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• To understand why polypharmacy is a significant issue for many older people, including those with frailty
• To consider how you could use medication reviews and deprescribing to optimise medicines use in older people with frailty and polypharmacy
• To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Polypharmacy is a significant issue for many older people, including those with frailty, and it is associated with a range of adverse effects. Therefore, it is important to address polypharmacy by optimising patients’ medicines use. Medication reviews are one of the main approaches to medicines optimisation, and various tools are available to support healthcare professionals with conducting these. Another approach is deprescribing, which can improve health outcomes for patients and may have financial benefits for healthcare organisations, but can also present various challenges. This article, the second of two parts, explores the benefits of medicines optimisation in the form of medication reviews and deprescribing for older people with frailty and polypharmacy.
Nursing Older People. doi: 10.7748/nop.2023.e1449
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Lyne S (2023) Benefits of deprescribing for older people with frailty and polypharmacy: part two. Nursing Older People. doi: 10.7748/nop.2023.e1449
Published online: 20 September 2023
The aim of this two-part article is to provide nurses and nursing students with an understanding of the adverse effects of polypharmacy on older people with frailty. Part one detailed the physiology of ageing and frailty, using a fictional case study to illustrate the adverse effects of polypharmacy on older people with frailty. This article, the second of two parts, aims to explain how such adverse effects in this population may be addressed via medicines optimisation. It uses the same case study to discuss how medicines can be optimised for older people with frailty and polypharmacy through medication reviews and deprescribing. After reading this article and completing the time out activities you should be able to:
Comorbidities, including frailty, become increasingly common with age and as a result it is likely that multiple medicines will be prescribed, leading to polypharmacy (taking five or more medicines). Polypharmacy is associated with various adverse effects and can increase the medicine burden for older people with frailty (Lyne 2023).
Optimising a person’s medicines is important to ensure they are taking their medicines as intended and to support the management of frailty, comorbidities and polypharmacy. Before medicines optimisation, the term ‘medicines management’ was used. This was primarily led by pharmacy teams and defined as a ‘system of processes and behaviours that determine how medicines are used by the NHS and patients’ (National Institute for Health and Care Excellence (NICE) 2015). Medicines optimisation shifts the emphasis from processes and systems towards patient engagement and collaborative working with health and social care professionals (NICE 2015). Patient involvement in optimising their medicines should be encouraged to support adherence, since only around 50% of medicines prescribed for long-term conditions are taken as prescribed (Blenkinsopp et al 2012, NICE 2021).
Medicines optimisation should be seen as a crucial component of a comprehensive geriatric assessment (CGA). CGA is widely accepted as the ‘gold standard’ framework for assessing and managing older people with frailty (Parker et al 2018) and its core aim is to optimise an individual’s function and health.
Two of the main approaches used in medicines optimisation are medication reviews and deprescribing.
Think of a medication review you have recently undertaken in your practice. What went well and what did not? What would you do differently next time? Do you use any medication review tools to support this process and what factors do you consider?
• Comorbidities, including frailty, become increasingly common with age and as a result it is likely that multiple medicines will be prescribed, leading to polypharmacy
• A medication review aims to improve the quality, safety and appropriate use of medicines
• Deprescribing provides an opportunity to reduce the risk of medicine errors, drug interactions and adverse effects, as well as to improve patients’ quality of life and reduce costs for healthcare organisations
• When considering deprescribing, it is essential to engage with the patient, ensuring that they are involved in and agree to any planned changes
A medication review aims to improve the quality, safety and appropriate use of medicines; it is arguably a ‘diagnostic intervention’ (Blenkinsopp et al 2012). It is patient-focused, ensuring that ‘the right patients get the right choice of medicine, at the right time’ (Royal Pharmaceutical Society 2013). This entails identifying the risks associated with medicines, recognising drug-related problems and suggesting solutions (Pharmaceutical Care Network Europe 2013), with a focus on all medicines that a person is taking and the wider adverse effects of these.
The prevention of falls and fall-related injuries is a priority due to the substantial health and financial burdens that these can have on older people and healthcare organisations. A common strategy to prevent falls is to review medicines known as ‘fall-risk increasing drugs’, with the aim of deprescribing these where possible. The following groups of medicines have been identified as placing older people at high risk of adverse drug reactions (ADRs), including falls (Lee et al 2021):
• Anticholinergics.
• Diuretics.
• Antihypertensives.
• Non-steroidal anti-inflammatory drugs.
• Analgesics.
• Antipsychotics.
Anticholinergics are commonly prescribed for older people. These medicines may be used in the treatment of a variety of conditions, including Parkinson’s disease, overactive bladder, depression and chronic obstructive pulmonary disease (Bell and Avery 2021). Adverse effects associated with anticholinergic use in older people include nausea, memory impairment, confusion and constipation (Rochon 2022). When these medicines are used in combination, their adverse effects may accumulate, creating anticholinergic burden. Older people are more at risk from the effects of anticholinergic burden than younger people because they tend to take more medicines, they may be more susceptible to the adverse effects of anticholinergics because of ageing, and their metabolic clearance of anticholinergics may be reduced (Bell and Avery 2021). The ACB calculator (King and Rabino 2023) can be used to determine a patient’s anticholinergic burden, with a score of 3+ being associated with increased cognitive impairment and mortality.
Box 1 shows some of the medication review tools that healthcare professionals can use.
• Beers Criteria (American Geriatrics Society Beers Criteria Update Expert Panel 2023) – this tool comprises a list of potentially inappropriate medications that are typically best avoided by older adults in most circumstances or in specific situations, such as certain diseases or conditions. It aims to reduce older people’s exposure to potentially inappropriate medications and is widely used to assess inappropriate medicines prescribing. The criteria are organised into five general categories
• STOPP-START (Screening Tool of Older Persons’ Prescriptions and Screening Tool to Alert to Right Treatment) (NHS England 2017) – this tool has several areas that overlap with the Beers Criteria, but it also considers drug-to-drug interactions and has been updated to reflect new medicines
• STOPPFall (STOPP in older adults with high fall risk) (Seppala et al 2021) – this tool aims to support healthcare professionals with managing fall-risk increasing drugs when conducting a medication review. It outlines various classes of medicines and provides guidance on deprescribing for each of these
• STOPPFrail (STOPP in frail adults with limited life expectancy) (Lavan et al 2017) – this tool comprises 27 criteria relating to potentially inappropriate medication use in older people with frailty and limited life expectancy
• NO TEARS (Need and indication, Open questions, Tests and monitoring, Evidence and guidelines, Adverse events, Risk reduction or prevention, Simplification and switches) (Lewis 2004) – this tool was developed in primary care and can be completed within a ten-minute consultation. It can prompt healthcare professionals to ask the necessary questions during a medication review
• FORTA (Fit fOR The Aged) (Kuhn-Thiel et al 2014) – this tool was developed in Germany and is a medicines classification system based on the available evidence regarding the risks, benefits and age-appropriateness of different medicines. It comprises four categories, ranging from Class A (medicines that have proved to be particularly beneficial) to Class D (medicines that should be avoided in older people)
Another tool that can be used is the 7-steps medication review (Table 1) (NHS Scotland 2020). One advantage of this tool is that most of it can be completed before seeing the patient, thereby making effective use of face-to-face time with the person, whether in a clinical environment or the person’s home. The approach is cyclical rather than linear, necessitating regular repeat reviews of the person’s medicines over time.
How would you approach deprescribing with a patient? What explanations would you provide to ensure the process is perceived as positive by the patient? What resources do you have access to in clinical practice to support patients when deprescribing? For example, are there pharmacists in your team and how often do you refer to them?
Deprescribing – that is, discontinuing medicines – should be considered an essential and positive intervention in the medicines optimisation process (Ibrahim et al 2021). Deprescribing provides an opportunity to reduce the risk of medicine errors, drug interactions and adverse effects, as well as to improve patients’ quality of life and reduce costs for healthcare organisations (NHS England 2021).
The deprescribing process can be proactive or reactive. Proactive deprescribing aims to prevent future harm associated with medicines use and should involve using a risk-benefit approach when making decisions, whereas reactive deprescribing is undertaken in response to existing harm (Wright et al 2019). Proactive deprescribing can be more challenging than reactive deprescribing because the person may not be experiencing any side effects or issues with their prescribed medicines.
It is important to be aware that stopping certain medicines suddenly can lead to morbidity and even mortality because of rebound phenomena and specific withdrawal syndromes (Iyer et al 2008). For example, abrupt discontinuation of the following medicines can have significant consequences (Best Practice Journal 2010):
• Beta blockers – may result in rebound tachycardia, an increase in blood pressure and, in some circumstances, cardiac ischaemia.
• Antidepressants – may result in withdrawal symptoms that are similar to those of depression, which may make it challenging to determine whether a person’s original depression has returned or if their symptoms are a result of the abrupt discontinuation.
• Proton-pump inhibitors – may result in rebound hyperacidity.
Therefore, for many medicines, tapering the dose is likely to be safer and better tolerated by the patient than abrupt discontinuation.
Read the fictional case study (Case study 1) and reflect on Simon’s 7-steps medication review. What benefits did Simon experience as a result of his medication review and deprescribing?
Following a recent fall at home, Simon was admitted to hospital for several days for treatment of a urinary tract infection. On discharge, the emergency department advanced practitioner referred Simon to the community frailty practitioner service. The referrer believed Simon would benefit from a comprehensive geriatric assessment (CGA) and a medication review.
A CGA was undertaken at Simon’s home and his medicines were reviewed using the 7-steps medication review (NHS Scotland 2020). The community frailty practitioner service found that Simon had orthostatic (postural) hypotension; that is, a drop in systolic blood pressure of 20mmHg when standing, accompanied by symptoms of dizziness (Royal College of Physicians (RCP) 2017). Orthostatic hypotension is a falls risk (RCP 2017). They also identified that he had moderate frailty, since he required assistance with fundamental activities of daily living such as washing, managing his medicines and using the stairs (Rockwood et al 2005).
In Simon’s case, the medication review was undertaken with a focus on reducing his risk of falls, after which several changes were made to his medicines. Table 2 shows the application of the 7-steps medication review to Simon’s case.
| Step 1: (Aim) What matters to the patient? | Simon was anxious that he was becoming a ‘burden’ on his family and he wished to optimise his health. Simon was particularly concerned about falling again, and he felt that he was taking ‘too many pills’. He was concerned about their side effects and that they might ‘work against each other and cause damage’. To address Simon’s concerns, a review of his medicines was undertaken to determine if they were contributing to aspects of his ill health |
| Step 2: (Need) Identify essential drug therapy. Consider all medicines – herbal, prescribed and/or traditional | Simon’s medicines were listed as follows*:
|
| Step 3: (Need) Does the patient take unnecessary drug therapy? | The following of Simon’s medicines were stopped or reduced:
|
| Step 4: (Effectiveness) Are therapeutic objectives being achieved? | The following of Simon’s medicines were continued:
|
| Step 5: (Safety) Is the patient at risk of adverse drug reactions (ADRs) or have they experienced any actual ADRs? | Simon’s anticholinergic burden score was calculated to be 1, as he was taking mirtazapine. Therefore, since his anticholinergic burden score was <3 he was not considered to be at increased risk of further cognitive impairment and mortality (King and Rabino 2023). Simon was confident in his ability to self-administer his medicines according to the prescribed list, thereby reducing the risk of drug-drug and drug-disease interactions |
| Step 6: (Efficiency) Is drug therapy cost-effective? | Prescribing was in accordance with current formulary recommendations and all opportunities to minimise cost had been considered |
| Step 7: (Patient-centred) Is the patient willing and able to take drug therapy as intended? | Simon said he felt a ‘sense of relief’ following the medication review and that he was ‘looking forward to taking fewer medicines’. He also said he felt happier knowing what the medicines had been prescribed for and why he was taking them |
(Adapted from NHS Scotland 2020)
Nurses may experience various challenges when attempting to optimise patients’ medicines. For example, Xu et al (2021) identified four categories of barriers to medicines optimisation:
• Patient-related barriers, such as limited understanding of their medicines, non-adherence to medicines and drug dependency.
• Prescriber-related barriers, such as inadequate knowledge, concerns about adverse consequences, clinical inertia and lack of communication.
• Environment-related barriers, such as lack of integrated care, insufficient investment and time constraints.
• Technology-related barriers, such as the complexity of implementing medicines optimisation and inapplicable guidance.
When considering deprescribing it is essential to engage with the patient, ensuring they are involved in and agree to any planned changes (Cesari 2020). Providing patient information that meets the needs of each individual is crucial (NICE 2009). It is also important to recognise that the patient’s priorities might not be the same as those of healthcare professionals, and to consider other factors that may affect the patient, for example cognitive decline, visual impairment and access to community pharmacists (NICE 2009).
Patients may be fearful of change, especially if they have been taking a medicine for a long time or if they believe a medicine is causing no harm or is beneficial to them. They may also be concerned that the cessation of certain medicines may cause a ‘relapse’ in their condition (Elbedinni et al 2021). This is a particular challenge in patients with palliative conditions or at the end of life, where medicines that require several years to realise a benefit might no longer be considered appropriate (Rochon 2022). Ultimately, if patients have capacity, they have the right to decide to continue or discontinue a medicine, even if this conflicts with the healthcare professional’s view (NICE 2009).
When undertaking a medication review, several factors need be considered. One such factor is the role of non-pharmacological interventions, such as massage and topical treatments for chronic pain management, which can be used alongside analgesics or, in some cases, may negate the need for analgesics (Elbeddini et al 2021, NICE 2021). Consideration should also be given to involving other members of the multidisciplinary team, for example referral to a physiotherapist for assessment of limb stiffness or a speech and language therapist if a patient is experiencing swallowing difficulties.
The person’s environment is another consideration, for example if they become housebound and cannot collect their prescription from the pharmacy it will not be possible to implement the adjustments made to their medicines following a medication review (Cesari 2020). In such cases, arranging the delivery of medicines by the pharmacy or volunteer drivers working with the GP surgery should be considered.
Older people with frailty are at high risk of polypharmacy and its associated adverse effects. Therefore, it is important to optimise their medicines through deprescribing and medication reviews, which can reduce the costs associated with medicines for healthcare organisations and improve health outcomes for older people with frailty. Nurses, especially those undertaking medication reviews, should feel confident in identifying cases of inappropriate prescribing. They should also be aware of the available tools that may assist them in preventing or reducing inappropriate medicines use, and that can enhance clinical decision-making in relation to medicines optimisation and deprescribing.
Identify how deprescribing for older people with frailty and polypharmacy applies to your practice and the requirements of your regulatory body
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account
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