How Pharmacists Can Help Frail Patients

The number of people age 60 and older will be approximately 2 billion people by 2050.^1,2 Faced with that number, it is imperative that pharmacists and healthcare professionals arm themselves with tools to recognize and address the complexities and healthcare challenges that come with age, including frailty. 

Theoretically, frailty can occur at any age. The significance of frailty in the geriatric population lies not only on the frequency with which it occurs, but also its association with underlying illnesses, and that it is often a precursor to other adverse events in aging patients.

Because standardized and validated screenings to diagnose frailty are lacking, all healthcare providers must educate themselves about frailty. Community pharmacists, in particular, can use their frequent patient contact and accessibility to identify, screen, and refer patients who are frail or at risk for becoming frail. 

What Is Frailty?

A frailty index to screen patients exists, but there is no consensus on how to define or screen for frailty. One definition of frailty is a condition that reduces an individual’s chances of recovering from a traumatic or stressful event.⁴ Unable to return homeostasis or the previous baseline, these stressors put these patients at risk for falls, hospitalizations, disability, delirium, and death.⁵ Physiologically, resilience declines with age, and as the hypothalamus-pituitary-adrenal (HPA) axis begins to fail over time, so does one’s ability to recover from stress.^{5, 6} Furthermore, illness accelerates the aging process, and aging itself compromises one’s ability to recover from stress and return to one’s original functional state.

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According to one study, frail subjects have a mortality risk six times that of non-frail subjects.⁵ The degree to which an individual exhibits signs of frailty may help forecast poor prognosis and the risk for adverse events.

Another clinical definition of frailty is a catch-all that not only refers to gait and muscle tone, but also signs and symptoms associated with mental health, including cognition and social behaviors.^5,7 Under this definition, frailty can be broken down into three categories: physical frailty, cognitive frailty, and psychosocial frailty.⁵

Physical Frailty

A patient who is physically frail has three to five of the following signs and symptoms:

• Fatigue
• Decreased muscle strength
• Slow movement or walking speed
• Decreased physical activity
• Weight loss.⁵

They may also have a shrinking in physical size.⁷ Patients classified as pre-physically frail exhibit one to two of these traits, but the importance of early identification and referral of patients who are pre-frail cannot be understated. Weakness is often the first symptom for pre-frailty, and caught early, can prevent the rapid progression to full-blown physical frailty.

Related article: More Older Patients Have Medication Troubles Than You Think

The earlier patients with signs of frailty can be guided to treatment, the greater the chances of improvement, and reducing the likelihood and/or severity of complications. In some cases, frailty can be reversed. Cognitive Frailty class="text">Cognitive frailty is a more complex category and can be more difficult to identify. Several factors contribute to the potential for misdiagnosis or missed diagnosis: Cognitive frailty often mimics signs of dementia and is best distinguished through biomarker testing for beta-amyloid plaques and neurodegeneration, along with evaluating the patient for signs of cognitive impairment.⁷

Some experts embrace the idea that cognitive frailty, like physical frailty, often emerges because of pre-existing disease states, many of which predominate in older populations, such as heart disease, hypertension, stroke, chronic kidney disease, or viral infectious such as HIV/AIDS and hepatitis C.

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Despite the nebulous definitions, cognitive frailty is important because of its association with physical frailty and its reversibility, unlike dementia, which tends to be irreversible. Like physical frailty, cognitive frailty can also mark poor outcomes.

Psychosocial Frailty

Even less understood and perhaps less studied is psychosocial frailty, which includes decreased or poor social interactions, and which can be the result of the patient’s frustrations with his or her declining physical state. These signs and symptoms may be consequences of societal challenges and manifest as depression, loneliness, anxiety, and reduced social interactions.

As the evidence demonstrating the effect of mental health on the physical body grows, it is important to understand how the isolation caused by being widowed, living alone, or having poor social support can exacerbate the consequences of frailty. The unique relationship community pharmacists form with their patients gives them some special insight into these risk factors that a standard medical evaluation might miss.

Risk Factors to Watch

Because of their frequent and continuing patient contact, community pharmacists have tremendous opportunities to identify certain risk factors for frailty, which can include:

• Gender: Women may have poor nutrition and are more likely to live alone.⁵ Women with lower body mass are at greater risk.
• Low socioeconomic status: This can reduce access to care and to a social environment conducive to receiving care and emotional support.
• Chronic illnesses that can weaken or debilitate the body and mind.
• Neuroendocrine dysfunctions: These can interfere with normal HPA axis activity which can accelerate physical and mental decline by reducing a patient’s ability to recover.
• Certain medications and medication regimens: These may increase the risk of frailty especially for anyone on a complicated medication regimen, subject to polypharmacy, and at risk for prescribing cascades.

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Inpatient and outpatient status also contribute to frailty. As one study points out, historically, frailty was only studied in patients in the hospital or living in nursing homes. This is an important consideration when reviewing literature because patients who are either hospitalized or in long-term care facilities are more likely to be extremely frail. This also further highlights the need for additional studies on frailty, as well the need for healthcare professionals to reach a consensus on how to define it and screen for it.

What Pharmacists Can Do

Pharmacists who suspect a patient is frail or at risk of becoming frail should review the patient’s medication records and identify medications that could amplify the effects of frailty, increase the patient’s fall risk, or escalate cognitive decline. Because patients may use more than one pharmacy, a patient interview might be warranted. Community pharmacists who have frequent contact with patients and their caregivers and/or family members might consider employing tactful discussions to engage those involved in the patient’s care in efforts to prevent falls. Depending on the circumstances, concerns about frailty, declining health, and any associated potential health risks might warrant a call to the patient’s doctor.

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Pharmacists who screen, identify, and refer patients in preliminary stages of frailty will help decrease healthcare costs, improve the patient’s quality of life, and increase patient survival.

References:

• Buckinx F, Rollard Y, Reginster JY, Ricour C, Petermans J, Bruyére O. Burden of frailty in elderly populations: perspectives of a public health challenge. Arch Public Health. 2015;73(1):19. Available at: https://www.nbi.nm.nih.gov/pmc/articles/PMC4392630
• Current Global Population. The Worldometers website. Available at: http://www.worldometers.info/world-population/. Accessed on March 13, 2018.
• https://www.merriam-webster.com/dictionary/frail. Accessed on March 3, 2018.
• Clegg A, Youn J, Illiffe S, Older Rikkert M, Rockwood K. Frailty in older people. Lancet. 2013:381(9868):752-762. DOI: 10.1016/S0140-6736(12)62167-9
• Fried LP, Tangen CM, Waltson J.Fraiilty in older adults: evidence for a phenotype.J Gerontol A Bio Sci Med Sci. 2001:56A(3):M146-M156.
• Gupta D. Morley JE. Hypothalmalmic-pituitary-adrenal (HPA) axis and aging. Comorbid Physiol 2014 Oct;4(4: 1495-510. DOI: 10.1002/cphy.c130049.
• Qingwei R, Zhuouwei Y, Ma C, Zhijun B, Jin L, Wei H. Cognitive frailty, a novel target for the prevention of elderly dependency. Aging Res Rev. 2015(20)1-10DOI: 10.1016/j.arr.2014.12.004.
• Mulasso A, Roppolo M, Giannotta F, Rabaglietti E. Associations of frailty and psychosocial factors with autonomy in daily activities: a cross-sectional study in Itailian community-dwelling older adults. Clin Interv Aging 2016; 11:37-45. DOI:10.2147CIA.S95182.