Enhancing knowledge, attitude, and perceptions towards fall prevention among older adults: a pharmacist-led intervention in a primary healthcare clinic, Gemas, Malaysia

Fall incidents among older adults have a negative impact on their personal lives and the economy as well. It burdens the health care sector as well because of the treatment cost. A past history of a fall is a significant predictor of future fall risk [1‐3]. Hence, it is essential to find solutions to prevent fall incidents, and fall-related injuries and fractures. As falls contribute to increased mortality, reduction of quality of life, increased hospitalization, and medical costs, this has led to the development of prevention strategies [4‐6]. Multifactorial prevention measures have been identified and implemented in various countries. Many interventional studies have been conducted in the past that show prescribing multiple medications is likely to increase the risk of falls. Several drugs can increase the risk of falls and are termed fall-risk-increasing drugs (FRIDs) which include antihypertensives, antihistamines, sedatives-hypnotics, antipsychotics, antidepressants, opioids, and non-steroidal anti-inflammatory drugs [6‐8]. Around one-third of older adults experience at least one fall incident every year while 10% of them experience multiple falls [1]. An earlier study found that amlodipine, a FRID increases the risk of falls among older adults compared to chlorthalidone (HR: 2.24; p = 0.03) or lisinopril (HR: 2.61; p = 0.04) [6]. Polypharmacy and FRIDs were the most common cause of falls reported by many studies [6‐8], 74.19% (n = 230) of older adults were prescribed polypharmacy (Mean: 5.18 ± 0.64), and 22.85% (n = 69) received four types of medications, majorly cardiovascular medications, that might have increased the risk falls in their population [6].

Deprescribing FRIDs may benefit in preventing falls among older adults [7, 8]. Besides deprescribing FRIDs and assessment of knowledge, attitude, and perception (KAP), an educational intervention was found to help reduce fall incidents among older adults [9‐11]. Optimistic fall outcomes such as reducing the risk of falls can be achieved by the utilisation of multiple intervention strategies [7]. These strategies include medication reviews, home safety checklists, fall brochures, and many more [12]. Educational materials are useful as they provide information and tips on ways to avoid falls. Any health programme’s outcome will be more effective if older adults take a more active role in fall prevention strategies.

Compared to other developed countries such as North America and Europe, fall prevention strategies and programmes in Southeast Asia are still in their infancy, as the aging population in these countries is expected to surpass in the future [13‐15].. The majority of studies conducted to date in Malaysia only assess the prevalence of falls as well as identify the risk factors that contribute to falls [16‐18]. Furthermore, these studies did not include older adult patients at primary care clinics; instead, they focused on older adults in hospital or community settings. Nonetheless, a pharmacist-led fall intervention study is scarce in the country. A multidisciplinary approach including educational intervention by pharmacists has proven to be effective in controlling chronic medical conditions and better health outcomes among the patient population. Pharmacists doesn’t only dispenses medications, but they do play a vital role in the health care sector to improve the health of the patient population. Educational intervention by pharmacists is essential, especially for older adults with fall risk to be aware of their medical condition and medications [19‐21]. Hence, health care policies governing fall prevention measures in primary care settings have yet to be developed. To fulfill the future demands arising from the increasingly aging population, changes in the current health policies are required. Thus, this will be the first study of its kind conducted in Malaysia as well as in Asia assessing the KAP of falls among older adults in primary healthcare, reviewing FRIDs and offering FRIDs intervention, and providing a pharmacist-led educational intervention to improve the outcome.

The current study evaluates the effectiveness of pharmacist-led educational intervention in improving the KAP of falls, fractures, and FRIDs among older adults and revealed that in post-intervention the majority of the current study participants had a good level of knowledge, a positive perception, and attitude towards falls. The medication review revealed that 32 types of FRIDs had been identified and 4.8% of respondents intervened for FRIDs. Generally, older adults are known to have multiple comorbidities. Multiple co-morbidities are more common with aging causing visual impairment, muscle weakness, a decline in organ function, and so forth. Long-standing medical conditions such as hypertension and diabetes in addition to the aging process will worsen the health condition [23‐25]. The comorbidities identified in this study reflect the overall prevalence data collected from the Malaysian National Health and Morbidity Survey (NHMS) conducted in 2019, pointing out T2DM, hypertension, and dyslipidaemia being the major non-communicable disease in this country [26]. As this study was carried out at a primary care clinic in a rural area, complex morbidities such as dementia and osteoporosis were not detected. Patients with high morbidity burden tend to obtain specialist services at secondary or tertiary health care facilities commonly situated in the urban area [27‐29]. The maximum number of comorbidities a respondent has detected in this study is up to four.

In the present study, 32 types of FRIDs have been identified. The majority of these belong to the cardiovascular medication classes. A majority of the respondents were taking prescription medication of four or more. Polypharmacy may indicate the presence of multiple FRIDs being prescribed to a single patient which in turn increases the risk of falls. Aging combined with multiple FRIDs are strong indicators of falls. There is evidence showing that multiple FRIDs either from the same class of medications or combining different classes such as cardiovascular and psychotropic medications can lead to increased fall incidents [30, 31]. There were considerably less psychotropic agents detected in this study probably because in this locality not many residents with psychiatric disorders or are seeking medical care at a tertiary care facility. There are numerous studies published have focused on the impact of psychotropic agents and falls [32, 33]. Cardiovascular medications such as diuretics, antihypertensive agents, and statins greatly affect the risk of falls. Statins use may exacerbate a decline in muscle mass leading to reduced muscle performance thus increasing the risk of falls among older adults [34‐36]. Besides muscle weakness, statins are also found to affect balance and gait performances in older adults [37].

Prior to educational intervention, a majority of the respondents were aware that biological factors and unsafe environments are risk factors for falls. This awareness comes from their own experience either from falling or observing other older people who experience falls. Initially, a majority of the respondents disagreed that behavioural issues such as lack of physical activity and alcoholism can be risk factors for falls. This can be due to a lack of awareness and low health literacy. Their understanding was improved after providing educational intervention. The socioeconomic status of older adults refers to an individual’s social standing, which is typically measured by several indicators such as occupation, income, education, and wealth [38]. Hence, older adults with poor socioeconomic status have an increased risk of falls as compared to older people with higher socioeconomic status [38, 39]. In Malaysia, the majority of the citizens obtain health care services from public health facilities as the services provided are heavily subsidised by the government. Due to this reason, the majority of the respondents don’t feel the socioeconomic status is a risk factor for falls. Besides easily accessible health care services, lack of awareness that it can be a risk factor could also be a possible reason. A similar situation was encountered when respondents asked if medications can be a risk factor for falls. The majority of them didn’t agree so because they feel medications bring benefits rather than harms. In the educational material provided, an explanation was given on how some classes of medications can contribute to the risk of falling through side effects. As compared to a study conducted in Sri Lanka, respondents from the current study had average knowledge at baseline [22]. In post-intervention, there was a significant improvement in respondents’ knowledge regarding medications as a possible risk factor for falls.

In the present study, respondents do perceive that fall is a preventable event after educating them about fall prevention measures. This group of respondents was aware that they were susceptible to falling. The respondents also perceive that the safety of the house is adequate and educational intervention does not have much impact on this perception. This can be probably due to the majority of fall incidents being experienced in outdoor settings. Less than a majority, perceive weakness negatively thus denying that they require help to prevent them from falling. Educational interventions help to change their negative perception to positive ones as they accept that they are frail and require fall prevention activities [40‐42]. The majority of the respondents were aware that recurrent falls can be prevented, if necessary, and steps are taken to avoid falling. They also agree that knowledge training programmes on fall-related injuries should be implemented in the community as they are beneficial. Currently, knowledge training programmes on fall-related injury are not widely implemented, particularly in the rural areas of Malaysia. Despite the education level and locality, the respondents do understand the importance of taking care of their health.

A majority of the participants don’t adjust their beds as they still use conventional bed frames. Hence, the educational intervention does not show any effect on this attitude. Attitude in terms of stopping medications when experiencing side effects improved after the intervention. Educating older adults about the possible side effects of medications and subsequent countermeasures is vital to avoid falls. This activity can be carried out during medication review and counselling by pharmacists. This is a novel study in the Malaysian setting analysing the attitude of older adults towards falls. So forth, no such studies have been carried out in the Malaysian setting, and hence this study will provide an insight into the attitude of older adults towards their experiences and practices towards falls. Moreover, the findings of this study may help healthcare providers in the management of fall risk and will help them to improve the quality of life of older adults. The outcomes reported in the current study are consistent with outcomes reported from other Asian studies proving that educational intervention does improve one’s attitude and perception towards fall [22, 43].

Out of 310 prescriptions reviewed, only 4.8% of prescriptions were found to have FRIDs with a potential chance of inducing falls and were intervened. Pharmacotherapies were not changed for the remaining respondents as the treatment was found to be more beneficial than harmful. Based on a prospective cohort study done by Van Der Velde et al. FRIDs intervention was effective in reducing fall incidents with an absolute risk reduction of 19% and relative risk reduction of 49%. Most of the intervention in the present study was done for cardiovascular medications as a majority was diagnosed with cardiovascular diseases. Since a majority of the intervention was done on cardiovascular medications, the risk reduction of fall incidents might be similar to the above-mentioned study.

Based on the statistical analysis carried out, the pharmacist-led educational intervention was found to be significantly effective in improving the respondent’s KAP of falls. This is evident by the scores reported before and after the intervention had been provided. The result from the statistical analysis also pointed out that the educational materials used in this study benefit the patients regardless of sex and education level. The educational materials can be used even for patients without formal education living in the rural areas.

Pharmacist-led education intervention was proven to be effective in controlling chronic medical condition(s). An earlier study conducted among the Malaysian diabetic population showed that pharmacist-led education intervention significantly improved their knowledge of diabetes and medication adherence behaviour [44]. Another study reported that Pharmacist-led educational interventions have reduced the rate of medication errors [45], and improved health outcomes, particularly medication adherence among patients with hypertension [46]. A study among asthmatic patients revealed that pharmacist-led educational intervention has shown a positive impact on the knowledge of asthma and self-management of the disease [47].

As the study was conducted only in a rural area of a single state, the findings may not represent the actual knowledge, attitude, perception, and practice of older adults in the whole country. Moreover, the ethnicity distribution in this study does not represent the nation’s ethnicity distribution as 99% of the respondents who participated in the study are Malays. There is a possibility of recall bias as some of the respondents may need to recall past events such as fall incidents.

The study was carried out in a rural area with a limited number of respondents, and hence it is recommended to extend the study to other parts of the country with a greater number of older adults to improve the generalisability. It is also recommended to carry out the interventional study with a control group and also for a longer duration of time with follow-up to assess the reduction in fall risk with educational intervention provided to older adults.

The findings of the study concluded that the older adults in this primary care setting had good knowledge, attitude, and perception (KAP) of falls and fractures in post-intervention. The review of the fall risk-increasing drugs (FRIDs) among older adults found that most of the patients were receiving polypharmacy or multiple medications that significantly contributed to the development of falls. The educational intervention provided to the respondents was significantly effective in improving the awareness of falls and FRIDs. More robust and comprehensive educational interventions on the falls and FRIDs are needed to prevent the occurrence of falls among the wider older adult population.