Special ArticleMedication Management in Frail Older People: Consensus Principles for Clinical Practice, Research, and Education
Section snippets
Principles for Clinical Practice
The following principles for medication management in clinical practice (Figure 1) are particularly relevant to settings where frailty is prevalent including long-term care. The principles are founded on frailty being routinely assessed using a valid and appropriate approach for the specific clinical practice setting.
Include Frail Older People in RCTs
Frail older people are commonly excluded from RCTs due to cognitive impairment, multimorbidity, and polypharmacy.18,32 RCT results may not be generalizable to frail older people.4,32 Frailty should be characterized at baseline and follow-up.33 Understanding whether there are changes in frailty status over time may be important, particularly interventions that may have an indirect impact on frailty status. Understanding the barriers to recruitment and retention of frail older people in RCTs
Provide Undergraduate and Postgraduate Education on Frailty
There are knowledge gaps on frailty prevention and management among healthcare professionals.49 The concept of frailty should be incorporated into undergraduate and postgraduate medication management education. The principles for clinical practice (Table 1) may assist to design education programs. Initiatives such as the Prescribing Safety Assessment,50 although not specific to frail older people, may be valuable for evaluating competency in aligning medication regimens to changing goals of
Implications for Practice, Policy, and Research
Consideration of frailty status is important for guiding medication management (Table 1). Increasing numbers of frail older people and recognition that frailty may confer heightened risk of ADEs highlight the importance of an individualized approach to medication management. There is a lack of frailty-specific prescribing recommendations to guide medication management in this vulnerable population. The 7 principles for clinical practice, 6 principles for research, and 4 principles for education
References (59)
- et al.
Frailty in elderly people
Lancet
(2013) - et al.
Accounting for frailty when treating chronic diseases
Eur J Intern Med
(2018) - et al.
The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty
J Am Med Dir Assoc
(2017) - et al.
Research priorities for optimizing geriatric pharmacotherapy: An international consensus
J Am Med Dir Assoc
(2018) - et al.
Medication management policy, practice and research in Australian residential aged care: Current and future directions
Pharmacol Res
(2017) - et al.
Outcome instruments to measure frailty: A systematic review
Ageing Res Rev
(2011) - et al.
Challenges and strategies pertaining to recruitment and retention of frail elderly in research studies: A systematic review
Arch Gerontol Geriatr
(2014) Prevalence of frailty in nursing homes: A systematic review and meta-analysis
J Am Med Dir Assoc
(2015)- et al.
Prevalence of potentially inappropriate medication use in older adults living in nursing homes: A systematic Review
J Am Med Dir Assoc
(2016) - et al.
Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: An observational study
Lancet
(2018)
Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study
Am J Med
AMDA-choosing wisely
J Am Med Dir Assoc
Updated Choosing Wisely® list from AGS highlights tests, treatments to consider carefully when caring for older patients
Geriatr Nurs
Defining and identifying concepts of medication literacy: An international perspective
Res Social Adm Pharm
Ageing and health
Frailty and multimorbidity: A systematic review and meta-analysis
J Gerontol A Biol Sci Med Sci
Best practice guidelines for the management of frailty: A British Geriatrics Society, Age UK and Royal College of General Practitioners report
Age Ageing
Frailty in older adults: Evidence for a phenotype
J Gerontol A Biol Sci Med Sci
Accumulation of deficits as a proxy measure of aging
Sci World J
State of the art report on the prevention and management of frailty
Association of polypharmacy and hyperpolypharmacy with frailty states: A systematic review and meta-analysis
Eur Geriatr Med
Decision making for older adults with multiple chronic conditions: Executive Summary for the American Geriatrics Society Guiding Principles on the Care of Older Adults with Multimorbidity
J Am Geriatr Soc
The High 5s Project Standard Operating Protocol - Assuring Medication Accuracy at Transitions in Care: Medication Reconciliation
Gaps in continuity of medication management during the transition from hospital to residential care: An observational study (MedGap Study)
Aust J Ageing
Beyond medication reconciliation: The Correct Medication List
JAMA
Standardised assessment of patients' capacity to manage medications: A systematic review of published instruments
BMC Geriatr
Appropriate use of dose administration aids
Aust Prescr
Clinical outcomes associated with medication regimen complexity in older people: A systematic review
J Am Geriatr Soc
Thinking through the medication list - appropriate prescribing and deprescribing in robust and frail older patients
Aust Fam Phys
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The consensus principles have been endorsed by the International Conference on Frailty and Sarcopenia Research (ICFSR), the European Geriatric Medicine Society (EuGMS), and the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR).
SJL was supported by a postgraduate research scholarship funded by the Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, and the Australian Government Research Training Program Scholarship. SJL and RV were supported by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Frailty and Healthy Ageing. JKS was supported by a NHMRC Early Career Fellowship. AH was supported by a grant from the Pro Humanitate Foundation. ECKT was supported by NHMRC-ARC Dementia Research Development Fellowship. JSB was supported by a NHMRC Boosting Dementia Research Leadership Fellowship.
MC received honorarium from Nestlé for presentations at scientific meetings and held membership on the scientific advisory board. MC also received honorarium from Nutricia for presentations at scientific meetings. SH received a lecture fee from Astellas. RV was on the Clinical Governance Committee of Resthaven Inc. RV undertook consultancy for Nestlé. RV also received honoraria, travel, and accommodation support from Nestlé, Abbott and Nutricia over the past 3 years. JSB received grant income paid to his employer from NHMRC, Australian Government Department of Health, Victorian Government Department of Health and Human Services, Dementia Australia Research Foundation, GlaxoSmithKline and several aged care provider organizations. There are no other conflicts of interest to declare.