Prescribing appropriately in frail older people

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Abstract

Frailty is one of the most important aspects associated with the elderly. It is defined as a state of increased vulnerability to poor resolution of homeostasis after a stressor event, which increases the risk of adverse outcomes such as falls, institutionalization and death. Frail older adults are more likely to have several concurrent disorders, requiring multiple treatments and hence, considerable medication consumption. The functional reserve of multiple organs deteriorates with ageing and this often leads to changes in drug pharmacokinetics and metabolism. As a result, prescribing medications for frail older people is often complex and challenging. Furthermore, there is a paucity of evidence from clinical trials on the effects of multiple drug consumption in patients aged above 80 years since people from this age group tend to be excluded from such studies. Because of the changes in the pharmacokinetics and pharmacodynamics of drugs in older people, especially in those who are frail, there is an increased risk of adverse drug events for these patients, which can result in hospitalization, increased morbidity and mortality. In this review, appropriate prescribing for frail older people is explored. Consideration will be given to the impact of frailty on medication prescribing and how individualized prescribing could reduce the risk of adverse drug events in at-risk older patients. Tools used to enhance prescribing practice are examined, including those aimed at reducing polypharmacy, underprescribing and inappropriate prescribing. These tools use either explicit (criterion-based) or implicit (judgment-based) criteria. However, most of the current therapeutic guidelines are applicable mainly for the fit older population and cannot be directly applied where frail individuals are concerned. Approaches to improving appropriate prescribing among frail elderly patients, including those with limited life expectancy, are also reviewed.

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