Special Article
Medication Management in Frail Older People: Consensus Principles for Clinical Practice, Research, and Education

https://doi.org/10.1016/j.jamda.2020.05.004Get rights and content

Abstract

Frailty is a geriatric condition associated with increased vulnerability to adverse drug events and medication-related harm. Existing clinical practice guidelines rarely provide medication management recommendations specific to frail older people. This report presents international consensus principles, generated by the Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network, related to medication management in frail older people. This consensus comprises 7 principles for clinical practice, 6 principles for research, and 4 principles for education. Principles for clinical practice include (1) perform medication reconciliation and maintain an up-to-date medication list; (2) assess and plan based on individual's capacity to self-manage medications; (3) ensure appropriate prescribing and deprescribing; (4) simplify medication regimens when appropriate to reduce unnecessary burden; (5) be alert to the contribution of medications to geriatric syndromes; (6) regularly review medication regimens to align with changing goals of care; and (7) facilitate multidisciplinary communication among patients, caregivers, and healthcare teams. Principles for research include (1) include frail older people in randomized controlled trials; (2) consider frailty status as an effect modifier; (3) ensure collection and reporting of outcome measures important in frailty; (4) assess impact of frailty on pharmacokinetics and pharmacodynamics; (5) encourage frailty research in under-researched settings; and (6) utilize routinely collected linked health data. Principles for education include (1) provide undergraduate and postgraduate education on frailty; (2) minimize low-value care related to medication management; (3) improve health and medication literacy; and (4) incorporate evidence in relation to frailty into clinical practice guidelines. These principles for clinical practice, research and education highlight different considerations for optimizing medication management in frail older people. These principles can be used in conjunction with existing best practice guidelines to help achieve optimal health outcomes for this vulnerable population. Implementation of the principles will require multidisciplinary collaboration between healthcare professionals, researchers, educators, organizational leaders, and policymakers.

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

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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.

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