Polypharmacy, Deprescribing and Falls: Running Safer Medicines Reviews in Older People’s Services

Polypharmacy is often described as a clinical issue, but in older people’s services it is also an operational risk: the more medicines a person takes, the greater the chance of dizziness, sedation, confusion, urgent toileting, and administration errors. Falls prevention therefore requires structured medicines review, not occasional “tick box” medication checks. This article sets out a practical, frailty-aware approach to polypharmacy and deprescribing within care services, including day-to-day delivery detail and how to evidence safer outcomes. For wider context, see the Knowledge Hub index and the topic page Medicines, Frailty, Falls & Safety.

Why polypharmacy increases falls risk in real-world settings

Older people often live with multiple conditions and multiple prescribers over time. Medicines can build up gradually, and what was once appropriate can become harmful as frailty increases. Falls risk rises when medicines interact with dehydration, poor nutrition, reduced mobility, infection, constipation, or fluctuating cognition. Operationally, services see this as “more drowsy”, “wobbly in the mornings”, “sudden confusion”, “rushing to the toilet”, or “unexplained bruises”.

A practical definition for services is: polypharmacy becomes falls-risk polypharmacy when the cumulative burden of medicines is likely contributing to unsteadiness, sedation, postural symptoms, or poor decision-making, or when staff must provide increasing supervision due to medication effects.

Make medicines review a routine with triggers, not a reactive scramble

Services can embed medicines review as a predictable assurance cycle using clear triggers. This reduces variability and ensures risks are surfaced before harm occurs.

Review triggers that should be non-negotiable

  • Any fall or near fall.
  • New or worsening dizziness, faintness, daytime sleepiness, or gait change.
  • Repeated PRN use (e.g., sedatives, opioids, anxiolytics) or PRN use linked to unsteadiness.
  • Hospital discharge or any significant medication change.
  • New confusion, suspected delirium, or significant change in appetite/fluid intake.

The service role is to identify and document these triggers consistently, then request and track clinical review. This can be owned by a medicines safety lead or senior manager with clear accountability for follow-through.

Run a structured review: what to prepare and how to present it

Clinical partners respond better when providers present clear, concise evidence. A structured review pack can include:

  • Current medicines list (including PRN usage patterns and timings).
  • Falls and near-falls summary (dates, times, activity, patterns such as nights/toileting).
  • Observed side effects (sedation, dizziness, confusion) with brief consistent documentation.
  • Frailty context (recent weight loss, reduced mobility, dehydration risk, cognition changes).
  • What has already been tried operationally (supervised transfers, hydration prompts, toileting support).

This approach shows commissioners and inspectors that the provider is not simply “blaming medicines”; it is using evidence to manage risk collaboratively and responsibly.

Deprescribing: how to approach it safely without creating new risk

Deprescribing should always be clinically led, but providers play a critical role in ensuring changes are implemented safely. Risk increases if medicines are stopped without monitoring or if staff are not briefed on what to expect.

Operational safeguards when deprescribing occurs

  • Change log and briefing: what changed, why, what to watch for, and when to escalate.
  • Enhanced monitoring period: typically 7–14 days after changes affecting sedation, blood pressure, pain, or sleep.
  • Non-pharmacological replacements: where sedatives reduce, ensure staff have practical alternatives (sleep routine, reassurance, pain assessment, toileting, sensory supports).
  • PRN controls tightened: avoid “replacement creep” where PRNs increase after regular medicines reduce.

Operational example 1: PRN anxiolytic creep driving daytime falls

Context: A person has increasing anxiety. Staff begin using a PRN anxiolytic most afternoons. Over several weeks the person becomes drowsier and has two falls when standing quickly from a chair.

Support approach: The service applies PRN threshold rules and triggers a medicines review. Staff implement structured anxiety supports (predictable routine, meaningful activity, reassurance approach) to reduce reliance on PRN.

Day-to-day delivery detail: PRN administration now requires documenting: trigger, alternative strategies tried, effect within 60 minutes, and sedation/unsteadiness check. A senior reviews PRN usage daily for two weeks and escalates patterns to the GP/pharmacist. Staff are briefed on consistent language and approaches to anxiety to avoid fragmented care.

How effectiveness is evidenced: PRN frequency reduces, drowsiness incidents decrease, and falls reduce. The service retains the PRN audit, the review request/outcome, and a brief summary of practice changes implemented.

Operational example 2: Polypharmacy with postural symptoms and morning falls

Context: A resident takes multiple cardiovascular medicines and experiences dizziness on standing. There are two near falls and one fall during morning personal care.

Support approach: The service gathers structured evidence: timing of symptoms, falls pattern, and current meds/timings. They implement a safe morning routine (slow rise, seated pause, supervised transfers) while requesting a review focused on dose/timing interactions and dehydration risk.

Day-to-day delivery detail: Staff use a consistent “slow rise” protocol and record dizziness in a standard way so the pattern is visible. Hydration is supported early in the day. The manager provides the GP/pharmacist with a short pack: falls timeline, symptom notes, and current dosing times.

How effectiveness is evidenced: After medicines timing is adjusted, dizziness reduces and falls stop. The service evidences the change via a falls log trend, care plan update, and review documentation.

Operational example 3: Pain medicines, constipation and night-time falls

Context: A person takes opioid analgesia. Constipation worsens, sleep deteriorates, and they begin getting up repeatedly at night. A fall occurs during urgent toileting.

Support approach: The service treats this as a linked system problem: pain management, bowel regimen, sleep routine, hydration, and night-time supervision. A medicines review is requested to consider alternative pain strategies and to tighten laxative and bowel monitoring.

Day-to-day delivery detail: Staff implement a bowel monitoring plan with escalation triggers, ensure predictable toileting support at night, and review the timing of opioid doses with the prescriber. Non-pharmacological pain supports are strengthened (positioning, heat packs if appropriate, activity pacing). PRN sedatives are avoided as a “quick fix”.

How effectiveness is evidenced: Night-time waking reduces, bowel function stabilises, and falls reduce. Documentation shows the integrated approach and the medicines review outcome, supporting defensible governance.

Governance: how to prove medicines review is embedded

Providers can demonstrate control and learning through:

  • Quarterly medicines review schedule for higher-risk individuals (plus trigger-based reviews as needed).
  • PRN audit focusing on rationale, alternatives tried, effect recording, and review triggers.
  • Falls review integration where every fall prompts a medicines side-effect check and review request if indicated.
  • Competency assurance for medicines administration and PRN decision-making (observations and refreshers).
  • Action tracking showing review requests, responses, implementation, and measured impact.

Explicit expectations

Commissioner expectation: The provider demonstrates active medicines risk management as part of falls prevention, including structured reviews, evidence-led escalation, and measurable improvement shown through audits and falls trend analysis.

Regulator / Inspector expectation (e.g. CQC): Medicines are managed safely, PRN use is controlled and reviewed, and the service learns from falls to reduce repeat incidents. Inspectors can trace how concerns were identified, escalated, and embedded into ongoing practice.

What good looks like

In strong services, polypharmacy is not tolerated as “just the way it is”. Staff can explain why medicines may be contributing to instability, what they monitor, and what triggers a review. Managers can show evidence packs, audit results, and clear outcomes. This is how deprescribing becomes a safe, person-centred process that reduces falls and improves day-to-day quality of life.

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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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