Samantha Cudby and Gupinder Syan explain the role of the practice pharmacist in supporting the management of frail older people in primary care
Read this article to learn more about:
- the role of the practice pharmacist in managing frail older people as part of the primary care network (PCN)
- practical approaches to the stratification of patients within a PCN to manage polypharmacy in frail older people
- setting up systematic frailty and polypharmacy reviews.
This article has been developed in association with Soar Beyond Ltd.
The formation of primary care networks (PCNs) as part of the new GP contract 2019–2020 will result in all PCNs having access to at least one clinical pharmacist, with 70% of their post being funded.1 The clinical pharmacist role will include the management of patients with chronic diseases as well as structured medication optimisation reviews in polypharmacy, as required by the Network Contract Directed Enhanced Service (DES) specification, especially in:1
- older people
- care home residents
- people with multiple co-morbidities, in particular frailty, chronic obstructive pulmonary disease (COPD), and asthma
- people with learning disabilities and autism.
Older people with frailty are high users of NHS and social care resources, require complex care, and often receive inappropriate polypharmacy. Optimisation of their medicines by a practice pharmacist can have a significant effect on their care and health outcomes.2 Pharmacists leading these structured reviews can proactively and effectively manage patients living with frailty in the primary care setting, using approaches such as the 7-Steps for medication review.3 Having a structured review will enable quick identification and management of potentially problematic medications, including:3
- medications with increased anticholinergic burden
- benzodiazepines and z-drugs
- medications that cause an increased risk of falls in the older person
- use of inappropriate antipsychotics in patients with dementia
- management of constipation and glycaemic control
- chronic pain management.
Polypharmacy itself should be thought of as a ‘disease’ with potentially more serious complications than those of the diseases that the medications have been prescribed to treat.4 Inappropriate polypharmacy leads to poorer health outcomes, demonstrates a lack of consideration of what is important to the individual patient, and poses a serious medicines safety risk.
Although frailty and old age are not synonymous, this article focuses on frailty in the older population. Sometimes frailty is considered an unavoidable aspect of ageing and something that cannot be controlled, but this is not the case. Understanding frailty helps to identify a range of opportunities for the practice pharmacist; timely, targeted interventions can have a positive effect on patient care by either slowing down the onset of frailty or reducing its progression. Stratifying the frail older patient population in a PCN, and doing so in line with their individual polypharmacy needs, is an extremely useful approach by clinical pharmacists and this article will later explore how to do so using a pragmatic ‘3S’ staged model.
Frailty is now recognised as a long-term condition5 identified by several factors6 including age, co-morbidity, increased risk of hospitalisation, increased length of stay in hospital, care home admission, and mortality. It is characterised by ‘age-associated declines in physiologic reserve and function across multiorgan systems, leading to increased vulnerability for adverse health outcomes’.7
Frail older people are those who are aged over 75 years with co-morbidities that may include dementia, reduced renal function (more vulnerable to developing complications), and reduced resilience to external stressors (may take longer to recover from illnesses such as urinary tract infections or from incidents such as falls). The British Geriatrics Society recognises frailty as a distinctive health state where an apparently minor event can trigger a major change with a potentially serious adverse outcome.8 This means that people living with frailty can experience an episode of acute illness during which their health deteriorates before improving, but they do not recover to the same level of functional ability that they had before the event.
Frailty is linked to a reduced quality of life, a greater risk of hospital admission and readmission, and a loss of independence, so it has significant adverse effects on older patients. Frailty develops gradually over time and becomes a condition that the person must live with. It must be remembered that, understandably, people can be uncomfortable with being described as ‘frail’, but recognition can also be a positive step to allow a focus on what is important to the patient.
Practice-based clinical pharmacists are uniquely placed to provide this management; for example, a blood test may identify a functional decline of an organ such as the liver or kidneys, which may precipitate the need for a medication review to prevent adverse drug reactions (ADRs). Falls, sedation, constipation, abnormal electrolytes, and cognitive impairment may be indications of ADRs.
One of the most common ways a person with frailty presents in primary care is with one or more of the five frailty syndromes (previously known as the ‘geriatric giants’):8
- recurrent falls, sometimes described as ‘collapse’ or ‘found lying on the floor’
- reduced mobility, particularly a sudden deterioration, sometimes described as ‘gone off legs’, ‘slowing down’, or ‘losing strength’
- delirium, e.g. acute confusion, or short-term memory loss
- new onset or worsening of urinary or faecal incontinence
- increased sensitivity to side-effects of medicines, e.g. confusion with codeine.
Often a person presents with more than one frailty syndrome, for example, falls caused by hypotension secondary to taking multiple antihypertensive medicines, or delirium secondary to an electrolyte imbalance caused by diuretics.
Assessment of frailty
Although several frailty screening and assessment tools are available and can be used by the practice pharmacist (e.g. Rockwood Clinical Frailty Scale, PRISMA-7), generally the electronic Frailty Index (eFI)6 will fulfil the role of helping to identify, stratify, and proactively review patients who are frail or at risk of frailty (see Table 1).
The eFI6 is a frailty assessment tool that is embedded in many primary care clinical software systems, for example, EMIS Web/SystmOne. It uses 10 care criteria data to identify older people with mild, moderate, and severe frailty, and it searches for 36 variable Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) in patient notes that are seen to increase the likelihood of frailty. It is a robust, predictive validity tool that helps to identify adverse outcomes of mortality, hospitalisation, and nursing home admission. Routine implementation of eFI enables delivery of evidence-based interventions to improve outcomes. Higher scores relate to a higher degree of frailty and, therefore, an increased risk of care home admission, hospitalisation, and mortality.
It is vital that the pharmacist understands how to interpret eFI scores and uses them to inform their support for patients with frailty to manage their conditions, comorbidities, and medications.
People who are slowing up in older age and may need help with personal activities of daily living such as finances, shopping, transportation.
People who have difficulties with outdoor activities and may have mobility problems or require help with activities such as washing and dressing.
People who are often dependent for personal care and have a range of long-term conditions/multimorbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within 6–12 months.
eFI=electronic Frailty Index
Routine population screening for frailty offers minimal benefit. Older people should be assessed for the presence of frailty during all encounters with health and social care professionals and support offered on this basis.
Polypharmacy and deprescribing
The scale of the polypharmacy problem is significant: one-third of people aged over 75 years take six or more medicines, and over 1 million people take eight or more medicines, per day. Some 6.5% of hospital admissions are related to ADRs and this rises to over 10% and up to 20% in the over 65 age group.10 Of those taking five or more medicines, 50% of such admissions are preventable.3
Leading medicines optimisation and reviewing patients prescribed 10 or more regular repeat medicines, with the aim of reducing medicines-related harm and deprescribing where possible, is therefore a good place for a practice pharmacist to start addressing polypharmacy.
Deprescribing is the complex process required for safe and effective cessation of inappropriate medicines considering the patient’s physical functioning, co-morbidities, preferences, and lifestyle. It should be part of the medication optimisation process. A comprehensive, structured medication review is important, remembering that pharmacists should always work within their scope of practice, know when to involve other clinicians in the practice, and when to refer for specialist advice.
Reviewing frail older patients on multiple medications
The clinical pharmacist has a vital role in supporting proactive management of polypharmacy and deprescribing. A typical 20–30 minute appointment at a polypharmacy clinic provides a good opportunity to investigate and understand a patient’s issues and support de-escalation and deprescribing. Examples of opportunities for proactive management include:
- structured medication reviews within the practice for patients who are aged over 65 years
- reviews for patients with co-morbidities
- structured medication reviews for patients taking 10 or more medicines
- reviews of:
- care home residents
- patients recently discharged from hospital.
The Soar Beyond ‘3S’ process provides a framework for how a pharmacist could approach leading the delivery of improvements to frailty services. It covers:
- scope of competence: knowing current and desired competencies allows pharmacists to manage patients within their competence, and they can also plan the development and expansion of their competencies
- stratification: agreeing a safe approach to identifying and managing all high-risk, complex polypharmacy patient cohorts across the organisation using searches
- standardisation: consultation templates and data collection tools that can be rolled out consistently will be critical for ensuring standardisation and evaluating the outcomes.
Step 1: scope of competence
With the emphasis on the role of the pharmacist in PCNs, it is likely that there will be an expectation for practice pharmacists to lead the review process. However, before a practice pharmacist starts considering which patients need to be reviewed, they should understand their own skillset and confidence gaps first.
The competencies outlined in Box 1 aim to help practice pharmacists identify gaps in their development, and where further support or training is required to ensure competence and confidence in managing patients living with frailty.
Box 1: Practice pharmacist competencies: frailty
- Understand how to interpret eFI scores as well as coding
- Understand the physiology and pharmacology in older people and the impact on drug handling
- Understand how to tackle polypharmacy and co-morbidity safely
- Understand how to deprescribe medications safely and appropriately
- Understand how to put together/contribute to care plans for older people
- Understand how to showcase and evaluate your interventions and outcomes.
eFI=electronic Frailty Index
Soar Beyond Ltd. The i2i Network. Reproduced with permission.
Step 2: stratification
To prioritise patient cohorts for review, pharmacists could run patient searches by age, polypharmacy (i.e. how many repeat medications the patient is taking), and the number of frailty syndromes that the patient has, if applicable. Once the pharmacist’s competencies have been appropriate assessed, they can effectively stratify patients and prioritise patient cohorts to the relevant clinic.
By running these searches, the pharmacist can determine the scale of the problem of polypharmacy and agree an action plan within the practice, or one to address unmet needs. Sometimes, if numbers are too large, further stratification is needed; for example, by eFI score, number of co-morbidities, or number of hospital admissions in the last 6 months. Once the number of affected patients is known, potential exclusion criteria can be applied.
The case study in Box 2 gives an example of how to set up a pharmacist-led polypharmacy/frailty clinic in general practice across a PCN.
Step 3: standardisation
Regardless of whether a pharmacist is working at a practice level or across a network of practices, a standardised approach is essential to ensure consistency and equitability, especially if the workload is being divided up among a multidisciplinary team within a PCN.
A clinical pharmacist is well placed to ensure systematic and standardised implementation of:
- SNOMED CT templates to prompt a consistent consultation and ensure all interventions are recorded for the DES and the quality and outcomes framework (QOF)
- tools used for reviewing patients—both assessment tools and de-prescribing tools such as STOPP-START11
- outcomes reporting, evaluation criteria, and frequency of reporting
- patient care plans for carers and patients
- local referral pathways and voluntary sector services.
Box 2: Primary care network case study for managing frail older people with polypharmacy
Situation: A clinical pharmacist, who has recently made the transition from hospital pharmacy, is now employed by a PCN covering 30,000 patients. The pharmacist has been asked by the PCN Clinical Director to help the PCN to prepare for delivery of the DES in 2020 for older patients with frailty. There are a number of care homes in the network and there has been a recent spate of hospital admissions for older patients, some of whom were taking >15 medications; this has raised some concerns about polypharmacy.
The clinical pharmacist needs to agree a network approach to managing these patients, including:
- identifying and stratifying cohorts of patients to ensure appropriate prioritisation
- undertaking effective structured medication reviews competently and confidently to help the PCN to deliver improved outcomes
- developing an audit to evaluate the impact of proactive outreach for the proposed changes.
Action: The pharmacist decided to implement the ‘3S’ model across the PCN.
Scope: The pharmacist conducts a self-assessment of their baseline competencies using the competencies (see Box 1) and completes a development plan with their GP mentor to agree which patients are within the pharmacist’s scope as well as the agreed outcomes to measure. The development plan includes attending a bespoke training workshop, which covers deprescribing and how to conduct effective structured medication reviews for older patients with frailty. The plan also explores the latest guidance and resources to support deprescribing.
Stratification: two key patient cohorts are identified:
1. Aged 65–74 years on ≥10 medications with no eFI score
- Exclusion criteria: housebound patients
- Proposed action for pharmacists:
- structured medication reviews in polypharmacy clinics
- reviews of patients in care homes.
2. Aged 65–74 years on ≥10 medications with an eFI score
- Exclusion criteria: severe frailty score (eFI >0.36), patients that are housebound or in care homes
- Proposed action for pharmacists:
- review patient notes and escalation to GPwSI where appropriate
- identify opportunities for deprescribing or improved management of frailty
- pharmacist to see patients in clinic, with support from a GPwSI who manages local care homes
- care home patients and patients with severe frailty to be managed by GPwSI until pharmacist competencies grow through planned development over the next 6 months.
Standardisation: Using a standard SNOMED CT-coded consultation template on the clinical system, the agreed outcomes for these patients are based on performing an audit 3, 6, 9, and 12 months later and evaluating the outcomes following the pharmacist-led interventions.
Metrics used to measure the impact on outcomes include:
- number of patients identified and reviewed in the defined patient cohorts
- number of patient notes reviews conducted
- number of patients called in for structured medication reviews
- prescribing interventions and rationale for change (including deprescribing and optimisation)
- other interventions (e.g. referral to social services)
- anticipatory care plans developed
- specific QOF-related targets (e.g. de-intensification targets for diabetes)
- frequency of follow up
- number of patients referred to a GP or other HCP.
This makes it easy to run searches and evaluate outcomes after a period of running clinics as part of the audit write up.
PCN=primary care network; DES=directed enhanced service; GPwSI=general practitioner with special interest; SNOMED CT=Systematised Nomenclature of Medicine Clinical Terms; QOF=quality and outcomes framework; HCP=healthcare professional.
Most pharmacists in general practice are already performing polypharmacy reviews as core practice work. However, with such a significant unmet need to proactively manage frail older patients, there is a great opportunity for pharmacists to drive targeted audits and stratification of patients by severity of frailty and extent of polypharmacy.
By doing so in a structured and methodical way, such as through the 3S process, the pharmacist is extremely well placed to lead the multidisciplinary team (MDT) approach to deprescribing and holistic management across a PCN population. This may mean that the clinical pharmacist leads the overall MDT approach, training, and process change, but they may not necessarily always be the clinician who sees all patients in the first year or so, while their competencies develop.
Clinical Pharmacist and Care Home Pharmacist
Senior GP Pharmacist; Clinical Outcomes and Training Manager for i2i Network by Soar Beyond Ltd.
To find out more about how Soar Beyond Ltd and the i2i Network can help your practice achieve better management of long-term conditions and support your clinical pharmacists, and to join the i2i Network, visit: www.i2ipharmacists.co.uk/
- NHS England. Network contract Directed Enhanced Service contract specification 2019/20. NHS England, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/03/network-contract-des-specification-2019-20-v1.pdf
- Duerden M, Avery T, Payne R. Polypharmacy and medicines optimisation: making it safe and sound. King’s Fund, 2013. Available at: www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation
- Scottish Government Polypharmacy Model of Care Group. Polypharmacy guidance, realistic prescribing. 3rd edition. Scottish Government, 2018.
- Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med 2010; 170 (18): 1648–1654.
- NICE. Multimorbidity: clinical assessment and management. NICE Guideline 56. NICE, 2016. Available at: www.nice.org.uk/ng56
- Clegg A, Bates C, Young J et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016; 45 (3): 353–360.
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- British Geriatrics Society. Fit for frailty part 1. Consensus best practice guidance for the care of older people living in community and outpatient settings. BGS, 2014. Available at: www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf
- De Biase S. The electronic Frailty Index guidance notes. Yorkshire and Humber Academic Health Science Network Improvement Academy. Available at: improvementacademy.org/documents/Projects/healthy_ageing/eFI%20Guidance%20SystmOne%2 0Notes%20for%20HAC%20Partners.pdf
- English Deprescribing Network. EDeN: English Deprescribing Network. Available at: www.sps.nhs.uk/wp-content/uploads/2019/04/EDEN-Briefing-Final.pdf
- Gallagher P, Ryan C, Byrne S et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008; 46 (2): 72–83.