implementation process was quantitively assessed by registering medication adaptations, recommendations, and referrals. Changes in patient scores on the Short Fall Efficacy Scale-International (FES-I) and a fall prevention knowledge test were documented at one month follow-up. Implementation was qualitatively evaluated by conducting semi-structured interviews with pharmacists before and after the project, based on the consolidated framework of implementation research. Results: The service was implemented in nine pharmacies and 91 consultations were performed. Medication was adapted of 32 patients. Patients' short FES-I scores were significantly higher at follow-up (p = 0.047) and patients’ knowledge test scores did not differ (p = 0.86). Pharmacists experienced the following barriers: lack of time, absence of staff, and limited multidisciplinary collaboration. Facilitators were training, motivated staff, patient engagement, and project scheduling. Conclusion: The service resulted in a substantial number of medication adaptations and lifestyle recommendations, but many barriers were identified that hamper the sustained implementation of the service

Patients' experience with a community pharmacy fall prevention service

BACKGROUND: Pharmacists can contribute to fall prevention, by offering services such as fall risk screenings, counselling, and medication reviews. Patient acceptance of the role of pharmacists in fall prevention is crucial. OBJECTIVES: The aim of this study was to explore patients' experience with a community pharmacy fall prevention service. METHODS: Interviews were conducted with patients one month after they participated in a pharmacy fall prevention service, in the Netherlands. Patient inclusion criteria for the service were: age ≥ 70 years, use of ≥5 drugs including ≥1 fall risk-increasing drug. The service included a fall risk screening followed by counselling and a medication review. The semi-structured interview guide was based on the consolidated framework for implementation research and included the following topics: outcomes, patient's motivation, and contact with the pharmacy technician. RESULTS: Of the 91 participants of the fall prevention service, 87 patients were interviewed with a median age of 78.0 years (first quartile [Q1] - third quartile [Q3]: 74.0-84.75) and 46.3% were female. Many patients expressed positive feedback about receiving a medication review. Most patients whose medication was deprescribed expressed to be positive about this. Others were reassured about the appropriateness of their medication use. Patients reported that the service enhanced their awareness about fall prevention. Only a few patients were motivated to adapt their lifestyle. Patients appreciated the attention and contact. CONCLUSIONS: Patients see a potential benefit for a community pharmacy falls prevention service, including a medication review. Patient education appeared to enhance their fall risk awareness

Using pharmacy dispensing data to predict falls in older individuals

Aims Associations between individual medication use and falling in older individuals are well-documented. However, a comprehensive risk score that takes into account overall medication use and that can be used in daily pharmacy practice is lacking. We, therefore, aimed to determine whether pharmacy dispensing records can be used to predict falls. Methods A retrospective cohort study was conducted using pharmacy dispensing data and self-reported falls among 3454 Dutch individuals aged >= 65 years. Two different methods were used to classify medication exposure for each person: the drug burden index (DBI) for cumulative anticholinergic and sedative medication exposure as well as exposure to fall risk-increasing drugs (FRIDs). Multinomial regression analyses, adjusted for age and sex, were conducted to investigate the association between medication exposure and falling classified as nonfalling, single falling and recurrent falling. The predictive performances of the DBI and FRIDs exposure were estimated by the polytomous discrimination index (PDI). Results There were 521 single fallers (15%) and 485 recurrent fallers (14%). We found significant associations between a DBI >= 1 and single falling (adjusted odds ratio: 1.30 [95% confidence interval {CI}: 1.02-1.66]) and recurrent falling (adjusted odds ratio: 1.60 [95%CI: 1.25-2.04]). The PDI of the DBI model was 0.41 (95%CI: 0.39-0.42) and the PDI of the FRIDs model was 0.45 (95%CI: 0.43-0.47), indicating poor discrimination between fallers and nonfallers. Conclusion The study shows significant associations between medication use and falling. However, the medication-based models were insufficient and other factors should be included to develop a risk score for pharmacy practice

Imminent fall risk after fracture

Rationale: Adults with a recent fracture have a high imminent risk of a subsequent fracture. We hypothesise that, like subsequent fracture risk, fall risk is also highest immediately after a fracture. This study aims to assess if fall risk is time-dependent in subjects with a recent fracture compared to subjects without a fracture. Methods: This retrospective matched cohort study used data from the UK Clinical Practice Research Datalink GOLD. All subjects ≥50 years with a fracture between 1993 and 2015 were identified and matched one-to-one to fracture-free controls based on year of birth, sex and practice. The cumulative incidence and relative risk (RR) of a first fall was calculated at various time intervals, with mortality as competing risk. Subsequently, analyses were stratified according to age, sex and type of index fracture. Results: A total of 624,460 subjects were included; 312,230 subjects with an index fracture, matched to 312,230 fracture-free controls (71% females, mean age 70 ± 12, mean follow-up 6.5 ± 5 years). The RR of falls was highest in the first year after fracture compared to fracture-free controls; males had a 3-fold and females a 2-fold higher risk. This imminent fall risk was present in all age and fracture types and declined over time. A concurrent imminent fracture and mortality risk were confirmed. Conclusion/Discussion: This study demonstrates an imminent fall risk in the first years after a fracture in all age and fracture types. This underlines the need for early fall risk assessment and prevention strategies in 50+ adults with a recent fracture

The role of the community pharmacist in fall prevention: The ups and downs of implementation

Falls are increasingly common among older people. One-third of people aged ≥ 65 years falls at least once annually. Among a diversity of risk factors for falls, medication use is considered as one of great importance. At least, community pharmacists’ role in fall prevention should include the identification and adaptation of use of fall risk-increasing drugs in patients at risk of falls. In this thesis, we aimed to answer the question how pharmacists can contribute to fall prevention and how fall prevention services can be implemented, including their barriers and facilitators. Also, this thesis aimed to assess the perspectives of patients, pharmacists, and other health care providers, for the provision of pharmacy-led fall prevention services. We found that community pharmacists are currently limited involved in fall prevention. Most patients are currently unaware of that their medications could have fall risk-increasing effects. Furthermore, other health care providers, including physiotherapist, practice nurses and home care nurses, experience suboptimal collaboration with community pharmacists in fall prevention. Fortunately, pharmacists indicated they wished to be more involved. Particularly, they believed they could contribute by advising on deprescribing of fall risk-increasing drugs. The following facilitators were identified for community pharmacists to provide fall prevention care, including deprescribing of fall risk-increasing drugs: patient engagement, good multidisciplinary collaboration, knowledge about fall risk-increasing drugs and deprescribing, and sufficient pharmacist communication skills. Lack of time and lack of reimbursement were often identified as barriers for implementation. To identify patients at medication-related fall risk more quickly, a contra-indication ‘fall risk’ could be added for saving in pharmacy information systems. This may support the screening of patients at risk, so targeted advice can be provided to them. Pharmacy technicians could be trained to identify patients at risk of falls and advise them on fall prevention accordingly. Therefore, pharmacy technicians can have an important role in the provision of pharmacy-led fall prevention services. Health care providers in primary care should be stimulated to make agreements with one another. Such agreements should be about coordination of care, multidisciplinary meetings, referral, role clarification, and manners of communication. Pharmacists might need additional training in communication techniques, in order to foster the collaboration in fall prevention. They also need good communication skills to engage their patients in fall prevention. Specifically, pharmacists should be recommended to warn patients proactively against fall-related adverse effects. In conclusion, falling in older people is a major public health issue. Pharmacists are in the position to contribute to fall prevention. The most obvious way for community pharmacists to contribute is by providing medication reviews and advising on deprescribing of FRIDs. Pharmacists should, however, take up the gauntlet and increase their visibility in fall prevention. Policy makers, professional organizations and payers should recognize and facilitate pharmacists in this role

Perspectives of primary care providers on multidisciplinary collaboration to prevent medication-related falls

Background: The causes of falls are often multifactorial. The prevention of falls benefits from a multidisciplinary approach. As people who fall are generally older and users of polypharmacy who frequently visit pharmacies, pharmacists may contribute to fall prevention. Objectives: This study aims to explore the perceptions of primary care providers on multidisciplinary collaboration in fall prevention especially with pharmacists. Methods: Two focus groups were held with each of the following health disciplines: physiotherapists, home care nurses, and practice nurses. A topic list was developed based on the capability opportunity motivation - behaviour (COM-B) model and the theoretical domains framework (TDF). Focus groups were audiotaped and transcribed verbatim. Data were collected in the Netherlands between March and June 2021. Results: Six online focus groups were held with 17 physiotherapists, 14 home care nurses, and 15 practice nurses. Participants reported to collaborate multidisciplinary to prevent falls, but they had very limited collaboration with community pharmacists regarding fall prevention. Participants had limited knowledge on drugs that increase the risk of falls. This contributed to their low awareness of the potential role of pharmacists in fall prevention. Other reasons for poor collaboration in fall prevention were lack of agreements with pharmacists, limited coordination and communication. Participants were open to more collaboration with pharmacists and believed this could potentially improve patient outcomes. Conclusions: Multidisciplinary agreements among health care providers, including community pharmacists, about referral criteria, roles and responsibilities, communication and coordination, could stimulate further collaboration in fall prevention

Community pharmacists’ perceptions on providing fall prevention services: a mixed-methods study

Background Pharmacists may contribute to fall prevention particularly by identifying and deprescribing fall risk-increasing drugs (FRIDs) in patients with high fall risk. Objective To assess community pharmacists’ perceptions on providing fall prevention services, and to identify their barriers and facilitators in offering these fall prevention services including deprescribing of FRIDs. Setting A mixed-methods study was conducted with Dutch pharmacists. Method Quantitative (ranking statements on a Likert scale, survey) and qualitative data (semi-structured interviews) were collected. Out of 466 pharmacists who were invited to participate, 313 Dutch pharmacists ranked statements, about providing fall prevention, that were presented during a lecture, and 205 completed a survey. To explore pharmacists’ perceptions in-depth, 16 were interviewed. Quantitative data were analysed using descriptive statistics. All interviews were audiotaped and transcribed verbatim. The capability opportunity motivation-behaviour model was applied to interpret and analyse the findings of qualitative data. Main outcome measure Community pharmacists’ views on providing fall prevention. Results Pharmacists stated that they were motivated to provide fall prevention. They believed they were capable of providing fall prevention by FRID deprescribing. They perceived limited opportunities to contribute. Major barriers included insufficient multidisciplinary collaboration, patient unwillingness to deprescribe FRIDs, and lack of time. Facilitators included goal-setting behaviour, financial compensation, and skilled communication. Conclusion Despite the complex decision-making process in medication-related fall prevention, community pharmacists are motivated and feel capable of providing fall prevention. Opportunities for pharmacists to provide fall prevention services should be enhanced, for example by implementing multidisciplinary agreements