Pharmacology & drugs
Guidance for clinicians on assessing risk of falls related to medication burden and implementing deprescribing interventions proactively.
Clinicians can systematically identify high fall risk due to polypharmacy, assess effect sizes, and implement proactive deprescribing plans that balance symptom control with safety, patient goals, and functional independence.
July 30, 2025 - 3 min Read
Fall risk is multifactorial, yet medication burden remains a modifiable contributor that clinicians can address through structured assessment. Start by compiling a complete medication list, including over-the-counter drugs, supplements, and recent changes. Evaluate each medication for known associations with dizziness, hypotension, cognitive impairment, or gait disturbance. Prioritize drug classes commonly implicated in falls, such as sedatives, antidepressants, anticholinergics, and cardiovascular agents that may cause orthostatic instability. Consider the patient’s comorbidity burden, frailty status, and functional goals to tailor deprescribing decisions. Document baseline measures of balance, reaction time, and medication-related adverse effects. Shared decision making with patients and caregivers reinforces adherence to a plan that emphasizes safety without sacrificing symptom relief.
A systematic framework helps clinicians translate risk assessment into actionable deprescribing steps. Start with goals of care: preserve independence, minimize delirium risk, and manage chronic symptoms effectively. Identify medications with the greatest potential to cause harm per dose and duration, then rank them by modifiability. Use a stepwise approach—dechallenge where appropriate, then taper to minimize withdrawal or rebound effects. Monitor for withdrawal symptoms, treatment gaps, and return of original complaints. Engage the patient in setting a realistic taper schedule, recognizing social determinants that affect adherence. Record planned reductions, anticipatory guidance for adverse effects, and contingency contacts. This disciplined process supports proactive deprescribing as a daily safety practice.
Monitor safety outcomes, adjust plans, and maintain patient engagement.
Deprescribing is not simply stopping medications; it is a deliberate collaboration that centers patient safety and preferences. Begin with a collaborative review of perceived benefits and risks, then align plans with functional objectives such as maintaining mobility, confidence, and independence. Document any dependence on medications for sleep, anxiety, pain, or blood pressure management, highlighting alternatives that carry lower fall risk. Establish a default stance of trying to reduce exposure to high-risk agents while ensuring symptom control remains acceptable. Use a patient-friendly language to set expectations about gradual changes and possible temporary symptom fluctuations. Provide written materials, offer dosage adjustment options, and arrange follow-up sooner if new balance issues or confusion emerge.
Evaluating risk hinges on understanding pharmacodynamics in older adults and how polypharmacy interacts with aging physiology. Age-related changes in renal and hepatic metabolism can prolong drug effects, increasing sedative load and orthostatic pressure fluctuations. Comorbidity profiles, such as cognitive impairment or Parkinsonian disorders, can amplify falls risk when combined with sedating or anticholinergic drugs. Consider nonpharmacologic strategies to complement deprescribing, like physical therapy, home safety modifications, and assistive devices. When reducing medications, reassess comedications that may similarly affect balance to avoid substitution with another agent carrying equal risk. Regularly revisit goals, monitor for reemergence of symptoms, and adjust plans accordingly to sustain progress.
Integrate safety, efficacy, and patient values into every deprescribing decision.
After identifying high-risk medications, construct a personalized taper plan that minimizes withdrawal and symptom rebound. This plan should specify taper rate, anticipated timelines, and clear milestones. Treat each reduction as a trial, with predefined criteria for success and early warning signs. Schedule frequent check-ins to detect changes in gait, dizziness, mood, or sleep quality. If withdrawal appears, pause the taper or slow the rate while introducing nonpharmacologic supports or alternative therapies. Document all conversations, consent forms, and safety instructions. When possible, coordinate with pharmacists and primary care teams to ensure unified messaging and consistent monitoring across care settings.
Communication with patients and caregivers is essential to sustain deprescribing momentum. Use plain language to explain why a drug is being reduced and how it may affect daily activities. Emphasize the potential benefits for balance and independence, but acknowledge concerns and preferences. Provide clear instructions on what to do if symptoms worsen during a taper and when to seek urgent help. Encourage patients to track symptoms, sleep patterns, dizziness, and falls events in a simple diary or app. Reinforce the availability of support services, such as telehealth check-ins, community programs, and caregiver education, to strengthen commitment to the plan.
Collaboration across disciplines strengthens fall prevention and deprescribing success.
A well-designed deprescribing plan also accounts for the pharmacokinetic changes that occur with aging. Slow metabolism and reduced fluid volume can amplify drug exposure, so adjustments may be necessary even for agents once considered routine. Clinicians should reassess dosing intervals and switch to safer alternatives when appropriate. Documented deliberations about risk reduction help patients understand the rationale behind each change. When considering polypharmacy reduction, ensure that essential symptom control is not compromised. The ultimate goal is a sustainable regimen that preserves function and quality of life while lowering the probability of falls.
Multidisciplinary collaboration enhances deprescribing effectiveness. Clinicians, pharmacists, nurses, and therapists each contribute unique expertise to optimize safety. Pharmacists can help identify drug interactions, verify dosing accuracy, and propose nonpharmacologic substitutes. Rehabilitation specialists can tailor balance training and gait improvement strategies to the patient’s needs, reinforcing the benefits of reducing sedative exposure. Nursing staff can monitor daily functioning and alert the team to early indicators of decline. Regular team meetings and shared care plans reduce redundancy and align orders with a common objective: minimizing fall risk without compromising comfort or purpose.
Turn deprescribing into an ongoing, proactive standard of care.
When implementing deprescribing interventions, document the anticipated benefits alongside potential risks. Create a risk-benefit matrix for each medication, highlighting who stands to gain the most from reduction and at what pace. Include patient-specific factors such as home environment, caregiver support, and access to transportation that influence safety. Use standardized deprescribing protocols that provide stepwise guidance but remain adaptable to individual circumstances. Ensure that plans are reversible if adverse outcomes arise. Transparent documentation supports accountability and continuity of care across primary, specialty, and home-based services.
Finally, embed monitoring and quality improvement into routine practice. Track metrics such as the rate of high-risk medications reduced, fall incidence, and functional outcomes. Collect patient-reported experiences to refine deprescribing strategies and procedures. Analyze data for patterns that suggest unintended consequences, then adjust taper plans or alternative therapies accordingly. Share insights with colleagues to promote best practices and reduce fragmentation in care. By institutionalizing deprescribing as a core safety activity, clinicians can reduce fall hazards while sustaining symptom relief and patient autonomy.
To sustain momentum, consider integrating falls risk and deprescribing into clinical workflows as standard practice. Use electronic health record alerts to flag potentially harmful polypharmacy, especially in patients with a history of falls or cognitive impairment. Establish a routine annual medication review with a deprescribing lens, supported by a multidisciplinary team. Provide patient education resources that explain how medications influence balance and the rationale for reductions. Encourage advance care planning that includes preferences for medication burden, goals for function, and safety priorities. By normalizing these conversations, clinicians can reduce medication-related falls across diverse populations.
In the long term, monitoring the impact of deprescribing on falls requires ongoing commitment and adaptation. Regularly revalidate risk factors, reassess medication lists, and update taper strategies as patient circumstances evolve. Ensure equitable access to deprescribing resources, including transportation assistance and caregiver support. Share success stories and lessons learned to foster a culture that prioritizes safety, function, and dignity. When clinicians view deprescribing as an essential component of comprehensive care, they empower patients to maintain independence while minimizing harm from medication burden.
