Case-based learning: optimising falls prevention through a multidisciplinary approach

Introduction

Falls are one of the most common — often preventable — presentations for older adults to health care services. According to Office for Health Improvement and Disparities data, around 30% of people aged 65 years or over will have a fall at least once each year, which increases to 50% in those aged 80 years and over^​1​. Falling can cause significant harm to the individual, including pain, distress, fracture, disability, loss of independence and even death^​2​. 

Falls present a substantial economic burden, costing the NHS more than £2.3bn per year^​2​. In 2023/2024, there were 219,155 emergency hospital admissions related to falls in England, with 76,755 of those occurring in people aged 65–79 years^​3​. Although hospital falls have reduced over the past five years, they remain a major concern. The 2025 National Institute for Health and Care Excellence (NICE) guideline — entitled, ‘Falls: assessment and prevention in older people and in people 50 years and over at higher risk’ — emphasises early identification of risk factors and comprehensive falls assessments, including medicines optimisation and multidisciplinary intervention^​4​.

Most falls are caused by the interaction of multiple risk factors, and, often, there is an interplay between intrinsic factors, such as frailty, comorbidities and impaired balance, and extrinsic factors such as environmental hazards and medication-related effects^​5​. Polypharmacy is recognised as an important risk factor for falls in older adults, as well as drugs that increase anticholinergic burden and falls risk-increasing drugs (FRIDs) such as psychotropics, antihypertensives and sedatives^​6,7​. Anticholinergic burden refers to the cumulative, unintended adverse effects of taking multiple medicines that block acetylcholine such as sedation, dizziness, delirium, blurred vision, constipation and urinary retention. See ‘Polypharmacy and deprescribing in older people’ for more information.

The multidisciplinary team (MDT) is the cornerstone of effective falls prevention, enabling comprehensive assessment and management of the diverse risk factors that contribute to falls risk^​4​. There is an emerging role for pharmacists in the falls clinic, whereby medicines are reviewed in the context of medical, mobility and social assessments aligned to the person’s wishes in real time. Pharmacists are involved in shared decision-making conversations and clinical risk assessments, providing immediate feedback on prescribing or deprescribing decisions to optimise patient outcomes, including reducing medication-related harm.

The following case describes the management of a patient attending a specialist falls clinic, illustrating how coordinated MDT input can identify and address multiple contributary risk factors to prevent falls.

Service description and multidisciplinary structure

The specialist falls clinic runs every Wednesday and Thursday afternoon with referrals received from the emergency department, patients discharged from inpatient wards, GPs and allied healthcare professionals based in primary care. All referrals are assessed by a consultant geriatrician before they are accepted. Although most referrals are for older adults aged over 65 years, adult referrals for those aged under 65 years are accepted if they have a high falls risk or have fallen. Composition of the MDT can be seen in the Box.

Two specialist frailty pharmacists join each consultant-led clinic with a member of the therapy team. Each appointment is scheduled for 30 minutes to enable a holistic approach and input from the full MDT.

Clinic lists for attendance are available for the MDT a week prior to clinic. For the pharmacists, reviewing the patient list before clinic is essential to ensure medication-related issues can be addressed efficiently, which is particularly important for those with complex polypharmacy. Medicines are usually discussed early in the consultation as part of the assessment of falls risk and adjustments are discussed at this point. The physiotherapist will provide an individualised exercise plan and link to the community falls team where appropriate. Dietician input is provided virtually following the clinic, where required, based on the patient’s nutritional needs identified during the consultation. At the end of the consultation, the geriatrician will summarise all the changes made and any follow up required. The pharmacist may also highlight or counsel on medicine changes. See Figure 1 for the patient’s case presentation^​8–11​.

Figure 1: Case presentation

MDT assessment and management

Medical assessment

A structured assessment was undertaken to identify the multifactorial contributors to falls, which used key components of the Comprehensive Geriatric Assessment (CGA)^​10​. This included a detailed falls history, covering the circumstances of falls, associated symptoms, injury history, medication review and assessment of functional status. Sarcopenia screening was performed using the SARC-F questionnaire^​8​, while cardiovascular causes of falls were assessed through screening for red-flag symptoms, including syncope and presyncope^​12​. Sarcopenia is a skeletal muscle disorder that is characterised by a loss of muscle strength, mass and function^​9​.

A comprehensive physical examination was conducted, including cardiovascular assessment with lying and standing blood pressure measurements, musculoskeletal examination for osteoarthritis and deformity, as well as an evaluation of muscle strength using Medical Research Council (MRC) grading (i.e. the Oxford Scale) and hand grip strength measured with a Jamar handheld dynamometer^​11​. Neurological assessment screened for peripheral neuropathy and features of spinal or cerebrovascular disease. Bone health was assessed using FRAX alongside biochemical review of bone profile and vitamin D status. Gait and balance were evaluated using the Timed Get Up and Go (TGUG) test and tandem walking^​10​.

Physiotherapy assessment

The musculoskeletal assessment indicated lower‑limb sarcopenia characterised by reduced muscle strength, impaired balance and altered gait coordination^​9​. Manual muscle testing demonstrated bilateral hip flexion and knee extension graded 3/5 on the Oxford scale, which was consistent with moderate weakness^​11​. Upper‑limb strength was also reduced marginally, with hand‑held dynamometry measuring 26 kg. Gait analysis showed independent mobility with a mild shuffling pattern and intermittent unsteadiness. The patient completed four steps of a toe‑to‑heel test but was unable to progress further owing to instability^​12​. The TGUG test of 20 seconds further supported functional impairment associated with sarcopenia.

Pharmacist assessment

Prior to the patient’s clinic consultation, the patient’s medications were reviewed and FRIDs identified^​13,14​. Several validated tools and guidelines are available to support FRID identification, including the STOPPFall criteria, which specifically focuses on medicines associated with falls in older adults, and the World Guidelines for Falls Prevention and Management, which recommend medication review as a core component of multifactorial falls assessment^​12,14​. Other tools, including the STOPP/START criteria and the Medication Appropriateness Index (MAI), can support identification of potentially inappropriate medicines and guide medicines optimisation in older adults^​15,16​.

During the clinic consultation, it was noted that lisinopril and amlodipine could be contributing to the patient’s postural hypotension and increasing his risk of falls^​15​. Postural hypotension is defined as a drop in blood pressure when standing up from a lying or sitting position. It can be diagnosed if there is evidence of a drop of 20 mmHg or more of systolic blood pressure or a drop of 10 mmHg or more of diastolic blood pressure measured 3 minutes after standing. Symptoms include dizziness, light-headedness, blurred vision or fainting; however, patients can be asymptomatic^​17​.

In addition, gliclazide was recognised as carrying a significant risk of hypoglycaemia, which can increase falls risk. Gliclazide should be used with caution in older adults^​15​. The patient was prescribed the maximum dose of metformin, while a review of his most recent HbA1c result demonstrated tight glycaemic control (41 mmol/mol). In frailty, HbA1c targets should be individualised, as having very strict blood glucose control can increase the risk of falls^​18​. In mild frailty, as in this case, the optimum target would be 53–58 mmol/mol^​19,20​. It was advised that gliclazide should be deprescribed. Metformin was continued at the current dose, with a plan to review glycaemic targets following the next HbA1c measurement and input from the dietitian, as nutritional status and dietary intake may influence ongoing diabetes management. A cautious approach was adopted to avoid making multiple medication changes simultaneously, allowing the impact of individual interventions on falls risk, nutritional status and glycaemic control to be assessed.

Evidence of sarcopenia was identified, which is more prevalent in older adults and contributes to an increased risk of falls through impairment in strength, balance and gait^​9​. Statins are widely used for cardiovascular health, but they are associated with muscle symptoms^​21​.  The relationship between sarcopenia and statins is complex and inconsistent across research^​22,23​. The patient was taking atorvastatin, which was reviewed in the context of well-controlled lipid levels. His lipid profile demonstrated an LDL cholesterol of 1.1 mmol/L, non-HDL cholesterol of 1.57 mmol/L, total cholesterol of 2.6 mmol/L and a total cholesterol:HDL ratio of 2.5, indicating excellent lipid control^​24​. As atorvastatin was prescribed for primary prevention, the potential benefits and risks of continued therapy were discussed alongside the patient’s overall cardiovascular risk and treatment goals. Given the well-controlled lipid profile and the patient’s preference to reduce his medication burden, a shared decision was made to discontinue atorvastatin, with ongoing monitoring of lipid levels and cardiovascular risk. 

MDT plan

The patient was assessed as having recurrent falls owing to impaired balance, mild postural hypotension, sarcopenia and FRIDs.

Following a shared decision-making discussion, it was agreed that discontinuation of atorvastatin, gliclazide and lisinopril was appropriate. The risk of hyperkalaemia with lisinopril was considered when deciding which of the two antihypertensives should be discontinued. The potential risks and benefits of deprescribing each medicine were considered individually, balancing the aim of reducing falls risk and medication burden against the risk of disease progression or loss of therapeutic benefit. Other long-term medicines were reviewed but were considered to have an ongoing clinical indication and a favourable risk–benefit profile; therefore, no further medication changes were made. To minimise the risk of adverse effects associated with multiple simultaneous medication changes, a cautious, prioritised approach to deprescribing was adopted. The patient was counselled regarding potential symptoms following withdrawal, including monitoring for symptoms of hyperglycaemia, such as polyuria, polydipsia or unexplained fatigue, after discontinuation of gliclazide and changes in blood pressure following withdrawal of lisinopril.

He was advised to continue home blood pressure monitoring and attend for repeat HbA1c and lipid assessment with his GP in three months. Safety-netting information was provided, directing the patient to seek further medical advice if he developed any concerns, including symptoms of hyperglycaemia, hypotension or other changes in his clinical condition. This monitoring strategy was implemented to mitigate the potential increase in cardiovascular risk associated with discontinuation of atorvastatin and lisinopril, enabling timely reassessment and reintroduction of therapy if clinically indicated. Furthermore, it was recommended that the patient takes a daily vitamin D supplement to support bone health^​25​.

In line with current evidence‑based recommendations, a progressive resistance-band-based strengthening programme was initiated to address both upper‑ and lower‑limb muscle strength deficits and promote functional improvement^​26,27​. To enhance long‑term adherence, the patient agreed to community physiotherapy, enabling structured monitoring and progression of the exercise plan. Given the elevated fall risk, a community falls assessment was arranged to evaluate environmental hazards and implement preventive strategies at home. A referral to a dietitian was also made to optimise nutritional intake, which is an essential component of sarcopenia management^​9​.

A follow-up clinic appointment was arranged for three months’ time to review the overall impact of the interventions, including reassessment of falls risk, functional status, mobility and any changes following deprescribing decisions. 

Outcomes and follow up

Following the initial MDT assessment, several coordinated interventions were implemented that led to meaningful improvements in the patient’s strength, stability and overall falls risk. Importantly, at the three-month review, the patient reported no further falls and felt more confident following the support provided. Although the patient continued to experience some unsteadiness, he confirmed consistent adherence to the strengthening programme, supported by community physiotherapy. In clinic, the patient demonstrated improvement in muscle strength. Hand‑grip dynamometry increased from 26kg to 31kg, while hip flexion and knee extension improved to 4/5 on the Oxford scale. His personal goal was to begin leaving the house occasionally to meet friends, highlighting the value of a person-centred approach and shared decision-making.

Medicines optimisation reduced exposure to FRIDs and mitigated risks of hypoglycaemia and postural hypotension, leaving him on amlodipine, metformin and vitamin D supplementation. He was pleased with the reduced medication burden and monitored his blood pressure at home with no concerns raised. In clinic, the patient’s blood pressure was stable. He was also advised to ensure adequate hydration. The patient was then informed that he was now due a HbA1c and lipid check via the GP to review his diabetes management.

His nutritional intake had been reviewed by the community dietitian, while the occupational therapist had assessed his home environment. As a result, the patient was awaiting rails for his stairs and bath to further reduce falls risk. He was discharged from clinic with advice to continue physiotherapy, monitor blood pressure, maintain vitamin D supplementation, as well as arrange his HbA1C and lipid check. All this information was relayed to the GP by clinic letter.

Discussion

Falls are rarely caused by a single factor, so undertaking a holistic review of medical, functional, environmental and medication-related risk factors is essential. The MDT model used in the specialist falls clinic enabled simultaneous assessment of these domains, ensuring that interventions were targeted, coordinated and person-centred. Patient feedback from this approach has been extremely positive, compared with where they have to make different appointments to see each professional.

The MDT structure allowed each professional to contribute their expertise in real time and consider each other’s assessment to create a care plan with the patient at the heart of decision-making. The geriatrician provided diagnostic clarity and oversight of medical complexity; the physiotherapist assessed gait, balance and sarcopenia; and the pharmacist optimised medicines within the context of falls and frailty. This integrated approach ensured that decisions were made collaboratively, reducing fragmentation and improving the efficiency at which interventions could be implemented. In turn, the patient benefited from a coherent plan that addressed their falls risks simultaneously.

Pharmacist involvement was important in reviewing medication-related harm and identifying medicines that could contribute to falls risk. In particular, lisinopril and gliclazide were identified as FRIDs owing to their potential to contribute to postural hypotension and hypoglycaemia, respectively, and were deprescribed following a careful assessment of the potential risks and benefits. The risks associated with stopping these medicines were considered, including the potential impact on blood pressure control and glycaemic management. In addition, mitigation strategies were implemented through increased home blood pressure monitoring, planned GP follow-up of HbA1c and lipid levels, and patient education on recognising symptoms requiring further review. Reviewing blood glucose control in the context of frailty ensured safer diabetes management. The pharmacist’s ability to counsel the patient, adjust treatment in real time and reinforce monitoring strategies had a positive impact on safety and confidence.

While the MDT model offers substantial benefits, it presents several practical and clinical challenges that can affect workflow and efficiency. Falls assessments are inherently complex. Integrating different healthcare professional reviews within a 30-minute appointment can be demanding and, often, will take longer. Each professional must gather sufficient information, contribute meaningfully to the discussion and agree on a shared plan without compromising the quality of the review. This time pressure can be challenging when patients have extensive multimorbidity, polypharmacy or communication difficulties. Coordinating referrals and ensuring follow-up can be challenging particularly when services have different waiting times or documentation systems. Delays in home adaptations or therapy input may also slow progress. Finally, patient engagement varies depending on motivation, confidence, cognition, social support and living circumstances. MDTs must therefore tailor interventions sensitively to the individual, ensuring goals are realistic and achievable.

This case demonstrates how MDT falls clinics can deliver measurable improvements in strength, confidence and falls risk within a short timeframe. It illustrates the importance of collaborative working among professionals to improve the quality of life for older adults who have fallen.