Medicines-Related Falls Risk in Older People’s Services: Identifying and Managing High-Risk Changes

Medication is one of the most common “hidden drivers” of falls and frailty-related harm in older people’s services. The challenge isn’t knowing that sedatives, hypotensives, analgesics and polypharmacy can increase risk — it’s translating that knowledge into day-to-day routines that reliably prevent avoidable harm while still supporting comfort, sleep, pain control and independence. This article sets out a practical, inspectable approach that services can implement and evidence, aligned with governance expectations across adult social care. For broader context and navigation, see the Knowledge Hub Index and the dedicated tag page for Medicines, Frailty, Falls & Safety.

Why “medicines optimisation” is a falls prevention intervention

In older people’s services, falls risk is rarely “just mobility”. Medicines can contribute through postural hypotension, dizziness, sedation, confusion, urinary urgency, dehydration, hypoglycaemia, or reduced reaction time. A safe service therefore treats medicines work as part of a wider risk enablement plan, not a pharmacy-only activity. The best systems do three things consistently:

  • Identify residents at higher risk (frailty, recent falls, new meds, dose changes, infection, dehydration, delirium).
  • Control the medicines pathway (ordering, storage, administration, observation, recording, escalation).
  • Evidence whether the controls are working (audit, incident review, learning actions, and measurable improvement).

Core operating system: the “five checkpoints” that reduce medicines-related falls

1) Medicines reconciliation at entry and after transitions

Transitions are where errors cluster: hospital discharge lists, GP repeats, family-supplied medicines, and old blister packs can conflict. A robust system includes same-day reconciliation (where possible) and a second check within 72 hours.

  • Confirm current medicines list against discharge summary and GP record.
  • Check indications, dose, timing, “when required” instructions and monitoring needs.
  • Identify high-risk categories (sedatives, antipsychotics, opioids, antihypertensives, diuretics, insulin/sulfonylureas, anticoagulants).
  • Document “medicines-linked risk flags” into the falls risk plan (not only in the MAR file).

2) High-risk medicines screen linked to falls and frailty

Services often have a falls risk assessment, and separately a medicines process. The safety gain comes from linking them. A practical approach is a simple “high-risk medicines screen” used by seniors during weekly clinical checks:

  • Any new medicine in the last 14 days?
  • Any dose change in the last 14 days?
  • Any “as required” sedation/analgesia used more than twice in 48 hours?
  • Any symptoms: dizziness, drowsiness, confusion, unsteady gait, nocturia/urgency, constipation, low appetite?
  • Any recorded low BP/slow pulse/hypoglycaemia episodes?

Positive answers trigger observation and escalation, not just “keep an eye”.

3) Observation after changes (the part many services miss)

Falls frequently occur after a medicine change — especially in the first 72 hours. A safe service defines an observation plan and records it in care notes and handovers. For example:

  • Orthostatic symptoms check at set times after morning meds (e.g., 30–60 minutes post-dose for the first 2–3 days).
  • Mobility supervision level temporarily increased (e.g., assisted transfers for 48 hours).
  • Hydration prompts increased where diuretics/laxatives or infection are present.
  • Sleepiness/confusion checks on late shift if sedatives/analgesics were given.

4) Escalation thresholds that staff can follow confidently

Many incidents happen because staff are unsure when symptoms are “normal” and when to escalate. Define clear triggers, written in plain language, and build them into shift routines.

  • Immediate escalation: new confusion/delirium, collapse, head injury, suspected stroke/TIA, severe drowsiness, uncontrolled pain, suspected hypoglycaemia.
  • Same-day GP/pharmacy review request: repeated dizziness, postural symptoms, new falls after a dose change, PRN sedative/analgesia pattern, constipation causing night-time rushing.
  • Routine review: frailty progression, multiple medicines with anticholinergic burden, repeated nocturia, persistent low BP readings.

5) Audit and learning loop (the “evidence engine”)

To stay CQC-ready and commissioner-ready, the service needs a repeatable way to show it learns and improves. A practical model is a monthly medicines safety dashboard reviewed in governance:

  • Falls where medicines may have contributed (theme coding).
  • Number of medicine changes and whether post-change observation was completed.
  • MAR errors (omissions, timing, transcription, PRN documentation).
  • Safeguarding referrals where medicines practice contributed to harm (if any).
  • Actions taken and impact tracked (e.g., falls reduction, fewer night-time incidents).

Operational examples: what this looks like day to day

Example 1: Post-discharge confusion and falls risk

Context: A resident returns from hospital after infection treatment with new antibiotics and altered analgesia. They appear drowsier and more unsteady on day one.
Support approach: The senior completes medicines reconciliation against discharge paperwork and flags two concerns: a sedating analgesic now scheduled three times daily, and an omitted stomach protector. The falls plan is updated with a “72-hour post-change observation” note.
Day-to-day delivery detail: Staff increase supervision for transfers, ensure call bell access, and add hydration prompts. The late shift records sedation level and mobility changes, and the senior reviews post-dose symptoms 45 minutes after morning meds for three days. Handover includes “observe for dizziness/confusion and report same-day”.
How effectiveness is evidenced: Care notes show observations completed; no falls occur; the GP agrees to step down analgesia after 48 hours. Governance minutes record the change and learning: post-discharge medicines reconciliation must be completed same day and rechecked within 72 hours.

Example 2: Night-time rushing linked to diuretics and constipation

Context: A resident has two near-falls at night when rushing to the toilet. They are on a morning diuretic and have intermittent constipation and poor fluid intake.
Support approach: The service links continence care to medicines and frailty risk: fluids plan, bowel monitoring, and review of diuretic timing and toileting prompts.
Day-to-day delivery detail: Staff implement planned night-time checks, offer a commode, and schedule evening prompts. The senior reviews bowel chart daily for one week and ensures PRN laxatives are used as per protocol. A request is made to the GP to confirm diuretic timing remains optimal.
How effectiveness is evidenced: Incident records show no further near-falls over 14 days; bowel chart shows improved regularity; hydration chart completion improves. The monthly falls review notes “medicines/continence interaction” as a learning theme.

Example 3: Recurrent dizziness after antihypertensive change

Context: A dose increase is made to an antihypertensive medicine after a routine GP review. Within days, the resident reports dizziness and appears unsteady when standing.
Support approach: The service applies its escalation thresholds: same-day GP contact and an observation plan linked to falls risk, rather than waiting for a fall to occur.
Day-to-day delivery detail: Staff record BP readings at set times (including post-dose), encourage slow position changes, and provide assisted transfers temporarily. The senior logs symptoms in a structured format (“time, trigger, severity, BP reading, outcome”) to support clinical decision-making.
How effectiveness is evidenced: The GP adjusts the dose and requests continued monitoring for one week. Records show symptom reduction and stable mobility; the falls risk score is updated and reviewed in supervision with staff to reinforce the process.

Commissioner and regulator expectations (make them explicit)

Commissioner expectation: The provider can demonstrate a coherent medicines safety system that reduces avoidable harm — evidenced through audits, incident analysis, and improvement actions (not just policy documents). Commissioners typically expect to see clear pathways for medicines reconciliation, post-change monitoring, and timely escalation, plus measurable learning from falls and medication errors.

Regulator / Inspector expectation (CQC): Inspectors will look for safe systems and competent practice: accurate MARs, staff who understand escalation, evidence that the service learns from incidents, and personalised risk management that supports independence. The service should be able to show how medicines are managed safely, how risks are assessed and reviewed, and how governance identifies and addresses themes such as falls linked to sedation, hypotension or polypharmacy.

Governance routines that keep the system working

  • Weekly: senior-led clinical review of high-risk residents (new meds, dose changes, recent falls, delirium risk).
  • Monthly: medicines audit (MAR accuracy, PRN documentation, fridge temps/storage, controlled drugs checks) plus a falls/medicines theme review.
  • Quarterly: competency refreshers (meds rounds, PRN decision-making, escalation), supervision sampling, and learning shared across teams.

What “good” looks like in practice

A strong older people’s service can articulate how medicines safety supports both independence and risk reduction. Staff can explain the observation plan after medicine changes, seniors can show how incidents are analysed and improved, and records make it clear that residents are supported to live well — not restricted “just in case”. That combination of practical controls and evidence is what reduces avoidable harm and stands up to commissioning scrutiny and CQC inspection.

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Written by Impact Guru, editorial oversight by Mike Harrison, Founder of Impact Guru Ltd — bringing extensive experience in health and social care tenders, commissioning and strategy.

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