Medicines optimisation for the frail older person

Frail older people often have multiple comorbidities and thus take multiple medications, some which may be inappropriate and lead to adverse effects. Optimising medication in the frail older person is vital and leads to safer clinical outcomes 

Frailty is a distinctive health state correlated to the ageing process in which there is a decline in the body’s physical and psychological reserves.¹ It is estimated that 10% of people aged over 65 years have frailty, which increases to half of those over 85 years.² 

Frailty in older people is characterised by reduced resilience to external stressors, reduced mobility and reduced functional reserve.^1,3 Older frail patients are extremely vulnerable to minor events such as an infection or new medication.¹ This results in frequent hospital admissions with geriatric syndromes such as falls, immobility, incontinence, confusion and susceptibility to adverse effects of medicines.¹ Frail patients are at a higher risk of adverse outcomes including major changes to their physical and mental health. Ultimately, this increases the length of hospital admissions as recovery is a slower process, increasing risk of mortality. Older frail patients are typically more functionally dependent on others and might reside in a care facility.^2,4  

Establishing frailty

Establishing whether an older patient has frailty is important in order to meet their care needs and this can be undertaken using simple methods such as the Frailty Phenotype and Prisma-7.^4,5 The Frailty Phenotype involves evaluating five criteria: unintentional weight loss; physical activity; exhaustion; weakness; and walking time.⁴ Similarly, the Prisma-7 is a questionnaire comprising seven questions that patients can self-complete. For both assessment tools, a score of ≥3 suggests the patient is frail. Additionally, after completing a comprehensive geriatric assessment (CGA) a scoring system can be used to examine the severity of frailty using tools such as the Rockwood Clinical Frailty Scale, Edmonton Frailty Scale and Gait Speed Test.⁶ CGA is the gold standard that includes a holistic, multidisciplinary team assessment of the older patient, showing a 30% higher chance of being alive and in their own home at six months (number needed to treat = 13).⁶

Why is polypharmacy an issue in frailty?

Polypharmacy is defined as taking five or more regular medications, which is commonly observed in older frail patients because multimorbidity leads to increased number of prescribed medication.^7–10 Older patients are commonly observed having multiple medications, due to them having multiple comorbidities. Traditionally, polypharmacy was defined as taking more than five medications. More importantly, a thorough assessment is required to identify whether the medication is appropriate or inappropriate. Appropriate polypharmacy refers to each medication having a clinical indication that has an evidence base.¹¹ Inappropriate polypharmacy refers to medication where the risk is greater than the benefit and there is little or no evidence base.¹¹ 

Studies have shown that a significant number of medications taken by older frail patients lack clear indication, hence causing further complications for older frail patients. The results from a study carried out by Hanlon et al indicated that more than 90% of frail inpatients took at least one inappropriate medication.¹² Furthermore, 5–11% of medications taken by older patients were identified as unintentional duplication of treatment for the same indication.^13,14 

Polypharmacy over the years has been characterised as a key element contributing to adverse events. However, it is difficult to establish whether the adverse events are a result of taking multiple medications or the progression of comorbidities in older frail patients. Appropriate polypharmacy can be achieved if individual needs, preference and goals of care are assessed accurately and appropriately. In patients who are generally mobile and functionally independent, prescribing multiple drugs will not be problematic. In contrast, frail patients would require a different approach as the predominant goal of medical therapy may be relieving symptoms of disease progression and maintaining function.⁷ 

Prescribing multiple medicines in older patients to some extent has contributed to hospitalisation and mortality. The risks involved with polypharmacy in older frail patients includes adverse drug reactions and also has the potential to cause long-term cognitive impairment, delirium, falls, urinary incontinence and unintentional weight loss.^8,11 This is largely a consequence of the increased sensitivity to medication due to age, multiple comorbidities and impaired hepatic or renal function.^6,11 

Another risk associated to polypharmacy involves the following interactions: drug–drug, drug–disease and drug–geriatric syndrome (for example, use of anticholinergics in patients with risks of urinary incontinence and falls).^14,15 The risks of adverse drug reactions can also be exhibited by specific classes of medicines such as, anticholinergics, anticoagulants, antiplatelet, antihypertensive and antidiabetics, which can be more harmful than beneficial when prescribed in older frail patients.^1,6,12,16 

Medicines optimisation and frailty

The prescribing of medicines has increased substantially due to an aging population with multimorbidity. This has a massive cost implication to the healthcare economy. Medicines optimisation is a process that aims to achieve ‘a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines’.¹⁷ In England approximately 10 million people have two or more long-term conditions, 1 million with frailty and 0.5 million are at end of life.¹⁸ Therefore, medicines optimisation is significant to improve medication adherence through multidisciplinary working, which leads to better health outcomes and reduces medication wastage.^11,17 

Importance of deprescribing in frailty 

The use of medicine in older people aims to reduce disease progression, cure disease or manage symptoms, as the prevalence of chronic disease develops with age.¹⁶ However, it is important that the selection of medication is appropriate as older people are also at greater risk of experiencing adverse drug events. Inappropriate prescribing involves the use of interacting drug combinations, ineffective drugs and multiple drugs for the same indication without adequate optimisation.¹⁰ As a result, this leads to an increase in the pill burden and hazardous prescription cascades. 

The factors that influence the choice of medical treatment in older people include therapeutic aims, pharmacokinetics, pharmacodynamics, and efficacy.¹¹ These factors are subject to change with age and vary significantly between individuals of the same age. Therefore, reviewing all medicines in older people is fundamental to achieve safe and appropriate therapeutic goals. 

Deprescribing is a complex process that requires careful consideration to balance the potential risks versus benefits of withdrawing medications to improve clinical outcomes.² 

The barriers that may discourage healthcare professionals to deprescribe medication include:^15,19

• Lack of confidence in healthcare professionals to discontinue medications initiated by specialist or other clinicians
• Management of drug withdrawal side effects (for example, benzodiazepines, antidepressants)
• Resistance of change to medication from patients and carers
• Limited time and resources.

Medication reviews and shared decision-making

Where multiple medicines are used to treat long-term conditions, it is important to establish the patients understanding of their condition and address any concerns about their medication to support their adherence.^20,21 Over time, the patients’ needs and suitability of medication will change, exploring these during the consultation aids successful medicines optimisation and deprescribing. For example, if non-adherence is identified, investigating the reason improves patient–clinician relationship, health benefits and reduces hospital admissions as older patients may stop and start their medication without consulting a doctor using their own understanding of the medicines prescribed in managing their symptoms.²⁰ 

In order to achieve these outcomes, the National Institute for Health and Care Excellence (NICE) has provided guidance for carrying out structured medication reviews. Ideally, medication reviews should be carried out annually as standard practice and more frequent reviews should be considered if necessary, particularly in older frail patients with chronic or long-term conditions and polypharmacy.^20,21 Various tools can be used to identify polypharmacy and assist with deprescribing such as STOPIT, STOPP/START and BEERS criteria. 

NICE guidance on shared decision-making states that during a medication review, all patients should be given the opportunity to be involved in making decisions about their medicines.Assumptions on the patient’s values, preferences, level of participation and capacity to make decisions should be avoided. The principles specified in the Mental Capacity Act 2005 should be used to assess the patient’s capacity to make each decision.²⁰ These discussions help to identify what is important to the patient about managing their condition(s) and their medicines. 

The Kings Fund also highlighted that there is strong evidence suggesting that better outcomes are achieved when patients actively contribute in manging their health in comparison to those who are inactive recipients of care.²² Therefore, shared decision-making should become the principal mechanism where this is ‘no decision about me, without me’ to ensure that patients get the care they desire and require.²² All healthcare professionals undertaking medication reviews should implement this in their practice to standardise care.  

How the pharmacist is key to providing better medications management

When initiating treatment in older people the lowest effective dose should be prescribed and then titrated up slowly to prevent adverse drug reactions. This approach provides cost-effective treatment with better health outcomes.²³ Pharmacists play a key role in the selection and optimisation of medication that is safe and appropriate in frail older people as well as safely deprescribing any inappropriate medication. 

Learning points

• Frail patients are at a higher risk of adverse outcomes including major changes to their physical and mental health.
• Inappropriate polypharmacy in older patients has contributed to hospital re-admissions and mortality.
• Medicines optimisation is significant to improve medication adherence and health outcomes.
• Deprescribing requires a balance between potential risks versus benefits of withdrawing. medications to improve clinical outcomes
• Make shared decision-making gold standard for consultations where there is “no decision about me, without me” .

References

1. British Geriatrics Society. Recognition and management of frailty in individuals in community and outpatient settings. 2014. www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-14/fff2_short.pdf (accessed May 2020).
2. Clegg A et al. Frailty in elderly people. Lancet 2013;381(868):752–62.
3. Kirkwood TB et al. Understanding the odd science of aging. Cell 2005;20:437–47.
4. Fried LP et al. Frailty in older adults: evidence for a phenotype. J Gerontol 2001;56A(3):M146–M156.
5. Raiche M et al. PRISMA-7: A case-finding tool to identify older adults with moderate to severe disabilities. Arch Gerontol Geriatr 2008;47(1):9–18.
6. British Geriatrics Society. Fit for frailty consensus best practice guidance for the care of older people living in community and outpatient settings. 2014. www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf (accessed May 2020).
7. Hubbard R et al. Medication prescribing in frail older people. Eur J Clin Pharmacol 2012;69(3):319–26.
8. Vasilevskis E et al. A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial. BMC Health Services Res 2019;19:165.
9. Best O et al. Investigating polypharmacy and drug burden index in hospitalised older people. Intern Med J 2013;43:912–18. 
10. Woodford HJ et al. New horizons in deprescribing for older people. Age Ageing 2019;48:768–75. 
11. Kings Fund. Polypharmacy and medicines optimisation: making it safe and sound. 2013. www.kingsfund.org.uk/sites/default/files/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf (accessed May 2020).
12. Hanlon JT et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother 2004;38:9–14. 
13. Schmader K et al. Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc 1994;42:1241–7. 
14. Gutiérrez-Valencia M et al. The relationship between frailty and polypharmacy in older people: A systematic review. Br J Clin Pharmacol 2018;84:1432–44.
15. Todd A et al. The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people. BMC Geriatrics 2018;18:295.
16. Hilmer SN et al. Thinking through the medication list: Appropriate prescribing and deprescribing in robust and frail older patients. Aust Fam Physician 2012;41(12):924–8. 
17. National Institute for Health and Care Excellence. Medicines optimisation. NICE Quality Standard 120. 2016. www.nice.org.uk/guidance/qs120 (accessed May 2020).
18. NHS England. Enhancing the quality of life for people living with long term conditions. www.england.nhs.uk/wp-content/uploads/2014/09/ltc-infographic.pdf (accessed May 2020).
19. Reeve E et al. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013;30:793–807.
20. National Institute for Health and Care Excellence. NICE guideline CG76. 2009. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. www.nice.org.uk/guidance/cg76 (accessed May 2020).
21. National Institute for Health and Care Excellence. NICE guideline NG5. 2015. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. www.nice.org.uk/guidance/ng5 (accessed May 2020).
22. Kings Fund. Making shared decision-making a reality: no decision about me, without me. 2011. www.kingsfund.org.uk/publications/making-shared-decision-making-reality (accessed May 2020).
23. Royal Pharmaceutical Society. Medicines optimisation: helping patients to make the most of medicines. 2013. www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Policy/helping-patients-make-the-most-of-their-medicines.pdf (accessed May 2020). 

First published on our sister publication Hospital Pharmacy Europe