Frailty and Polypharmacy: the Role of the Practice Pharmacist

Samantha Cudby and Gupinder Syan Explain the Role of the Practice Pharmacist in Supporting the Management of Frail Older People in Primary Care

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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

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.

Table 1: Electronic Frailty Index Scores for Different Categories of Frailty⁶

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:

• clinics:
  • 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.

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.

Conclusion

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.

Samantha Cudby

Clinical Pharmacist and Care Home Pharmacist

Gupinder Syan

Senior GP Pharmacist; Clinical Outcomes and Training Manager for i2i Network by Soar Beyond Ltd.