Frailty, polypharmacy and falls prevention in older people

In Learning

Follow this topic

Bookmark

Record learning outcomes

Ageing is a natural biological process that reflects the gradual loss of regenerative and bioprotective mechanisms. Increasing chronological age raises the risk of frailty, immobility and reduced physical resilience, which may present as delayed or incomplete recovery after surgery, hip fracture or infections such as pneumonia.

Ageing also contributes to the development of many chronic diseases that account for substantial morbidity, hospitalisation, healthcare costs and mortality worldwide. The impact of selected age-related changes on organ systems is summarised in Table 1.

Age-related physiological changes also alter drug handling. Changes in the gastrointestinal tract can affect pharmacokinetics, while reduced total body water, lower muscle mass and increased adipose tissue increase the volume of distribution of lipophilic drugs such as diazepam, prolonging elimination half-life and increasing the risk of accumulation.

Declines in hepatic blood flow and renal glomerular filtration rate can further impair metabolic clearance and excretion, making dose adjustment and careful monitoring important in older adults.

Together, these physiological changes can contribute to clinically important complications in older adults. This article outlines common challenges and considers how pharmacists can support patients and help reduce avoidable risk.

Multimorbidity

Many older adults experience multimorbidity, defined as the co-occurrence of at least two chronic diseases.

Multimorbidity is rarely random and often clusters around shared pathophysiological mechanisms; for example, people with cardiometabolic disease may have type 2 diabetes, hypertension and ischaemic heart disease, while those with respiratory-vascular disease may have chronic obstructive pulmonary disease, heart failure and atrial fibrillation.

In one study of 41,909 individuals, hypertension was present in 79% of people with stroke and 71% of those with angina in the overall sample.⁶

Multimorbidity commonly leads to the use of multiple medicines, or polypharmacy. As discussed below, polypharmacy is one of the most challenging aspects of therapy management in older adults.

Frailty

Frailty is another common feature associated with ageing. It has been defined as “a state of increased vulnerability to poor resolution of homeostasis following a stress, which increases the risk of adverse outcomes including falls, delirium and disability”.⁷

Frailty is a progressive condition linked to declining functional status and reduced cognitive, emotional and physical reserve, particularly after stressors such as a low-grade infection or a medication change. However, it is not an inevitable consequence of ageing, as up to three-quarters of people aged over 85 may not be frail, suggesting that frailty is a distinct medical syndrome characterised by a marked reduction in physiological reserve.⁸

There are two recognised models of frailty that are commonly used: the frailty phenotype and the frailty index. The frailty phenotype, first proposed in 2001, describes a group of characteristics including:

• Muscle weakness
• Slowness (reduced gait speed)
• Low physical activity
• Self-reported exhaustion
• Unintentional weight loss.

Each of these characteristics predicts poor outcomes, and, using the phenotype model, an individual is considered frail when they meet at least three of the five characteristics above.

The second model is the cumulative deficit model, in which deficits accumulate over time and increase the risk of poor outcomes.⁹ These deficits may include conditions such as dementia, symptoms such as hearing loss, or signs such as tremor.

When combined, these deficits increase an individual’s frailty index, from which a clinical frailty scale can be determined. The scale (see Resources) ranges from 1, indicating someone who is robust, active and motivated, to 9, indicating complete dependence and a limited ability to recover even from minor illness; a score of 5 or more indicates frailty.

Frailty is common. According to the British Geriatrics Society, it affects around 1 in 10 people aged 65 and over in the community, rising to between a quarter and a half of those aged 85 and over.¹⁰

Frailty and polypharmacy

As ageing increases the risk of chronic disease, medicine use also rises. Polypharmacy, typically defined as taking at least five medicines, shows a significant linear association with frailty: as polypharmacy increases, so does frailty.¹¹

One recent analysis found that polypharmacy prevalence in frail older adults was 59% and that these adults were more likely to experience poorer health outcomes.¹² Other research has reached a similar conclusion, indicating that polypharmacy increases the likelihood of becoming frail.¹³

Addressing polypharmacy

Two key medication review tools are used to address polypharmacy: the Beers Criteria and the STOPP/START criteria (see Resources). Both are designed to reduce iatrogenic harm, optimise prescribing safety and support structured deprescribing, but they use different frameworks and have distinct operational features.

Beers Criteria

The Beers Criteria, developed in the US, organises potentially inappropriate medicines by drug class into five categories:

• Medicines that may be inappropriate regardless of disease state, such as first-generation antihistamines because of high anticholinergic burden
• Medicines to avoid, or use only with dose adjustment, in specific diseases or syndromes, such as avoiding diltiazem or verapamil in heart failure
• Medicines that require cautious use and monitoring
• Medicines with potentially clinically relevant drug-drug interactions
• Medicines requiring dose adjustment according to renal function.

STOPP/START criteria

The Screening Tool of Older Persons’ Prescriptions (STOPP) and the Screening Tool to Alert to Right Treatment (START), developed by European geriatricians, take a different approach and are organised around physiological systems. STOPP/START has the advantage of identifying medicines that may be inappropriate and medicines that may have been omitted.

Pharmacists’ role

In many cases, multiple medicines use in older adults can arise from a prescribing cascade. This occurs when an unrecognised adverse effect from one medicine leads to the prescribing of another medicine to manage it. If the second medicine causes a further unrecognised adverse reaction, additional treatment may be added, and so on.

For example, a diuretic may be prescribed to manage oedema associated with a dihydropyridine calcium-channel blocker, placing the patient at risk of fluid depletion.

Polypharmacy is also associated with an increased risk of hospitalisation.

Deprescribing, defined as stopping medicines when the harms outweigh the potential benefits, can benefit frail adults. A recent systematic review of deprescribing in older adults concluded that the process was safe and reduced the number of medicines taken or the dose used.¹⁴

As older adults become frailer, treatment priorities may shift from prolonging life and reducing major adverse events towards symptom control and harm reduction.

Structured medication reviews

To help address polypharmacy, the NHS has identified structured medication reviews (SMRs) to optimise medicines use in primary care. An SMR is “a critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste”.¹⁵

Currently, SMRs should target six specific patient groups:

• Individuals in care homes
• Those with learning disabilities
• Complex polypharmacy
• Medicines commonly associated with errors
• Severely frail individuals
• Patients taking addictive drugs/drugs of dependence such as opioids, gabapentinoids, Z-drugs and benzodiazepines.

The effectiveness of SMRs can vary according to the training, experience and confidence of the healthcare professional conducting them. SMRs are in-depth reviews that involve shared decision-making, particularly when discussing tapering or discontinuing treatment, and they depend on patient trust and pharmacist confidence to support medicine changes. The recommended minimum time for an SMR is 30 minutes.

Although SMRs are designed primarily to be undertaken by practice-based pharmacists, there is evidence supporting the role of community pharmacists in medicines optimisation for housebound older adults i.e. domiciliary medication reviews.¹⁶

Falls prevention

A fall is an unintentional event in which a person comes to rest on the ground or another lower-level surface, not resulting from a major intrinsic event, such as a stroke, or an overwhelming hazard.¹⁷ Falls are common. It has been estimated that 30% of adults aged over 65 years experience a fall each year.¹⁸

Risk factors for falls include:

• Previous history of falling
• Conditions affecting mobility or balance, such as arthritis, diabetes or incontinence
• Muscle weakness or sarcopenia, poor balance, visual impairment or cognitive impairment
• Polypharmacy, particularly medicines associated with postural hypotension, such as antihypertensives or benzodiazepines
• Frailty in older adults.

There are also potential extrinsic factors, such as poor lighting, uneven surfaces and slippery floors.

Anticholinergic burden

Anticholinergic medicines (see below) are associated with a higher risk of falls. In older adults, the cumulative effect of taking multiple medicines with anticholinergic properties is referred to as the ‘anticholinergic burden’.

Anticholinergic activity in older people is a concern because it is associated with complications including impaired physical function, loss of balance, cognitive impairment, delirium, dizziness, hallucinations, dry mouth, blurred vision, constipation, urinary retention and tachycardia.

Pharmacists’ role

Community pharmacists have frequent contact with patients, creating opportunities to identify those at higher risk of falls. NICE guidance on falls advises that healthcare practitioners, can ask people aged 50 to 64 with one or more fall risk factors whether they have fallen in the last year.

In practice, this screening question can be incorporated into consultations such as the New Medicine Service, particularly where medicines or conditions are associated with falls risk, including antihypertensives, urinary incontinence, Parkinson’s disease and depression.

Additional support

Malnutrition
Malnutrition in older adults is a significant health concern. Community pharmacists can help identify older adults at risk, including those with limited income, poor appetite, mobility issues or disabilities that make it difficult to buy or prepare food.

Other at-risk groups include people with mental health issues, dysphagia or chronic illness, and those who are socially isolated.

Medicine-related malnutrition can also be problematic. For example, anticholinergic medicines or opioids may cause dry mouth or delayed gastric motility, leading to constipation and early satiety, while metformin and selective serotonin reuptake inhibitors can cause nausea and loss of appetite; loop diuretics can cause taste disturbance.

Starting a conversation about what someone eats and encouraging a balanced diet can help identify concerns and support signposting.

Physical activity
Sarcopenia is a geriatric condition characterised by progressive loss of muscle mass and function and affects 10-16% of older people worldwide.²¹ It is associated with an increased risk of adverse outcomes, including functional decline, hospitalisation and mortality.

A recent review suggested that resistance training and combined exercise interventions are the most effective approaches, with additional benefit when combined with nutritional support.²² Community pharmacists can advise older adults that increasing physical activity, including resistance exercise with weights or elastic bands, may improve muscle function when combined with increased protein intake.

Communicating concerns
Pharmacists may have genuine concerns about the welfare of an older adult. Whether those concerns can be shared with a relative depends on the relevant legal and ethical framework.

The first issue is mental capacity. If an older adult has capacity, pharmacists cannot legally share concerns without the person’s explicit consent. However, if the patient lacks capacity and a relative has Lasting Power of Attorney (LPA), pharmacists can legally discuss relevant concerns with that person.

In the absence of a formal LPA, pharmacists may still discuss concerns under the best interests principle of the Mental Capacity Act 2005. Patient confidentiality may also be overridden under public interest and safeguarding mandates where there is clear and imminent evidence of immediate risk of self-harm, severe neglect or danger to the public. This might include, for example, a person with cognitive deficits who continues to drive against medical advice.