New NHSGGC Guideline - Polypharmacy Review in Adults living with Moderate to Severe Frailty
Key Messages:
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Polypharmacy guidance can be used by all healthcare professionals to improve patient care
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Pay particular attention to high risk medicines such as anticholinergics, antipsychotics and benzodiazepines as well as any medicine linked to falls
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Frailty can cause loss of function (including falls and confusion) and can be improved by early identification and polypharmacy medication review
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Rockwood Clinical Frailty Scale (CFS) is a tool that can be used to identify/score level of frailty in those over 65 years
Frailty
Frailty is a reduced ability to withstand illness without loss of function and should be regarded as a long-term condition. It is associated with a host of symptoms; weakness, lethargy, weight loss, falls, confusion and incontinence. As well as being linked to loss of function it can also lead to hospitalisation, care home admission and mortality. Although frailty can be age associated, it is not an inevitable part of ageing. Importantly, it is a dynamic, modifiable and preventable state.
It is well recognised that timely identification of frailty and medication review are key components of improving frailty. There are a number of tools to identify and assess level of frailty. The Rockwood CFS is one of the validated tools that can be used by healthcare professionals in all settings to identify and assess level of frailty. Teams can learn more about using the CFS with this online learning module CFS Training. There is also a useful app available to make it easier to carry out frailty assessments with patients available here.
NHSGGC Polypharmacy Guideline
The NHSGGC guideline available here provides advice on prescribing and de-prescribing of medicines in patients living with moderate to severe frailty. It is relevant to all healthcare professionals in all settings and may be particularly relevant (but not limited to) those treating older adults in community, care home and hospital settings. It supports the REALISTIC MEDICINE agenda. More information on REALISTIC MEDICINE can be found here and if you would like to become a champion within NHSGGC contact Judith.Marshall@nhs.scot.
There are useful tables within the polypharmacy guideline arranged by BNF category and they are referenced throughout so that healthcare professionals can refer to the original reference source. Please see full guideline for information to aid clinical decision making in relation to medicines for GI, CV, CNS, Respiratory and Endocrine conditions. Certain drug classes, individual medications and combinations of medicines confer greater risk for frail patients than the general adult population. Any medicine which can cause sedation, hypotension or hypoglycaemia can increase falls risk. Medicines which contribute to anticholinergic burden (antihistamines, antispasmodics, tricyclic antidepressants) can increase the risk of adverse effects such as postural hypotension, urinary retention, constipation, dry mouth as well as causing and worsening of cognitive impairment.
There should however be a focus on an individualised approach and careful consideration of the risk of continuing a medicine versus the risk of stopping. The Scottish Government National Polypharmacy Guidance here describes a 7 step approach and in step 2 highlights medicines that may need to be continued to prevent rapid symptomatic decline eg. Parkinson’s Disease, Heart Failure, Epilepsy.
Links to other blogs in the polypharmacy series:
Polypharmacy Review in Adults living with Moderate to Severe Frailty - Falls
Published: 24/01/2023. Links updated 04/10/2023. Medicines Update blogs are correct at the time of publishing.