Meet Mr. Wilson
 
 
rxPassport Pharmacy Newsletter
 
July 2015
 
 
Identifying & Caring for Frail Elders
 
Meet Mr. Wilson
 
Mr. Wilson (87 yo) presents complaining of exhaustion, weakness, dizziness and difficulty doing activities of daily living (ADLs). His daughter says that he has been slowing down, seems confused and has been falling lately, despite the use of a walker.
Ramipril 10mg daily
 
• Atorvastatin 40mg daily
 
Hydrochlorothiazide 12.5mg daily
 
• ASA 81mg daily
 
Amlodipine 10mg daily
 
• Rabeprazole 20mg daily
 
Metformin 500mg BID
 
• Lorazepam 1mg qhs for sleep
 
Glyburide 5mg BID
 
You gather the following information:
 
Blood pressure today: 130/58 mmHg
 
Blood glucose is well controlled ; A1C = 6.7%, with the occasional episode of hypoglycemia
 
Upon further assessment, you identify that Mr. Wilson is moderately frail.
What is Frailty?
 
Frailty is a clinical syndrome that influences an individual’s physiological state in a way that increases their vulnerability to stressors, placing them at a greater risk for adverse health outcomes, such as:1,2,13
 
Recurrent falls
 
New or worsened functional impairment
 
Hospitalization
 
Death
 
Despite many of the misconceptions that exist, not all elderly people are considered frail.
How Can Frailty Be Recognized in Your Patients?
 
The Clinical Frailty Scale
 
The Clinical Frailty Scale can be used to quickly assess frailty in primary care. It acknowledges that frailty is not fixed, but rather it exists along a continuum from very fit to terminally ill.10 Each level of frailty embodies a different level of functioning, cognitive ability and vulnerability that helps determine approaches to care.10
 
Figure 1: Non-modifiable and Modifiable Risk Factors1:
 

*Click to enlarge

 
Objective determination of frailty has been defined using the validated Frailty Phenotype and Frailty Index. These tools are rarely used in clinical practice and mainly used for research purposes.
 
Clinical Practice Tip!
 
Frailty can be assessed at any stage of patient care. As pharmacists, the Clinical Frailty Scale can be used to assess patients in both community and hospital settings to help drive the patient’s care.
 
Why Should Pharmacists Assess Frailty in Patients?
 
Assessment of frailty can help guide the creation of personalized care plans for your patients, with the goal of maximizing the likelihood of achieving positive outcomes.2 This challenges pharmacists to think about the efficacy and safety of interventions in the context of your patients, using their frailty level as a marker of prognostic value.2 Ultimately it comes down to risk versus benefit, and often times for these patients the risk of treatment outweighs the benefit.
Clinicians must recognize that they aren’t withholding care; but rather delivering it in a more patient-centered fashion.2
What Can Pharmacists Do to Help Improve Outcomes in Frail Patients?
 
1. Re-define blood pressure (BP) targets
 
Table 1. CHEP hypertension guideline recommendations for the very elderly (≥80 years old)3
 
The higher treatment target in this population reflects the current evidence in the elderly population and heightened concerns of precipitating adverse effects, such as hypotension, falls, bradycardia, arrhythmias and hyperkalemia, in frail patients if BP is kept too low.3
 
2. Personalize glycemic control in diabetic patients
 
Table 2. Canadian Diabetes Guideline recommendations for frail elderly patients5
 

*depending on the level of frailty as denoted by the Clinical Frailty Scale
 
3. Re-assess the use of statins
 
Table 3. Statin recommendations in the frail elderly7
 

*There may be extenuating circumstances that shift the risk/benefit ratio7
 
Vascular event reduction with statins is not clinically relevant for the majority of frail patients and they may be more susceptible to musculoskeletal adverse effects of statins.7
 
4. Address polypharmacy and complicated regimens
 
Polypharmacy in frail older adults is associated with a variety of negative consequences that can significantly worsen outcomes.9 These include reduced adherence to necessary medications, decline in physical and social function, and increased risks of delirium, falls, hospitalization and death.9
 
Five important things to consider when conducting a medication review on a frail elderly patient:9.
 
1. Remaining life expectancy
 
2. Time until treatment benefit
 
3. Goals of care versus overall risk
 
4. Treatment targets
 
5. Patients thoughts on treatment
 
Use an algorithm to help decide if a medication should be stopped.
 
The Beers Criteria and STOPP are also useful resources for determining medications to eliminate or adjust.
 
Clinical Practice Tip!
 
These drug classes are poorly tolerated in the frail elderly and should be re-assessed:8
Benzodiazepines, zolpidem, zopiclone
 
Antipsychotics
 
Tricyclic antidepressants
 
Anticholinergics
 
Combination analgesics
 
What Should We Do for Mr. Wilson?
 
Many of Mr. Wilson’s current problems could be related to his pharmacotherapy. By actively assessing his frailty level, we were able to determine the following adjustments to ensure he is optimally managed at the lowest possible risk:
Discuss loosening both BP and A1C targets based on his frailty level
 
Blood pressure
 
o Discontinue amlodipine
 
o Recommend ramipril 10mg/hydrochlorothiazide 12.5mg combination tablet to reduce his pill burden and increase adherence
 
o Reassess BP to ensure he is not exceeding his new target
 
Glycemic control
 
o Discontinue glyburide and assess A1C in 3 months to see if below the A1C target of ≤ 8.5%
 
Vascular protection
 
o Discontinue atorvastatin
 
o Discontinue ASA. The benefits do not outweigh the risks
 
Other therapies
 
o Taper lorazepam to discontinue. Benzodiazepines should not be used chronically in the elderly. Counsel on sleep hygiene measures instead
 
o Discontinue rabeprazole. The risks of fractures with PPI’s in the elderly likely outweigh the benefits. NPS Medicinewise has reviewed the risk of PPI’s in older people
 
 
Pharmacists are encouraged to prioritize any changes with the patient and/or caregiver. Minor changes to a frail patient’s regimen can lead to significant improvement. By actively assessing a patient’s frailty and working with the patient and their prescriber, pharmacists can reduce a patient’s risk and improve their overall quality of life.
 
 
Cassandra Turchet
 
By Cassandra Turchet, PharmD Student
 
With appreciation to Mike Boivin, B. Pharm.
 
In this issue
 
What is Frailty?
 
How Can Frailty Be Recognized in Your Patients?
 
Why Should Pharmacists Assess Frailty in Patients?
 
What Can Pharmacists Do to Help Improve Outcomes in Frail Patients?
 
Back to the Case: What Should We Do for Mr. Wilson?
 
References
 
Pharmacy Student Blog
 
References
 
1. Boockvar, K.S. & Meier, D.E. Palliative care for frail older adults. “There are things I can’t do anymore that I wish I could” JAMA 2006; 296(18): 2245-2253.
 
2. Afilalo, J. et al. (2014). Frailty assessment in the cardiovascular care of older adults. Journal of the American College of Cardiology 2014; 63 (8): 747-762.
 
3. Houle, S.KD. et al. The 2014 Canadian Hypertension Education Program (CHEP) guidelines for pharmacists: an update. Can Phar, J 2014; 147(4): 203-208.
 
4. DiWang & Lam-Antoniades, M. Challenges of hypertension management in the frail very elderly with multiple co-morbidities. CGS Journal of CME 2013; 3(1): 5-7.
 
5. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212.
 
6. Fried, L.P. et al. Frailty in older adults: evidence for a phenotype. Journal of Gerontology 2001; 56(3): M146-M156.
 
7. Treating hyperlipidemia in severe and very severe frailty (n.d). Retrieved from: View Source
 
8. All Wales Medicines Strategy Group. (2014). Polypharmacy: Guidance for prescribing. Retrieved from: View Source
 
9. Yong, T.Y. & Khow, K.SF. Prescribing appropriately in frail older people. Healthy Aging Research 2014; 21(4): 1-12.
 
10. Walston, J. et al. Research agenda for frailty in older adults: Toward a better understanding of physiology and etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. Journal of American Geriatrics Society 2006; 54(6): 991-1001.
 
11. Li-Xue, Q. The frailty syndrome: definition and natural history. Clin Geriatr Med 2012; 27(1): 1-15.
 
12. Rockwood, K. et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173(5): 489-495.
 
13. Lally, F. & Crome, P. Understanding frailty. Postgrad Med J 2007; 83(975); 16-20
 
 
 
 
© 2015 mdBriefCase Group Inc. 90 Eglinton Ave East, Suite 504, Toronto ON M4P 2Y3.
 
About Us | Privacy Policy | If you have any other questions, please email us.
Follow us on twitter