Frailty is a global concern as populations age. The World Health Organization (WHO) describes frailty as one of the ‘geriatric syndromes’, which also include urinary incontinence, delirium and falls (WHO, 2017a). The prevention of frailty in older age requires early interventions to help people maintain good health as they age (WHO, 2017a).
It is estimated that by 2050, one in five people will be over 60 years of age, accounting for 2 billion people globally (WHO, 2017a). Moreover, by 2068, the number of people living to 100 years of age in the UK is expected to have nearly doubled (Office for National Statistics, 2019). Older age often leads to complex healthcare needs and comorbidities requiring medication (Kojima et al, 2019).
Frailty and polypharmacy are interlinked, with structured medication reviews (SMRs) deemed central to optimising medication use (National Institute for Health and Care Excellence (NICE), 2015; Scottish Government Polypharmacy Model of Care Group, 2018). Today's medical practices tend to address single disease systems, which is not conducive to current demographics, because a majority of the ageing population will have co-existing morbidities and will not present with one simple diseased system or problem (WHO, 2015). Early intervention treatments that focus on health prevention are in line with today's healthcare directives (Department of Health and Social Care, 2018). As people age they are at greater risk of medication-related harm, with the SIMPATHY project (Mair et al, 2017) advocating the need to look at more innovative means to help address medication management in older populations. Strengthening this, the Scottish Government Polypharmacy Model of Care Group (2018) has demonstrated that the frailer population are at greater risk of polypharmacy and it is this group that the NHS needs to target with preventive medicine. The transformations taking place within general practice are to support more robust means of addressing the increased complexity of care needs through collaborative working and quality improvement programmes (Scottish Government, 2017a). Quality improvement and innovations are essential in meeting public expectations and pivotal to the future care needs of the elderly population. This can help build resilience into the NHS and create a culture of creativity, by exploring new ways of working to enable a reduction in the pressures on acute hospital services, assist in lowering the economic burdens and help keep frail older people in community settings (British Geriatric Society, 2014; The King's Fund, 2014).
Defining frailty
Frailty is a complex, multidimensional, dynamic process that is still not fully understood or clearly defined (Clegg et al, 2013). Many depict frailty as a health status related to the ageing process whereby individuals have reduced resilience to combat acute insults, whether social or medical in nature (British Geriatric Society, 2014; WHO, 2015; National Institute for Health Research (NIHR), 2017). De Lepeleire et al (2009) defined frailty as ‘a state of increased vulnerability to adverse outcomes’ (2009:178).
Two main models of frailty are depicted within the literature, providing the basis of the many screening tools used today. Mitnitski et al (2001) took data from the Canadian Study of Health and Aging (1994). and applied mathematical indices. They developed a frailty index by ascertaining that ageing had an accumulative health deficit over an individual's lifespan. The higher the health deficit in an individual, the more likely they were to develop frailty. This is known as the accumulative effect model.
In contrast, Fried et al (2001) developed the phenotype model related to frailty after carrying out a prospective observational study of community-dwelling men and women aged 65 years and over, with data originally extracted from a cardiovascular health study. From this study, the authors deduced that frailty had a phenotype that was correlated with weakness, self-reported exhaustion, unintentional weight loss, slow gait and low physical activity. Fried et al (2001) also postulated that those in lower socio-economic communities had a higher prevalence of frailty. This is an important observation that still rings true today with the WHO (2017b) documenting that older populations living in low-to-middle-income countries are not only living longer but also carrying with them a high disease burden.
These two studies from Mitnitski et al (2001) and Fried et al (2001) underpin much of today's concepts and understandings of frailty (British Geriatric Society, 2014; WHO, 2015; NIHR, 2017). Furthermore, although evidence suggests that people are living longer, there is no current evidence to support the theory that people are living healthier lives as they age (WHO, 2015). Therefore, it could be argued that, although the research is dated, there is nothing to suggest it is not still relevant today.
Polypharmacy
With an ageing population and potential increases in comorbidities, polypharmacy and medication misuse play an important role in the proliferation of health and social care pressures and demands (Mair et al, 2017).
Polypharmacy is synonymous with the elderly population and a cause of many preventable hospital admissions (Scottish Government Polypharmacy Model of Care Group, 2018). The WHO (2017c) referred to polypharmacy as the use of four or more medications by a single person. However, the Scottish Government Polypharmacy Model of Care Group (2018) defines polypharmacy as the use of two or more medications by a single person. Mair et al (2017) discussed two concepts of polypharmacy: appropriate and inappropriate polypharmacy. Appropriate polypharmacy means that multiple medications are prescribed for complex conditions using evidence-based practice at the core of prescribing and decision making. In contrast to this, inappropriate polypharmacy is the improper use of medications, with a poor evidence base behind decision making, leading to an increased risk of harm.
Prescribing medication has been referred to as one of the most common therapeutic interventions (Scottish Government Polypharmacy Model of Care Group, 2018). The WHO (2017c) has estimated that drug-related errors cost the global economy US$42 billion annually. There are approximately 8.6 million hospital admissions every year across Europe due to adverse drug reactions (Mair et al, 2017). Fifty per cent of these admission were considered to be preventable in the over-65 age group (Mair et al, 2017; Scottish Government Polypharmacy Model of Care Group, 2018). Moreover, NIHR (2017) has postulated that 12% of patients aged 70 and over will have a reduction in their functional capabilities after being admitted to hospital. Therefore, the WHO considers medication use to be a global threat and has ranked reduction in medication-related harm as the third global patient safety challenge (WHO, 2017c).
Reducing medicines-related harm using a structured medication review: literature review
To evaluate the impact of a structured medicines review on medicines-related harm, a search of the literature was undertaken in February 2020 using the Medline, CINAHL and EMBASE databases. No ethical approval was required for this study. Initially, the search was broad, using Boolean terms and the keywords ‘medicines review’ OR ‘medications review’ Then the population, intervention, comparison and outcome (PICO) framework was used to help focus the literature search, ensuring that all available literature was obtained. Grey literature was also accessed using the opengrey.org site. Ninety articles were found and inclusion and exclusion criteria were applied (Table 1), leaving four articles for review:
Table 1. Inclusion and exclusion criteria for the study
| Inclusion criteria | Exclusion criteria |
|---|---|
| Study patients aged 65 and over | Patients under 65 or where age not clear |
| Patient cohort in community setting | Studies of patients in care homes or secondary care settings |
| Data from 2017–2020 | Evidence from pre-2017 |
| English language | Studies not in Engish |
| Studies using structured medicine reviews | Studies not investigating structured medicine reviews |
| Primary research studies | Qualitative research |
The key themes found in the reviewed literature were:
- Identified high-risk medications
- Renal function
- Drug-related problems (DRPs)
- Potentially inappropriate medications (PIMs)
- Economic benefits.
Three articles demonstrated that SMRs identified DRPs and PIMs (Willeboordse et al, 2017; Rhalimi et al, 2018; Hurmuz et al, 2018). One article reported that medications related to constipation, diabetes, lipid regulation, diuretics, and the nervous system, and drugs acting on the renin–angiotensin system, were connected with an increased risk of DRPs and PIMs (Hurmuz et al, 2018). Rhalimi et al (2018) corroborated these findings, identifying that a cohort of medications linked to the aforementioned systems were connected with DRPs.
Three articles made reference to renal function, stating that it plays an important role in the risk of developing DRPs and the use of PIMs (Schmidt-Mende et al, 2017; Hurmuz et al, 2018; Rhalimi et al, 2018). However, none of these articles expanded on this aspect, but alluded solely to the fact that renal function is central in SMRs. This is an important finding as elderly patients have an increased risk of harm from reduced renal function and have higher affiliations with chronic disease burdens than younger people (Faber et al, 2019).
One article mentioned that cost savings could be realised due to reductions in medication doses (Hurmuz et al, 2018). In contrast, one study found no financial benefits from SMRs (Schmidt-Mende et al, 2017), with another study advocating that more research is required in this area (Rhalimi et al, 2018).
Discussion
The aim of this article was to evaluate the impact of SMRs in the frail, older community-based population, thus informing the role of advanced clinical practitioners (ACPs) when caring for this population. Primary care is the first point of contact for most of the population, with general practice often viewed as the gatekeeper of health care (Scottish Government, 2017a). Prescribing medications remains a large part of the workload for ACPs within a general practice setting (Simon et al, 2014), yet despite this, much of the research relating to frailty and medicines-related harm has taken place in the hospital setting. That said, the key findings outlined in this review may inform community advanced practice. The literature suggested that there are key medicines associated with drug-related harm and greater awareness of these medications is advantageous for ACPs.
SMRs are the gold standard and are of particular importance when prescribing for the frail elderly population. Yet, some SMRs are too complex and can reduce patients and practitioners' interactions due to a poor understanding of the process and time restraints. Schmidt-Mende et al (2018) demonstrated these points in their qualitative study on data extrapolated from pharmacist dairies kept during a randomised controlled trial. They carried out a thematic analysis and found that the complexities of SMRs, experiences and guidelines, can influence practitioner interactions. This suggests that medication reviews that are well-structured, straightforward to implement and adhere to guidelines are most successful. Thus, ACPs should take every opportunity to review medication use and it is recommended that this is carried out at least on an annual basis.
The seven steps approach to polypharmacy reviews developed in Scotland (Table 2) takes a realistic approach to medication use and assists in assessing the relevance and appropriateness of medication taken by individuals (Scottish Government Polypharmacy Model of Care Group, 2018). It aids health professionals in taking a holistic evidence-based approach to medication reviews, with shared decision making central to the approach. The document has the added advantage of illustrating the number needed to treat (NNT) for high-risk medicines, thus assisting the decision-making process. This can help eliminate inappropriate medications, reducing the risk of side effects and increasing safety in the frail elderly population. The use of ‘patient sick day rule cards’ (Scottish Government Polypharmacy Model of Care Group, 2018) is also advocated to help prevent complications due to dehydration during acute illness, such as viral gastroenteritis, for patients using high-risk medications. These cards provide information on medications that should be stopped during acute illnesses and should be discussed with patients during SMRs, helping to prevent complications secondary to medication use. NICE (2015) has advocated a process of medicine optimisation whereby practitioners assess the suitability of prescribed medicines through shared decision making and evidence-based medication use. NICE has also advocated the use of screening tools, such as the 7 steps approach developed in Scotland, to identify medication-related harm, encouraging a culture of transparency, reflection and feedback to aid in learning from errors and omissions.
Table 2. Overview of the key considerations of each step in the 7 Steps Medication Review
| Domain | Step | Process |
|---|---|---|
| Aims | 1. What matters to the patient? | Review diagnoses and identify therapeutic objectives with respect to:
|
| Need | 2. Identify essential drug therapy | Identify essential drugs (not to be stopped without specialist advice):
|
| 3. Does the patient take unnecessary drug therapy? | Identify and review the (continued) need for drugs:
|
|
| Effectiveness | 4. Are therapeutic objectives being achieved? | Identify the need for adding/intensifying drug therapy in order to achieve therapeutic objectives:
|
| Safety | 5. Does the patient have adverse drug reactions (ADRs)/side effects or is at risk of ADRs/side effects?Does the patient know what to do if they are ill? | Identify patient safety risks by checking for:
|
| Cost-effectiveness | 6. Is drug therapy cost effective? | Identify unnecessarily costly drug therapy by:
|
| Patient centeredness | 7. Is the patient willing and able to take drug therapy as intended? | Does the patient understand the outcomes of the review?
|
Source: adapted from Scottish Government Polypharmacy Model of Care Group, 2018
These processes reflect the ethos and aims of realistic medicines use (Scottish Government, 2017b) in which it is hoped that harm and waste can be reduced by shared decision making, transparency and openness.
Employing these strategies can aid ACPs in identifying frail older patients on high-risk medication and help prevent complications secondary to these. It also highlights the need for practitioners to be mindful of renal function and to consider the wider aspect of prescribing, such as microbial stewardship, costs, realistic prescribing practices and, most importantly, the risk of harm.
The review has had a positive impact on the authors' own practice, in that every opportunity has been taken during the patient consultation process to discuss medication use and review those medications on a repeat prescription list. This does not have to be a long in-depth review of medication use but can be simple, even if just removing inappropriate medication from a repeat list, after discussion and explanation for the patient. Helping to prevent medication-related harm is an important part of nursing the older population.
Conclusion
Medication use and old age are inextricably linked, with research demonstrating that the older the population, the greater chance there is of multiple drug use. Medication without harm has been identified by the WHO as the third global patient safety challenge due to an increased threat of adverse events. Current guidelines indicate that SMRs can have a beneficial effect and advocate their use. However, to date, studies have produced equivocal results as to the benefits of SMRs, with some studies showing beneficial effects and others drawing no clear conclusions.
One finding from this review was that very little research has been carried out in the primary care environment, despite the fact that the prescription of medications is a large part of the primary care workload. The four studies in this literature review were analysed using the Effective Public Health Practice Project (EPHPP) tool (EPHPP, 2020). Clear study limitations and poor-quality ratings made it difficult to draw any solid conclusions or provide any definitive answers as to the benefits of SMRs. Some qualitative evidence indicates that SMRs are too complex and time consuming, leading to reduced participation from patients and practitioners (Schmidt-Mende et al, 2018). This is an area where more research would be advantageous to help draw conclusions and make the process more robust. Mair et al (2017) stated that more innovative ways of carrying out medication reviews are needed, reminding practitioners that change is a dynamic process and never stagnant. With this in mind, opportunistic medication reviews are an area where further research would be advantageous. If processes are less complex and more flexible, this may encourage more extensive use of medication reviews. Therefore, it could be hypothesised that this will have positive results in the identification of drug-related problems and potentially inappropriate medication use. This would lead to earlier interventions and help to reduce the risks from adverse events and aid in keeping older people safe. It is hoped that this would have a domino effect in helping reduce hospital admissions and have a positive influence on NHS costs.
Finally, quality of life is important for people as they age, and more robust studies are needed to evaluate the effect that medication reviews could have on this. This can only benefit patient care and help in holistic approaches to health care.
KEY POINTS
- Frailty and polypharmacy are interlinked, with structured medication reviews (SMRs) deemed central to optimising medication use
- The World Health Organization has identified medication use as the third global patient safety challenge
- Despite current recommendations, to date studies have produced equivocal results as to the benefits of SMRs
- Advanced clinical practitioners have a key role to play in medication review and looking at innovative way to carry out these processes
- Early interventional treatments that focus on health prevention are in line with today's healthcare directives
CPD reflective questions
- Reflect on your own practice in prescribing and reviewing medications for older people and identify any learning needs
- Review the policies for structured medication reviews and realistic prescribing practices in your place of work
- Think about ways in which you could incorporate medication reviews into your daily practice or review those you currently undertake