Structured medication reviews in frailty

Frailty has a diverse subset of definitions that commonly align with crucial contributory factors. Correlations have been drawn between frailty, increasing age, self-rated health and/or the presence of multimorbidity. While frailty itself is heterogeneous, virtually all patients will fit a definition of frailty at some point in their life, though caution must be taken to avoid ageism and presumptuous healthcare^​1,2​.  

In 2020, the Primary Care Network (PCN) Direct Enhanced Service Specification directed PCNs to identify patients who would benefit from a structured medication review (SMR), with focus on individuals “with severe frailty, who are particularly isolated or housebound or who have had recent hospital admissions and/or falls”^​3​. NHS England uses the electronic Frailty Index (eFI) to identify patients living with frailty, though the Rockwood Frailty Scale is another commonly used tool to support clinical evaluation of this patient group^​4,5​.

The association between frailty and polypharmacy — which usually owes to multimorbidity — demonstrates the highly relevant input of pharmacy and their importance in the management of the frailty paradigm, particularly for targeted interventions in screening inappropriate polypharmacy^​6,7​. Before the list of medicines is considered, pharmacists should undertake holistic assessment during the early stages of the SMR process, to build a detailed clinical picture and allow individually tailored discussions and decisions about medicines.

However, research suggests that in England, between 2021 and 2024, only one-third of those living with severe frailty received a SMR, which indicates that work is needed for pharmacists in primary care to properly support the frail population^​8​.

The ‘Comprehensive geriatric assessment’ (CGA) is a separate process by which patients are holistically reviewed in different care settings, usually involving a multidisciplinary team, comprising pharmacists and pharmacy technicians^​9​. The frailty SMR and the CGA are alike in nature, and each have their place in the healthcare system, with a commonality in their need for pharmacy input. 

This article will provide an overview of the additional considerations that frailty presents in the context of a SMR, including additional observations or actions and how these conversations can be approached with patients and care givers. 

The patient 

The ability of a patient to participate in discussions and decisions about their healthcare can vary considerably. Patient capacity can fluctuate with disease progression, neurologic or psychiatric illness, alcohol or substance misuse, intercurrent illness and/or timing of the day^​10​. The Mental Capacity Act (2005) outlines that capacity should always be assumed until evidence proves otherwise, and this should be ingrained in every pharmacist before they undertake any consultations with patients, even where there is predocumented cognitive disease¹¹. Discussions with patients should be scheduled to maximise patient ability to communicate their needs and, where capacity is diminished, there should be appropriate measures in place to ensure the patient is fairly represented in all decisions about their health and wellbeing^​11​.

The appointment of a ‘lasting power of attorney’ has long been established in healthcare and, in some cases, patients with poor capacity are subject to ‘deprivation of liberty’, which limits a person’s freedom owing to concerns about their safety. In other cases, patients may make ‘advanced decisions’ about their care for when capacity is diminished, which may describe treatments or medical interventions that a patient does not wish to have^​11​. 

To uphold principle 4 of the Mental Capacity Act — “Anything done for or on behalf of a person who lacks mental capacity must be done in their best interests” — it may also be necessary for discussions to take place outside of the SMR process, perhaps as a follow-up where the SMR highlights that decisions around medicines may need to be made on behalf of a patient. These discussions are often entitled ‘best interest meetings’. 

Pharmacists undertaking the SMR process, whereby decisions are being made regarding treatment or medical intervention for patients with diminished capacity, must always consider the circumstances around patient capacity and follow principle 5 of the Mental Capacity Act, by using the “least restrictive option”^​12​.

This is particularly essential when considering covert administration of medicines, or the appropriateness of prescribing psychotropic medicines. Use of psychotropics should only be included as part of an individualised care plan and for when circumstances involve a severe risk of harm to the patient and/or others or involve severe psychologically distressing symptoms. The nature of psychotropic medicines means that they can be used to control a patient’s behaviour or restrain them; to administer without an appropriate care plan would contravene principle 5 of the Mental Capacity Act^​13​. 

The ability to communicate effectively should be carefully observed and documented, since patients may use a variety of media, from verbal to written communication or sign-language, and this can influence how information is shared between healthcare professionals and the patient. Documenting communication needs as part of the review will allow other clinicians to better prepare for future consultations. For instances where patients may lack the ability to communicate clearly despite adjustments, asking questions of those regularly engaged with the patient’s care may allow us to elicit better understanding of the patient for assessment. 

“Are you able to observe physical cues which might indicate pain, hunger or toileting needs?”

Documentation of such cues gives great insight for the wider team, so when assessing the patient, they know to observe for cues or ask carers for changes in behaviour.

Functional ability

When picture-building, the patient’s functional capacity in their environment should also be considered. Since frailty can negatively impact on mobility, fine and gross motor function, cognitive impairment, toileting ability and other prominent daily activities^​14​, the ability of the patient to perform important daily tasks in their place of residence (e.g. at home or in a care home) should be understood, since this could indicate where there is a level of risk and/or a need to refer for social care services input or for occupational therapy assessment. Social care services can assist with multiple aspects of care for patients living with frailty, including telecare for alerts and remote monitoring, and provision of social care in the community^​15​, while referrals to occupational therapists allow for assessment and intervention to enable patients to participate in their daily activities and improve quality of life^​16​. 

“How are you managing to get about at home? Are you managing to wash and dress independently? Do you find yourself needing help?” 

Asking the patient about their mood and general wellbeing may give an indicator as to whether action is needed regarding medicines for mental health or additional non-pharmacological support. Those with psychiatric illness may need to be asked about suicidal thoughts, self-harming behaviours and/or hallucinations. This information may also need to be asked of carers and/or family members. 

“You’ve said you have been feeling quite low recently, can you tell me more about that and how often this has been happening? Has this made you feel different about how you approach each day?”

In instances where there are concerns about patient behaviour, and in cases where capacity fluctuates, it may be necessary to ask carers/relatives to describe patient behaviour in more detail. 

“You’ve told me that Mrs Andrews is often displaying aggressive behaviour, can you tell me more about that and when it occurs. Is there a pattern to these episodes, or a trigger you could identify?” 

In instances where complex psychiatric presentations are a concern, it may be necessary to involve the local mental health services for psychiatrist review. When pharmacists have concluded the SMR and documented outcomes, additional time may be taken to write letters of referral to relevant specialists as indicated during the review.   

Physical assessment 

Patients living with frailty often have additional physical needs and, before considering medicines, questions pertaining to physical assessment will guide pharmacists in both pharmaceutical care and identifying need for multidisciplinary support. 

Nutritional status

Since patient nutrition is a modifiable risk factor for frailty, it is essential to assess for and encourage good nutrition^​17​. Questions about nutritional status will reveal if strategies need to be implemented to promote change. A patient’s isolated current weight can give a general idea of immediate status, but a history of weight recordings can show trends in weight loss or weight gain. This is particularly useful for patients in care settings, since carers can assess whether the nutritional offering is sufficient to meet patient need. 

“Do you feel you are eating well? What do a typical day’s meals look like for you?”

The patient’s weight measurement itself can influence medicines prescribing directly, exemplified in cases, such as dosing of direct oral anticoagulants^​18​. It is important to consider whether the patient may be under the care of the dietitians and whether there are nutritional supplements already being prescribed. If the dietitians are not already involved and it is identified that nutritional intake and/or weight loss is a concern, then a referral may be indicated as part of the SMR process.  

“I can see the most recent weight is 49kg, can I see the pattern of weight in the patient’s charts from the past few months?” 

Additionally, dysphagia (i.e. difficulty in swallowing) can both contribute to, and is a consequential factor of, frailty^​19​. Dysphagia can lead to serious complications, including malnutrition, subsequent weight loss, dehydration and pneumonia^​20​. During the SMR, asking questions about whether the patient has any difficulties in swallowing will offer insight into whether the patient requires adjustment of medicine formulation to assist in safe administration and/or thickeners for fluids. The International Dysphagia Diet Standardisation Initiative (IDDSI) framework describes standard food texture and fluid thickness, by which patients with dysphagia are directed to modify their intake to reduce risk of aspiration^​21,22​.

For example, a patient may be indicated for level five solids, described in the IDDSI framework as “mince and moist”, which may contain lumps that are easy to squash with the tongue and require minimal chewing. The framework also provides a guide for the modification of food to minimise ongoing risk. The speech and language therapists (SALT) team can be referred to for assessment and management^​23​.

Mobilising and transfer

The presence of frailty has been shown as a predictor of falls risk in older people^​24​. There is a strong association between walking ability, frailty and falling, therefore patient mobility and falls history is an essential part of the SMR process^​25​. There are several medicines that can be associated with an increased risk of falling — including benzodiazepines, opioids and antihypertensives^​26​ — so it is important to understand the circumstances around falling, because this can guide decision-making about medicines. Decisions made in favour of continuation of medicines with a recognised risk of falls should be part of a shared decision-making process; risks and benefits should be discussed with patients and/or representatives, while the discussions and outcomes should be clearly documented. 

“Have you found yourself struggling to do things at home? Have you noticed yourself falling?” 

Following the SMR, it may also be appropriate to refer patients for occupational therapy assessment and guidance, since they can provide assistance with exercises to improve functional mobility, advise on measures or equipment to aid in transfer (e.g. from bed to chair) or design novel ways to attend to daily tasks where mobility is prohibitive^​27​. In cases where patients are no longer mobilising out of bed and are laid supine, this may trigger review of medicines. For example, administration of oral bisphosphonates requires ability to maintain an upright posture for 30 minutes to minimise risk of oesophageal reactions, but considerations must be made for the patient’s prognosis, since end-of-life frailty differs from chronic disability and deprescribing bisphosphonates may not always be the appropriate decision^​28,29​.

Continence and toileting

A relationship has been established between chronic constipation and frailty, with the results of a study, published in 2021, demonstrating that an increasing degree of frailty is positively associated with constipation severity^​30​. Other studies have demonstrated that urinary incontinence is twice as prevalent in older people who live with frailty^​31​. Data such as these are useful reminders of the importance of considering a patient’s bowel and bladder function as part of the SMR process. Pharmacists can ask to see the patient’s stool charts in care settings to guide their assessment. Embarrassment around the topic can lead to some discomfort in discussing toileting habits and, as pharmacists develop confidence with consulting, they will learn to build rapport with patients quickly and know how to adapt their use of language appropriately for patient need. Examples of things that could be said include:

“I’m going to need to talk about poo now. I hope that’s OK, since it helps me understand whether your medicines are affecting your bowels opening and then we can decide if we need to do something to help you go to the toilet.” 

“I see that you have been having some ongoing trouble with constipation, and you are prescribed some laxatives — do you feel these are helping? How often are you currently taking them?”

Documenting the use of stoma bags and/or catheter devices, alongside a description of any issues with urinary incontinence and/or constipation or loose bowels, will aid in determining whether interventions need to be made; referrals to local bladder and bowel services may be necessary, or there may be opportunities for deprescribing medicines in use. Since many medicines for overactive bladder are associated with an increased anticholinergic burden, and therefore the risk of developing cognitive impairment or dementia, the SMR may reveal opportunities to reduce or stop these in order to reduce risk^​32​. It may also be prudent to have a person-centred constipation care plan in place in care settings^​33​. 

Skin integrity 

“I can see you have some dry skin there on your legs, do you have any creams that you already use on this?” 

There is an undeniable relationship between ageing and frailty, and ageing is known to cause delayed wound healing and increased risk of skin tears, meaning that asking about patient skin integrity should be considered^{​1,34,35​}. Pressure sores are also a known issue for bed-bound patients and, therefore, skin health is a crucial component of the holistic review process^​36​. It may be necessary to involve the tissue viability team in cases of delayed wound healing, or district nursing teams for regular ulcer assessment and dressing. Many care homes have a skin tear management pathway to assist carers in supporting patient skin safety^​37​.

Social and environmental factors

There are several non-medical factors that can contribute to a frail patient’s overall health and wellbeing. Research suggests that environmental factors can play an important part in advancing frailty, with exercise access, living in clean air, a tobacco-free lifestyle and “maintaining an active role in society” identified as components that have been shown to decrease frailty^​38​. As such, these are topics that may be of relevance to discuss during the SMR. 

“Do you have support from family and friends? Are you managing to do things that you enjoy?” 

Social factors broader than the patient’s environment should also be assessed during the SMR — feeling lonely and a lack of social activity can influence frailty, and pharmacists should also consider if there is a role for social prescribing in these patients^​39,40​.

Conclusion

While the title ‘structured medication review’ directly refers to medicines, the number of factors that must be considered in the review process in patients living with frailty demonstrates that pharmacists should think beyond medicines and move towards a holistic approach. From nutritional status, to mobility, continence and skin integrity, picture building is essential to better understand patients before medicines can be deemed appropriate to either continue or discontinue prescribing. Holistic approaches to the SMR offer opportunities for building multidisciplinary team input into patient care, with the aim of optimising opportunities to support the frail patient and reduce the progression of frailty.