Deprescribing, Frailty, and Bone Health

Polypharmacy

• Definition: Prescribing or taking multiple medicines.

  • Appropriate Polypharmacy: Medicines use is optimized and prescribed according to best evidence.

  • Problematic Polypharmacy: Inappropriate prescribing of multiple medicines, where the intended benefit is not realized.

• in appropriate polypharmacy, risks are still present-eg DDIs, ADRs so monitoring and meds optimisation are important

• Overprescribing (and Underprescribing):

  • Not needed/wanted.

  • Potential harm outweighs benefit.

  • Not prescribing better available alternatives.

  • Medicine appropriate for condition but not patient or harmful combinations.

  • A change in condition making medicine inappropriate.

• underprescribing - omission of medications required to treat a condition, without a valid reason it is not prescribed, under STOPP START criteria. More likely in polypharmacy. Can be a change in a condition that means new medicarion is required.

• Resources: Specialist Pharmacy Service (SPS) - the first stop for professional medicines advice.

Consequences of Problematic Polypharmacy

• Increased cost, pill burden, and medicines waste.

• Leads to prescribing cascade.

• Hospitalizations.

• Increased frailty, falls, and mortality.

• Increased clinical workload.

• Solutions: Reduce ADRs, increase appropriateness, reduce falls, improve adherence, maintain quality of life, reduce readmissions, and provide cost benefits.

• Reference: National overprescribing review report - GOV.UK.

Addressing the Consequences of Polypharmacy

• Interventions:

  • Medication reviews.

  • Clinical decision support tools.

  • Checklists.

  • Audit and feedback.

  • Patient education & training.

• Deprescribing Tools:

  • ACB

  • Opioid deprescribing.

  • Medicines overuse in dementia and people living with learning disabilities.

  • Medichec.- identifies meds w anticholinergic cognitive effects, highlight cumulative impact of multiple medications.

  • STOPP/START tool.

  • STOPPFrail tool.

  • ThinkCascades tool. outlines 9 clinically important prescribing cascades consistent with potentially inappropriate prescribing in older people.

  • PrescQIPP. - improving medicines and polypharmacy appropriateness clinical tool- helps identify clinical and deprescribing priorities. Gives recommendation for appropriately continuing or stopping meds and highlights key issues to consider.

• Approach: Person-centered. deprescribing is more successful with patient centred approach.

• sedating meds commonly overused in dementia and more likely to occur where sx of aggression present.

Anticholinergic Burden

• Resource: https://www.acbcalc.com/

• Recap on Anticholinergic Medications:

  • Function by blocking the neurotransmitter acetylcholine.

  • Systemic effects impact smooth muscle function in the lungs, gastrointestinal system, and urinary tract.

  • Prescribed for various medical conditions, including Parkinson’s disease, allergies, COPD, depression, and urinary incontinence.

• Adverse Drug Reactions (ADRs) Associated with Anticholinergics:

  • Dry eyes, urinary retention, dizziness, cognitive impairment, and falls.

  • Anticholinergic effects intensify with stronger medications or combinations.

  • Older patients are more susceptible to ADRs due to multiple medications and age-related changes.

• Anticholinergic Burden Scales:

  • Quantify the effects of anticholinergic medications.

  • Over 22 different published scales.

  • Anticholinergic Cognitive Burden Scale (ACB) and the German Anticholinergic Burden Scale (GABS) are chosen for reliability.

  • Designed as practical tools for optimizing prescribing, especially in older patients.

• Association with Cognitive Impairment and Dementia:

  • Longitudinal studies show a link between anticholinergic use and the risk of developing cognitive impairment and death.

  • Dose-dependent association found between long-term anticholinergic use and dementia risk.

• Anticholinergic Burden Calculator:

  • Designed to aid clinicians during medication review.

  • Offers alternatives with lower anticholinergic burden, considering patient suitability.

  • Emphasizes the importance of continuing medications with robust clinical evidence.

• Evidence-Based Decision-Making with Anticholinergics:

  • Acknowledges that many medications with anticholinergic properties are prescribed based on strong clinical evidence.

  • The Anticholinergic Burden Calculator supports clinicians in decision-making during medication reviews, considering both evidence-based prescriptions and alternatives with a lower burden.

Person-Centered Deprescribing

• Assess the patient. - perspective and priorities

• Agree on goals.

• Identify potentially inappropriate medicines. - risks of stopping medicines vs benefits of not continuing them

• Assess risks and benefits. - evidence based in context of situation and preferences

• Agree on actions. - shared decision making

• Communicate with others.- doccumentation

• Monitor, review, and adjust regularly. involve MDT

Frailty

• Definition: Gradual decreased physiological reserve with increased vulnerability to stressors, a multisystem decline.

  • Affects 10% of those >65 and 25-50% of those >85.

• Links: Multimorbidity, LTCs (75% of >75s have more than one LTC), 20-50% of older people with CVD are frail.

not the same as multimorbidity or disability - can be exacerbated by them.

prevention of frailty is around modifiable influences- exercise, obesity

• Phenotype Model: Patient characteristics which predict poorer outcomes (unintended weight loss, reduced grip or muscle strength/gait speed, self-reported exhaustion, trouble with DAL - daily activities of living).

• Cumulative Deficit Model: Accumulation of deficits that increase frailty index (hearing loss, low mood, tremor, disease such as dementia). Symptoms, signs, diseases, diasbilities that are associated with ageing.

• Frailty Index: \text{Frailty Index} = \frac{\text{Number of deficits}}{\text{Total number of deficits}}

Frailty Models

• Deficit Accumulation Model: Incorporates a large number of candidate factors ranging from disease states, symptoms, signs, to abnormal laboratory values. When combined and divided by the total number of deficits, these yield a frailty index.

• Physical-Biological Model: Presence of three or more of the following five components: weight loss, exhaustion, weakness, slowness, and low physical activity.

• Multidimensional Model: A dynamic state affecting an individual who experiences injuries in one or more human biopsychosocial function fields (physical, psychological, social), that increases the risk of adverse outcomes.

models should be used cautiously or not at all when pt acutely unwell.

Frailty Risk Assessments

• Fried Frailty Phenotype (Physical Frailty Criteria).

• Clinical Frailty Scale (CFS).

• FRAIL Scale.

• Edmonton Frail Scale (EFS).

• Rockwood Frailty Index (FI).

• Comprehensive Geriatric Assessment (CGA) - Gold Standard.

• Geriatric G8 screening tool. - useful to assess whether an older patient with cancer needs a CGA.

G8 Screening Tool

1. Age

2. Declining food intake?

3. Recent weight loss?

4. Mobility level

5. Neuropsychological conditions?

6. BMI

7. >3 prescription drugs daily

8. Self-rated health status

brief assessment

higher score= better, lower score means CGA needed.

CGA Tool

• Identifies older cancer patients needing CGA.

• Structured assessment framework that uses multiple validated instruments to form a personalized care plan for older adults, especially those who are frail, have complex comorbidities, or are at risk of functional decline.

• Evaluates mental, cognitive and physical health, functional ability, and social context of older people.

• Multidisciplinary diagnostic and treatment process to identify reversible medical, psychosocial and functional limitations (as well as consideration like chemotherapy) and develop a plan to optimise health.

CGA Toolkit

• Developed by the British Geriatrics Society for professionals in primary care and endorsed by the Associate National Clinical Director for Older People and Integrated Person-Centred Care for NHS England, and by the British Geriatrics Society Scotland Council, this toolkit provides an overview of CGA in primary care.

• Framework includes:

  • Physical Assessment

  • Psychological/Mental Assessment

  • Functional Assessment

  • Mobility/Balance Assessment

  • Socioeconomic/Environmental Assessment

  • Medication Review

  • Creation of Problem List

  • Regular Planned Review

  • Intervention

  • Personalised Care Plan

Common Bone Conditions in the Elderly

• Osteoporosis:

  • Characterized by low bone density and structural deterioration.

  • Often undiagnosed until a fragility fracture occurs.

  • Key sites: Hip, vertebrae, distal radius.

• Osteomalacia:

  • Often due to Vitamin D deficiency; presents with bone pain and muscle weakness.

• Paget’s Disease:

  • A chronic illness where bones enlarge & weaken, most commonly pelvis, skull, spine, femur.

Bone Health in Elderly Patients

• Bone Aging and Pathophysiology:

  • Aging - decreased bone mass, increased structural deterioration of bone tissue, increased fragility fracture risk.

  • Decreased bone formation and increased resorption, trabecular thinning and loss of connectivity.

  • Reduced osteoblast activity and hormonal changes (e.g., ↓ oestrogen, ↓ testosterone, ↓ IGF-1).

• Fractures: Significant morbidity, loss of independence, mortality.

• Prevalence: 1 in 2 women and 1 in 5 men over 50.

• Cost: Total annual cost £4.4 billion (hip fractures; £2B, social care £1.1).

• Sarcopenia and Frailty: Muscle weakness further increases fall risk and fracture likelihood.

• Sarcopaenia- age related loss of muscle mass and functioning - signs like falls, walking slowly, feeling weak.

• osteoclast activity is maintained or increased while osteoblast activity decreases

• ageing affects the remodeling balance in a sex specific manner. women- inc bone reabsorption , men- dec bone formation and turnover.

• Oestrogen - ↑osteoblast proliferation and differentiation and ↓osteoclast differentiation

  Testosterone - ↑osteoblast proliferation and differentiation

  IGF1 (insulin growth factor 1) - ↑osteoblast proliferation and differentiation and ↑osteoblast proliferation
  

• Risk Factors for Poor Bone Health in the Elderly

• Non-modifiable:

  • Age, female sex, menopause, family history, white or Asian ethnicity, previous fragility fracture, rheumatological conditions, parent with hip fracture.

• Modifiable:

  • Vitamin D deficiency

  • Inadequate calcium intake

  • Sedentary lifestyle

  • Smoking and alcohol use

  • Polypharmacy (i.e., corticosteroids, anticonvulsants, SSRIs)

  • Falls

  • Low BMI <18.5

Bone Health and Cancer

• Cancer and cancer treatments significantly increase the risk of bone loss and skeletal complications.

• Bone; third most common site for metastases (after lung & liver).

• Bone fragility can lead to pain, fractures, immobility, and reduced quality of life.

• Cancers commonly affecting the bone include:

  • Breast, prostate, lung, renal, multiple myeloma.

  • Primary bone cancers [osteosarcoma, chondrosarcoma, fibrosarcoma etc] which are less common

Mechanisms of Bone Involvement in Cancer

• Bone Metastasis:

  • Osteolytic or Osteoblastic lesions: Cancer cells disrupt the balance of osteoclast and osteoblast activity via signaling pathways.

• Treatment-Related Bone Loss:

  • Hormonal therapies

  • Chemotherapy

  • Direct toxic effects on bone remodelling

  • Induced premature menopause or hypogonadism

  • Steroids: Glucocorticoid-induced osteoporosis (e.g., in lymphoma or multiple myeloma)

• osteolytic- breakfown of bone

• osteoblastic- xs bone fomration but structurally weak

Aromatase inhibs - dec oestrogen → inc bone resorption

androgen deprivation therapy - dec testosterone → dec bone mass

Falls: Risk Factors and Risk Assessments

• Risk Factors:

  • Muscle weakness.

  • Poor balance or gait disorders.

  • Cognitive impairment.

  • Polypharmacy.

  • Vision impairment.

  • Urinary incontinence.

  • Environmental hazards (loose rugs, poor lighting).

  • Inappropriate footwear.

  • Assistive device misuse.

• Risk Assessment Tools:

  • Timed Up and Go (TUG).

  • Berg Balance Scale.

  • Morse Fall Scale.

  • Frailty Assessment Tools:

    • Clinical Frailty Scale (CFS).

    • FRAIL questionnaire.

    • Edmonton Frail Scale.

  • FRAX.

  • Q fracture.

Who Should Be Assessed for Fragility Fractures?

fragility fracture- fracture following fall from standing height or less.

• All women > 65 years and all men > 75 years.

• All women aged < 65 years and all men aged < 75 years with:

  • A previous osteoporotic fragility fracture.

  • Current use or frequent recent use of oral corticosteroids.

  • History of falls.

  • Family history of hip fracture.

  • Low body mass index (less than 18.5 kg/m2).

  • Smoking.

  • Alcohol intake of more than 14 units per week.

  • A secondary cause of osteoporosis.

Fragility Fracture Risk Assessment

• FRAX or Qfracture (preferred) AND clinical judgment

• Absolute risk of hip and major osteoporotic fractures (spine, wrist, shoulder) over 10 years.

• FRAX assigns green, amber, or red zone score for fracture, but underestimates some risk factors (high alcohol, heavy smoking, regular corticosteroid use).

• Q fracture – developed for the UK population, can be updated annually, validated tool, includes additional risk factors.

• 10% threshold.

Diagnosis and Screening

• Patients Without Cancer:

  • Bone Mineral Density (BMD) via DXA scan:

    • T-score ≤ -2.5 = Osteoporosis

  • Screening recommended in:

    • All women ≥65 and men ≥70

    • Younger individuals with risk factors (e.g., previous fracture, steroids)

  • FRAX tool: 10-year probability of fracture with or without BMD.

  • Consider:

    • Vitamin D levels, Serum calcium & phosphate, PTH, TSH, renal function, markers of bone turnover in complex cases

• Patients With Cancer:

  • Baseline and periodic BMD testing (DXA scans) for:

    • All patients on aromatase inhibitors or androgen deprivation therapy

    • Long-term corticosteroid use

    • Metastatic bone disease

  • Laboratory tests:

    • Serum calcium, phosphate, vitamin D, PTH, ALP (especially if elevated in bone metastasis)

  • Imaging:

    • Bone scans, PET-CT, MRI for bone metastases

Falls Prevention Strategies

• Exercise:

  • Weight-bearing (walking, dancing), resistance/strength training, balance and flexibility exercises (Tai Chi, yoga).

• Lifestyle:

  • Smoking cessation

  • Alcohol moderation (<14 units weekly)

  • Home safety interventions

  • Medication review (deprescribing high-risk drugs)

  • Vision correction (regular eye tests)

  • Footwear and orthotics

• Nutrition:

  • Vit D, calcium, protein

Falls Prevention Strategies (cont.)

• Calcium and Vit D:

  • Calcium: at least 1g daily with Vitamin D: 400–1,000 IU/day (higher if deficient)

  • Adequate protein intake, caution in CKD2-3B, avoid in CKD4-5

  • adequate protein intake from animal or vegetable sources- augmented by ca intake

• Frailty Management:

  • G8/Comprehensive Geriatric Assessment (CGA), Multidisciplinary interventions, Nutrition optimisation (especially protein and Vitamin D), Resistance and aerobic exercise, Social support and caregiver involvement

Treatment Options for Poor Bone Health

• First-line:

  • Bisphosphonates (alendronate, risedronate, zoledronic acid), inhibitors of bone resorption.

  • appropriate counselling needed for bisphosphonates reviewed at 5 years.

• Alternatives:

  • Denosumab (especially in renal impairment)

  • Teriparatide or abaloparatide (anabolic agents), Romosozumab (dual action; newer specialist option)

  • Hormone replacement therapy (select postmenopausal women; assess risk-benefit)

Consequences of Falls, Fractures, and Frailty

• Fracture Management and Post-Fracture Care:

  • Hip fracture mortality: ~20% at 1 year.

  • Immediate orthopedic and geriatric co-management improves outcomes.

  • Post-fracture osteoporosis treatment should begin during hospitalization or shortly after.

• Impact:

  • Physical injuries: fractures, head trauma

  • Psychological: fear of falling (FoF), depression, loss of confidence. FoF may impact more than pain or depression on actual recovery- can instigate significant reduction in independence , cause isolation

  • Functional decline

  • Increased institutionalization and healthcare costs

  • Higher mortality

Monitoring and Follow Up

• Tolerance to treatment after 12-16 weeks (ADRs such as upper GI effects).

• Check adherence after 12 weeks.

• Reassess the need for continued bisphosphonate after 5 years.

• Maintain good oral hygiene.

• Attend routine dental check-ups & inform dentist of treatment.

• Report signs/symptoms of osteonecrosis of the jaw.

• Follow up on FoF and psychosocial impact, depression

The Role of the Healthcare Team

• Multidisciplinary care is essential: primary care, geriatrician, pharmacist, endocrinologist, physiotherapist, dietitian.

• Educate patients and caregivers about fall risks and bone health.

• Incorporate bone health into routine geriatric assessments.

• Incorporate wellbeing and mental health into follow-up care

Cancer Conversations

• Acknowledge

• Normalise

• Empathise

• Signpost – Macmillan Cancer Support, Cancer Research UK, Maggie’s Centres, Future Dreams, The Childhood cancer Charity , Teenage Cancer Trust, CAMHS, self-help, family/friends

• Refer - GP, dietician, oncologist, oncology nurse, counsellor

• Follow up and monitor – PHQ-9 [PHQ9 – A, modified for adolescents ages 11-17]

• phq9 can be used from age 12