Medication optimization matters with older adults living with frailty
Older adults living with frailty and multiple chronic conditions are often prescribed many medicines, which by design address these conditions individually, but cumulatively may have a negative impact on health outcomes.
This is known as polypharmacy, and it is a serious health concern affecting more than half of Canadians aged 65 years and older. Medications can be essential, but each additional one increases the risk of an adverse drug event (ADE).
Polypharmacy is the number one identifiable risk factor for ADEs and Canada’s 1.1 million frail older adults are especially at risk. The risk of polypharmacy may be underappreciated, as there are few studies of drug interactions in those receiving numerous drugs, and very limited information concerning medications in older adults living with frailty who may have altered drug clearance because of age-related changes.
ADEs are responsible for nearly 27,000 hospital admissions annually in Canada and up to 20% of return visits to the hospital within 30 days of discharge. Many ADEs could be preventable or made better through interventions to reduce inappropriate prescribing. This is called deprescribing, and can be described as safely and intentionally stopping a medication or reducing its dose to improve the person’s health or reduce the risk of adverse side effects.
Deprescribing has been studied extensively in the general medical population, but there is little work in older patients living with frailty and multiple conditions, or those nearing the end of life.
Canadian Frailty Network funded a study by Drs. Todd Lee and Emily McDonald of McGill University Health Centre on this topic, Reducing post-discharge potentially inappropriate medications amongst the elderly.
The investigators created MedSafer, an electronic application, to identify deprescribing opportunities for older patients (aged 65 and older) when hospitalized. The tool cross-references patient conditions with established sources (Beers, STOPP and Choosing Wisely Canada) to flag potentially inappropriate medications (PIM’s).
At the time of hospitalization a patient’s medications and chronic diseases or conditions (often referred to as comorbidities), along with a measure of frailty, are entered into MedSafer. An individualized, prioritized, deprescription plan is generated targeting potentially inappropriate medications using three criteria: likelihood of causing harm; potential to reduce the risk of future illness; and, the potential for a drug to improve symptoms. The plan is then discussed with the patient/caregiver before implementation.
Using MedSafer enables better use of medications in this vulnerable population which can contribute to more effective treatment and better outcomes and potential cost savings from decreased re-admissions.
The findings are a step to incorporating deprescribing as a part of standard care upon discharge from hospital, and ultimately decreasing the burden and cost of potentially inappropriate medications and their associated complications. This could lead to a reduction of several thousand hospitalizations annually across Canada.
The work funded by CFN was a pilot study, developing and testing MedSafer at four sites in Montreal, Toronto and Ottawa, with over 1000, hospitalized older adults living with frailty. The preliminary results from the CFN grant were very promising and led to a $1.67 million CIHR grant over three years to run a national clinical trial using MedSafer in nine hospitals in four provinces.