frailty - geriatrics

PART 1: UNDERSTANDING FRAILTY

Section 1: What is Frailty? (Page 1)

1.1. Definition:

• Key Concept: Frailty is not a single disease but a state of increased vulnerability.

• A minor stressor (e.g., a urinary tract infection, a fall, a new medication) can trigger a disproportionately large decline in health (e.g., hospitalisation, loss of independence, delirium).

1.2. Overlap with Other Concepts:

• There is often overlap between:

  • Multimorbidity: The presence of two or more long-term conditions.

  • Frailty: The state of vulnerability described above.

  • Disability: Difficulty or dependency in carrying out activities of daily living.

1.3. Signs of Frailty:

• Low energy expenditure (physical inactivity).

• Reduced muscle strength (sarcopenia).

• Reduced gait speed (walking slowly).

• Self-reported exhaustion.

• Unintentional weight loss.

Section 2: The Frailty Syndromes (Page 2)

The British Geriatrics Society (BGS) refers to five 'frailty syndromes' – common presenting features that should raise suspicion of frailty:

Section 3: Epidemiology of Frailty (Page 3)

• Prevalence: 7% of the population over 65 years old are likely to be severely frail.

• Average Onset: 69 years old, but frailty can occur earlier in life.

• Risk Factors: Deprivation, Asian ethnicity, female sex, and urban living increase the risk of living with frailty.

• Geographical Distribution: Increasing concentrations of older people in rural, semi-rural, and coastal areas of the UK may create future problems in healthcare planning (access to services).

• Projected Increase: The number of people living with moderate to severe frailty is expected to double between 2016 and 2041.

• Impact: This increasing burden increases demands on health and social care services (more hospital admissions and care packages).

Section 4: Interventions to Delay Onset of Frailty (Page 4)

• Evidence-based interventions:

  • Tailored physical activity (e.g., strength and balance training).

  • Dietary interventions (e.g., ensuring adequate protein and calorie intake).

• Addressing Contributing Factors:

  • Anaemia

  • Dizziness

  • Fatigue

  • Polypharmacy (medication review and deprescribing)

• Important Note: People may move in and out of frailty states – it is not necessarily a one-way progression. Interventions can improve frailty status.

PART 2: DIAGNOSING AND CLASSIFYING FRAILTY

Section 5: The Electronic Frailty Index (eFI) (Page 5)

5.1. What is the eFI?

• The electronic frailty index (eFI) uses data that is already available in the GP electronic health record to identify and severity-grade frailty.

• It enables identification of older people who are fit, and those with mild, moderate, and severe frailty.

5.2. How Does It Work?

• Uses a cumulative deficit model, measuring frailty based on the accumulation of a range of deficits.

• Made up of up to 36 deficits, including:

  • Tremors

  • Sight loss

  • Polypharmacy

  • Diagnoses (e.g., diabetes, hypertension)

  • Abnormal test values (e.g., anaemia, low eGFR)

5.3. Important Caveat:

• The eFI score is not a diagnosis in itself. A clinical diagnosis of frailty needs to be made using clinical judgement.

5.4. Why Do It?

• Knowing the frailty status for people you care for enables you to plan interventions, such as:

  • Medication reviews

  • Falls prevention initiatives

  • Planning for palliative care when required

  • Support to prevent hospital admissions

Section 6: Classifying Frailty – The Rockwood Scale (Page 6)

• The Rockwood Clinical Frailty Scale is a validated tool that classifies frailty on a scale from 1 (very fit) to 9 (terminally ill).

• It is based on clinical assessment of a person's mobility, function, and comorbidities.

• Image Description (Page 6): A visual representation of the Rockwood Scale, showing images and descriptions for each level of frailty, from "Very Fit" to "Terminally Ill." This helps clinicians quickly assess and communicate frailty status.

PART 3: COMPONENTS OF GOOD CARE IN FRAILTY – THE PHARMACIST'S ROLE

Section 7: Pharmacist Expertise – Medication Reviews (Page 7)

Pharmacists play a crucial role in the care of people living with frailty, particularly through medication reviews.

7.1. Changing Physiology and Pharmacology in Frailty:
People living with frailty may have changes (often reductions) in the following, which affect pharmacokinetics (how the body handles drugs):

7.2. Limited Evidence Base:

• The clinical evidence for using many drugs in people with frailty is limited or lacking (older, frail patients are often excluded from clinical trials).

7.3. Using Number Needed to Treat (NNT) and Number Needed to Harm (NNH):

• Considering the Number Needed to Treat (NNT) can help guide prescribing decisions.

  • Example: "How many people do I need to treat with drug X for one year to prevent one heart attack?"

• This should be balanced against the Number Needed to Harm (NNH) – how many people need to be treated for one to experience a significant adverse effect.

• In frail patients with limited life expectancy, a high NNT for a preventive medication may not be justifiable.

Section 8: Structured Medication Reviews (SMRs) in Frailty (Pages 8-9)

8.1. What is a Structured Medication Review (SMR)?

• An SMR is a critical examination of a patient's medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, and minimising the number of medication-related problems.

8.2. Who Should Have an SMR? (Page 8):
From October 2020, Primary Care Networks (PCNs) were required to identify patients who would benefit from an SMR, specifically those:

• In care homes.

• With complex and problematic polypharmacy, specifically those on 10 or more medications.

• On medicines commonly associated with medication errors.

• With severe frailty, who are particularly isolated or housebound, or who have had recent hospital admissions and/or falls.

• Using potentially addictive pain management medication (e.g., opioids, gabapentinoids).

• Note: Since 2024, many patients have not had access to these reviews due to service changes.

8.3. What Should Happen in a Frailty Medication Review? (Page 9):

Key Discussion Points:

1. When can medications be deprescribed? (Stopping medications that are no longer appropriate or may be causing harm).

2. Watch out for different treatment targets and goals in hypertension, diabetes, and cardiovascular risk management.

   • For example, the target HbA1c (for diabetes) and the intensity of treatment may depend on whether the patient is mildly, moderately, or severely frail.

   • General principle: Consider relaxing targets (e.g., HbA1c and blood pressure) in more moderately and severely frail people to reduce falls risks, hypotension, and hypoglycaemia.

   • However, be careful not to discriminate against older people by denying them the appropriate standard of care where intensive management of long-term conditions will benefit them.

3. Use of other tools (e.g., STOPP/START criteria, anticholinergic burden scales).

PART 4: CASE STUDY – JIM

Section 9: Case Study – Jim (Pages 10-12)

9.1. Background (Page 10):

• Jim is an 86-year-old man living alone.

• He was recently discharged from hospital after a fall.

• He mobilises with a stick and has some unsteadiness.

• He has a history of:

  • Hypothyroidism

  • Hypertension

  • Hypercholesterolaemia

  • Osteoarthritis (post knee replacement)

Image Description (Page 10): A photograph of an elderly man (Jim) to personalise the case study.

9.2. Current Prescription and Observations (Page 11):

• Additional Information from Notes:

  • The atorvastatin was prescribed for primary prevention (no history of cardiovascular events).

  • The pregabalin was prescribed after a knee replacement in 2019 (for post-operative neuropathic pain).

Section 10: Pharmacist Review and Recommendations (Pages 11-13)

The pharmacist uses a local frailty prescribing guideline (e.g., 2023-update-BSW-Frailty-Prescribing-Guidance) to review each medication.

10.1. Levothyroxine 50 mcg OD (Page 11):

• Patient's View: Jim remembers the period when he was hypothyroid in his 60s and it negatively impacted the end of his working career. He feels very strongly that this is an important medicine for him.

• Clinical Assessment: His TSH levels look good (within range, slightly low).

• Decision: Continue levothyroxine at the same dose. It provides essential replacement therapy and the patient values it highly.

10.2. Amlodipine 10 mg OD (Hypertension) (Page 12):

• Patient's View: Jim is pleased his blood pressure is lower than expected, as he is used to being told it was high for most of the last twenty years.

• Clinical Reasoning: Now that he is older and more unsteady on his feet, it might be better to maintain his blood pressure at a higher level to reduce the risk of falls (over-treatment of hypertension can cause postural hypotension and falls).

• Decision: Agreed with Jim to STOP amlodipine. The goal is to reduce falls risk, even if BP rises slightly.

10.3. Atorvastatin 20 mg OD (Hypercholesterolaemia) (Page 12):

• Patient's View: Jim is anxious when stopping is suggested, as he trusted the original prescriber.

• Clinical Reasoning:

  • The statin was prescribed for primary prevention.

  • There is not much evidence to support its use in people over 85 years old for primary prevention (the NNT becomes very large).

  • Stopping it now will not significantly affect his stroke and heart attack risk at his age.

• Decision: After explanation and reassurance, Jim agreed to STOP atorvastatin.

10.4. Pregabalin 100 mg BD (Knee Pain) (Page 13):

• Patient's View: Jim explains he had awful post-operative pain after knee surgery in 2019. He tried stopping pregabalin abruptly 4 years ago but experienced withdrawal symptoms (diarrhoea, "dark feelings," nausea) – but not knee pain – so he restarted after 48 hours.

• Clinical Reasoning:

  • The pregabalin is causing drowsiness, increasing his risk of falls.

  • The original indication (post-operative pain) is likely resolved.

  • Abrupt cessation causes withdrawal symptoms; a slow taper is needed.

• Decision: Agreed to a dose reduction to 75 mg BD (slow tapering). A follow-up review is planned.

Section 11: Old vs. New Prescription (Page 13)

• Follow-up: Agreed with Jim to have a follow-up review over the phone in a week to see how he is getting on with the changes and to make a plan for further reductions in pregabalin (if tolerated).

Section 12: Prioritising Interventions to Reduce Health Inequalities (Page 14)

• Key Principle: Prioritise interventions for the most deprived to reduce health inequalities.

• Frailty is more common in deprived areas, and access to healthcare (including medication reviews) may be lower. Targeting resources to these populations can have the greatest impact.

SUMMARY TABLE: KEY CONSIDERATIONS IN FRAILTY MEDICATION REVIEW