Optimising medication in frail older people

MEDICINES OPTIMISATION Optimising medication in frail older people MARYAM JIWA Medicines optimisation is key to the successful management of frail older people in order to reduce harm and minimise inappropriate admissions. This article discusses the screening tools available to help identify frailty and gives guidance on how to optimise prescribing in frail individuals. Since 1 July 2017, general practices in England are required under NHS England s General Medical Services (GMS) Contract to identify and manage patients over the age of 65 years who are living with moderate to severe frailty. 1,2 Because frailty has no gold standard measure, validating its definition is intrinsically complex. Many older people are frail but many are not, and there is often confusion between the different states of frailty, multimorbidity and disability. Many people with multiple long-term conditions (multimorbidity) also have frailty, which may be concealed when the focus is on treating the individual conditions. Furthermore, some people who are frail may be low consumers of healthcare resources. Therefore, it is important to stratify populations by risk of future health and social care use in order to tailor appropriate support or preventative interventions to those in greatest need, and to improve access to care. 3 Frailty is often described as a phenotype and the central physical feature is loss of skeletal muscle (sarcopenia). Other characteristics include unintentional weight loss, reduced muscle strength and reduced gait speed, and individuals may also experience deficits associated with ageing such as loss of hearing or tremors. 3 The British Geriatrics Society 3 defines frailty as a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. It describes five syndromes associated with frailty (see Table 1), in which individuals can present with 18 Prescriber March 2018 prescriber.co.uk

Prescribing in frailty l MEDICINES OPTIMISATION straightforward symptoms that may conceal more complicated or serious underlying medical issues. Patients may have one or more of these syndromes. The English Longitudinal Study of Ageing (ELSA) 4 reported that the prevalence of frailty, using the physical frailty phenotype, rose from 6.5% in those aged 60 69 years, to 65% in those over the age of 90 years, with frail individuals reporting decreased physical function and difficulties in performing activities of daily living. The incidence of frailty occurred more frequently in women (16% versus 12% in men), and 93% of frail individuals had mobility issues compared with 58% of non-frail persons. 4 1. Falls, eg collapse, legs gave way, found lying on floor 2. Immobility, eg sudden change in mobility, gone off legs, stuck in toilet 3. Delirium, eg acute confusion, muddledness, sudden worsening of confusion in someone with previous dementia or known memory loss 4. Incontinence, eg change in continence new onset or worsening of urine or faecal incontinence 5. Susceptibility to side-effects of medication, eg confusion with codeine, hypotension with antidepressants Table 1. Five frailty syndromes, reproduced with permission from the British Geriatrics Society 3 Screening for frailty There are many validated tools to screen for frailty. The most common instruments to identify frail older adults include: 3 The Groningen Frailty Indicator (GFI). A validated 15-item questionnaire that is suitable for postal completion. A score of four or more indicates frailty. PRISMA-7. A seven-item questionnaire that is suitable for postal completion. A score of three or more indicates frailty. GP clinical assessment. This may involve an informal assessment of gait speed, eg time taken to answer the door, time taken to walk from the waiting room. 5 Gait speed. This can be performed in any individual who is able to walk four metres. An average gait speed of longer than five seconds to walk four metres indicates frailty. Clinical Frailty Scale 1. Very fit People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age. 2. Well People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, eg seasonally. 3. Managing well People whose medical problems are well controlled, but are not regularly active beyond routine walking. 4. Vulnerable While not dependent on others for daily help, often symptoms limit activities. A common complaint is being slowed up, and/or being tired during the day. 5. Mildly frail These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework. 6. Moderately frail People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cueing, standby) with dressing. 7. Severely frail Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~6 months). 8. Very severely frail Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness. 9. Terminally ill - Approaching the end of life. This category applies to people with a life expectancy <6 months, who are not otherwise evidently frail. IADLs = instrumental activities of daily living Scoring frailty in people with dementia The degree of frailty corresponds to the degree of dementia. Common symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal. In moderate dementia, recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting. In severe dementia, they cannot do personal care without help. Table 2. The Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale ( 2007-2009, Dalhousie University) 9,10 prescriber.co.uk Prescriber March 2018 19

MEDICINES OPTIMISATION l Prescribing in frailty Digoxin at doses of 250µg or greater Antipsychotics Tricyclic antidepressants Benzodiazepines and z-drugs Anticholinergics Phenothiazines (eg prochlorperazine) Combination analgesics (eg co-codamol) NSAIDs Table 3. Drugs considered poorly tolerated in frail individuals 17 Timed Up and Go test. This is the time, in seconds, that a person takes to rise from a chair, walk three metres, turn around, walk back to the chair and sit down. Longer than 12 seconds indicates frailty. 5 Self-reported health status. In the study examined, this was assessed with the question: How would you rate your health on a scale of 0 10. A cut-off of <6 was used to identify frailty. The Edmonton Frail Scale. This has been proven to be both valid and reliable. 6 It consists of 10 domains; the maximum score is 17, which represents the highest level of frailty. The efi (electronic frailty index). 7 This is based on the manipulation of clinical data stored on the clinical system in general practice. In a primary or community care setting, NICE guidance on optimising care for adults with multimorbidity 5 recommends the use of one of the following tools for frailty assessment: informal assessment of gait speed, self-reported health status, a formal assessment of gait speed, or the PRISMA-7 questionnaire. In a secondary-care setting, the tools that are recommended include: self-reported health status, Timed Up and Go test, a formal assessment of gait speed, the PRISMA 7 questionnaire, and self-reported physical activity, with frailty indicated by scores of 56 or less for men and 59 or less for women using the Physical Activity Scale for the Elderly. 5 The efi is a validated tool 7 recommended in general practice in England to identify individuals likely to have frailty in a large patient population. Since the efi (or any other frailty assessment tool) is not 100% sensitive or specific, 8 further verification of frailty diagnosis is required. Following direct clinical assessment, the degree of frailty can then be recorded using a system such as the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS) or another validated tool. A CFS score of 4 5 indicates mild frailty, 6 indicates moderate frailty and a score 7 or above indicates severe frailty (see Table 2). 9,10 Research has demonstrated that the efi can predict the likelihood of unwanted events in elderly populations and can be used to identify people who may benefit from a care plan. 11 Ideally, this should be incorporated into an enriched summary care record, so it is clear to other healthcare professionals what is being recommended. The efi has been embedded in primary care clinical information systems to help clinicians identify frail individuals. The data used in efi derives from the patient s health record through identification of clinical codes. The efi is made up of 36 problems comprising 2000 read codes and is presented as a score; higher scores indicate increasing frailty. 11 The frailty score can be calculated using clinical codes for signs (eg tremor) and symptoms (eg vision problems), diseases, disabilities and abnormal test results. Prescribing in the frail It is recognised that suboptimal prescribing and polypharmacy (concurrent use of multiple medicines) can lead to poorer outcomes. The common consequences are adverse drug reactions, hospital admissions and subsequent healthcare costs. 12,13 Furthermore, studies have demonstrated that anticholinergic drugs are associated with harm and frailty through increased functional decline, increased falls and greater incidence of dementia and delirium. 14-16 Several groups of drugs (see Table 3) are recognised as being poorly tolerated in people with frailty and are associated with adverse events (particularly falls). Although these medicines may be necessary, it is important to clarify if the indication is still valid and treatment is considered effective. Falls are common in the older population and are recognised to be associated with considerable morbidity, immobility and mortality. 18 Approximately 30% of people aged 65 years or older have a fall each year, increasing to 50% in people aged 80 years or older. 19 Fractures are a common complication of falls. In the UK, 95% of hip fractures occur as a consequence of falls. 19 Although there are several risk factors contributing to falls, the use of medications such as those that act on the central nervous system (eg benzodiazepines, antidepressants, neuroleptics and anticonvulsants), diuretics and antiarrhythmics has been identified as a risk factor for falls (see Table 4). 20 These types of drugs are also commonly associated with hospitalisation. 22 Under the 2017/18 GP Contract, it is a contractual obligation to record a reported fall for patients with moderate to severe frailty. 2 A clinical intervention such as a falls risk assessment or referral to a falls clinic is advocated. Important pharmacokinetic changes that occur in patients with advancing age affect many medicines, including a reduction in renal and hepatic clearance, and an increase in volume of distribution of lipid-soluble drugs (hence a prolongation of elimination half-life). Additionally, the implications of age on pharmacodynamics (the effect of a drug on its target site) are due to altered sensitivity to drugs; 23 Any long-acting or long-term hypnotic or anxiolytic; it is advised to reduce the dose if the medication cannot be stopped completely Antihypertensives/diuretics/beta-blockers; optimise therapy with reference to falls risk, adverse effects, mobility and postural hypotension Other central nervous system medicines such as antidepressants, antipsychotics, anti-epileptic medications (particularly if for pain) First-generation (sedating) antihistamines, eg chlorphenamine, promethazine Anticholinergic drugs for bladder spasm or other drugs with anticholinergic sideeffects, eg tricyclic antidepressants, digoxin Table 4. Medicines that require review in patients at risk of falls 20,21 20 Prescriber March 2018 prescriber.co.uk

Prescribing in frailty l MEDICINES OPTIMISATION for example, older patients are known to be more sensitive to benzodiazepines. 24 Therefore, an improved understanding of age-related pharmacology could enhance the quality of prescribing. Barriers to deprescribing Once a person has been identified as frail, a holistic review will allow for optimisation of their health, which should include a medication review. For patients with severe frailty, an annual medication review is contractually required. Most prescribers are aware that inappropriate prescribing in the frail is a significant problem; however, there are several obstacles to implementing change. Anderson et al. 25 describes four analytical themes to categorise barriers to deprescribing (see Table 5). These are: awareness or level of insight a prescriber has with regard to the appropriateness of their prescribing; inertia or inactivity despite awareness of inappropriate prescribing, because deprescribing is perceived to be of lower priority than continuing inappropriate medication; self-efficacy, which relates to a prescriber s belief and confidence in their ability to alter prescribing; and feasibility, which refers to the external constraints to optimal prescribing. Awareness, inertia and self-efficacy reflect factors intrinsic to the prescriber. Historically, there has been a cultural belief that clinicians are there to treat conditions or diseases with medicines. This perception, held by both patient and, less commonly, clinicians, can be challenging to overcome. The wishes and expectations of patients/carers can restrain deprescribing along with patient underestimation of the risks/harms associated with prescribing. In order to overcome these barriers, prescribers should manage patient expectations, have awareness of their limitations in prescribing and seek advice where needed. Consultation models may be used to guide discussions, particularly through the use of ICE exploration of a patient s ideas, concerns and expectations enhances understanding of patient perspective and treatment adherence through shared decision making. 26 Equal importance ought to be given Awareness Poor insight into appropriateness of prescribing Discrepancy between beliefs and actual prescribing Prescriber belief at a population level does not necessarily translate to optimal prescribing practice at an individual level Inertia Prescriber belief/attitudes Fear of unknown/negative consequences of medication alteration Medicines are effective and adverse effects are uncommon Prescribing is a good solution to a problem and meets the patient needs Stopping is futile/difficult/high risk of failure Stopping is low priority Prescriber behaviour Conflict of responsibility Self-efficacy Skills/knowledge Deficits Information/influencers Lack of evidence Incomplete clinical picture Guidelines and specialists Other healthcare professionals (eg care staff) Feasibility Patients Ambivalence/resistance to change Poor acceptance of alternative therapies Intractable adverse circumstances Conflicting goals to prescriber Resources Time and effort Insufficient reimbursement Limited availability of effective alternatives Work practices Prescribing without review Medical culture Discomfort in challenging another prescriber s decision Health beliefs and culture Culture to prescribe more Prescribing validates an illness Regulatory Quality measure-driven care Table 5. Barriers to deprescribing categorised by four analytical themes 25 prescriber.co.uk Prescriber March 2018 21

MEDICINES OPTIMISATION l Prescribing in frailty to the initiation of new medication; consideration should be made into the ongoing appropriateness of each medicine, the need for regular review (eg proton-pump inhibitors for non-ulcer dyspepsia and antidepressants for longterm depression), the intended duration of treatment and recommendation of alternative non-pharmacological options where possible. Additionally, there is a distinct lack of robust clinical trial data providing evidence on when to discontinue medications or the consequences of deprescribing. This lack of evidence base might contribute to a fear of harm and litigation when deprescribing. To help guide and rationalise deprescribing decisions, the School for Advancing Generalist Expertise (SAGE) defendable decision tool 27 can be used to guide the prescriber through a step-by-step decision-making process (see Table 6). This tool may be applied to several deprescribing scenarios to rationalise the process and optimise patient care. Furthermore, educational interventions focusing on geriatric pharmacotherapy can enable clinicians to optimise prescribing. 28 In order to uphold safe practice and reduce the risk of clinical negligence, a prescriber should consider the following: 29 Prescribing (and the reverse deprescribing) must be evidence based and/or in line with the decisions of a reasonable body of their peers. To ensure fully informed consent, the prescriber must discuss all clinically appropriate options, ie potential risks and benefits of stopping the medication or continuing with the medication, and appropriate alternative treatments. Medication review A Comprehensive Geriatric Assessment is the gold standard for the management of frailty in older people. 3 It reflects a hospital focus and its demands and resources may present challenges across the NHS, which may not have adequate capacity to deliver it. It encompasses a holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people s health and has been demonstrated to be associated Data collection Interpretive process Explanation offered Generalisability Evaluate validity with improved outcomes in a variety of settings. 3 A structured medication review represents the main approach to deprescribing in the frail population and ideally should be regularly conducted in primary care; increasingly, clinical pharmacists are involved in this process. There are a number of recognised methods of reducing inappropriate prescribing, which may be categorised as explicit (criteria-based) or implicit (judgement-based). 30 Explicit tools such as the STOPP/START (Screening Tool of Older Person s Prescriptions/Screening Tool to Alert doctors to Right Treatment) criteria 31 include a list of medications to avoid or indicators to avoid for several medications and diseases. The STOPP/ START tool comprises criteria that recognise the duality of potential inappropriate prescribing and potential prescribing omissions. 31 Another explicit intervention to reduce the number of medicinesrelated safety incidents is the application of the pharmacist-led information technology intervention for medication errors (PINCER) tool to the general practice clinical system. 32 The PINCER tool is an audit instrument developed from the PINCER trial, which demonstrated that the intervention reduced the frequency of clinically important medication errors. 33 In addition, prescribing safety indicators may be employed. These describe scenarios in which there is potentially inappropriate prescribing that puts the patient at risk of harm. Research has demonstrated that the prescribing indicators are appropriate to assess the safety of prescribing in general practice. 34 The Medication Appropriateness Collection of an appropriate range of data from multiple sources Use of data to inform shared decision making Decision supports/addresses improving health/quality of life Decision same for others in similar circumstances Nature of impact of decision on patient and exploring benefits and minimising harm Table 6. The School for Advancing Generalist Expertise (SAGE) defendable decision tool to support deprescribing 27 Index (MAI) is an implicit screening tool. 35 It consists of 10 domains that allow three rating choices: A being appropriate, B being marginally appropriate and C being inappropriate. Being an implicit tool, reliability depends on the evaluator s judgement. In particular, the MAI does not address other aspects of suboptimal prescribing (ie polypharmacy or potential prescribing omissions). 30 When approaching deprescribing in the frail, dose tapering should be considered prior to cessation of treatment, and the cessation order should be considered in the case of polypharmacy. Those medicines that require more caution are those with a high potential for adverse withdrawal reactions, adverse effects or rebound symptoms (such as benzodiazepines, proton-pump inhibitors, antihypertensives, antidepressants, analgesics and antipsychotics). 36 Figure 1 summarises the approach to medication review and deprescribing in frail individuals. Similarly, suboptimal prescribing should be reviewed. There is renewed emphasis on recognising that many frail individuals manage better in the home environment, but only with an adequate support system to fulfil all their health and care needs. 3 In terms of medicines optimisation, points to consider include: use of rescue antibiotics for appropriate management of chronic conditions; switching from warfarin to a direct-acting oral anticoagulant to eliminate the need for frequent International Normalised Ratio (INR) monitoring; and simplifying or optimising a medication regimen to improve adherence. The British Geriatrics Society 3 advises the presence of relatives, carers 22 Prescriber March 2018 prescriber.co.uk

Prescribing in frailty l MEDICINES OPTIMISATION Compile medication history Discuss patient s long-term and immediate goals Review indication of each medication With use of deprescribing tools, discuss medications to discontinue and any medications to prescribe For each step: Ensure medicines optimisation is at its core Ensure adequate documentation Communicate all changes with relevant parties as well as encouraging participation in falls prevention programmes. 19 Conclusion Medicines optimisation is a central theme in the management of frail individuals to reduce harm and minimise inappropriate admissions. Prescribing in the frail is complex; the fog of polypharmacy, multimorbidity and fluctuating patient needs with advancing age results in prescribing challenges. Ultimately, to improve patient outcomes in this cohort, it is paramount that care plans are individualised, patient-centric and involve close collaboration with all relevant parties with the intention of regular review. Discuss cessation order Discontinue harmful medication first Review in 2 3 weeks after each medication discontinuation Continue to discontinue medication if no symptoms/no adverse effects Figure 1. Approaching deprescribing in the medication review of frail patients and care workers involved in a patient s care at a medication review/holistic medical review. This patient-centric approach should be central to the review, as emphasised by NICE guidance. 5,32 Long-term goals and aspirations should be discussed with reference to stopping preventive chronic disease medication such as statins, or aspirin in atrial fibrillation. Scenarios such as covert administration of medication or palliative care present as possible opportunities to open up discussions on whether it is time to start deprescribing. A shared care and support plan should be compiled, which may include referral to other community specialists such as intermediate care, a memory clinic or falls service, and which should document treatment goals, management plans, plans for urgent care and, where appropriate, advanced planning for end-of-life care. 3 Non-pharmacological measures A central feature of physical frailty is loss of muscle mass and strength. A non-pharmacological intervention to address this aspect of frailty is exercise. Home- and group-based exercise interventions can result in improvement in both mobility and functional ability. 3 In addition, nutritional interventions such as optimising protein intake are recommended. 3 For patients at risk of falls, NICE advocates multifactorial interventions such as strength and balance training, home hazard assessment, and interventions such as vision assessment and referral, References 1. BMA, NHS Employers. Identification and management of patients with frailty. Summary of requirements. 2017 Available from: http:// www.nhsemployers.org/~/media/employers/ Documents/Primary%20care%20contracts/ GMS/Summary%20of%20requirements%20 for%20frailty.pdf [accessed 8 September 2. NHS England. Toolkit for general practice in supporting older people living with frailty. March 2017. Available from: https://www. england.nhs.uk/wp-content/ uploads/2017/03/toolkit-general-practice-frailty.pdf [accessed 12 December 3. British Geriatrics Society. Fit for frailty consensus best practice guidance for the care of older people living in community and outpatient settings. 2014. Available from: http:// www.bgs.org.uk/campaigns/fff/fff_full.pdf [accessed 2 September 4. Gale CR, et al. Prevalence of frailty and disability: Findings from the English Longitudinal Study of Ageing. Age and Ageing 2015;44(1):162 5. 5. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management. NG56. September 2016. Available from: https://www.nice.org.uk/ guidance/ng56 [accessed 12 September 6. Rolfson DB, et al. Validity and reliability of the Edmonton Frail Scale. Age and Ageing 2006;35(5):526 9. 7. Clegg A, et al. Development and validation of an electronic frailty index using routine primary care electronic health records data. Age and Ageing 2016;45(3):353 60. 8. How can practices fulfill the new frailty requirements? Pulse Today 2017. Available from: http://www.pulsetoday.co.uk/hot-topics/ gp-contract-2017/18/how-can-practices-fulfil- prescriber.co.uk Prescriber March 2018 23

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