Skip to main content

Advertisement

SpringerLink
Log in

Relationship between frailty, polypharmacy, and underprescription in older adults living in nursing homes

  • Pharmacoepidemiology and Prescription
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Purpose

Frailty, polypharmacy, and underprescription are considered a major matter of concern in nursing homes, but the possible relationships between them are not well known. The aim is to examine the possible association between medication underprescription, polypharmacy, and frailty in older people living in nursing homes.

Methods

A cross-sectional analysis from a concurrent cohort study, including 110 subjects ≥ 65 years living in two nursing homes. Four frailty scales were applied; polypharmacy was defined as ≥ 5 medications and underprescription was measured with Screening Tool to Alert to Right Treatment (START) criteria. Logistic regression models were performed to assess the associations.

Results

The mean age was 86.3 years (SD 7.3) and 71.8% were female. 73.6% of subjects took ≥ 5 chronic medications and 60.9% met one or more START criteria. The non-frail participants took more medications than the frail subjects according to the imputated frailty Fried criteria (8.1 vs 6.7, p = 0.042) and the FRAIL-NH scale (7.8 vs 6.8, p = 0.026). Multivariate analyses did not find an association between frailty and polypharmacy. Frail participants according to the Fried criteria met a higher number of START criteria (1.9 vs 1.0, p = 0.017), and had a higher prevalence of underprescription (87.5 vs 50.0%), reaching the limit of statistical significance in multivariate analysis.

Conclusion

The positive association found in previous studies between frailty and polypharmacy cannot be extrapolated to institutionalized populations. There is a trend towards higher rates of underprescription in frail subjects. Underprescription in frail older adults should be redefined and new strategies to measure it should be developed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K (2013) Frailty in elderly people. Lancet 381(9868):752–762. https://doi.org/10.1016/S0140-6736(12)62167-9

    Article  PubMed  Google Scholar 

  2. Rodríguez-Mañas L, Féart C, Mann G, Viña J, Chatterji S, Chodzko-Zajko W, Gonzalez-Colaço Harmand M, Bergman H, Carcaillon L, Nicholson C, Scuteri A, Sinclair A, Pelaez M, Van der Cammen T, Beland F, Bickenbach J, Delamarche P, Ferrucci L, Fried LP, Gutiérrez-Robledo LM, Rockwood K, Rodríguez Artalejo F, Serviddio G, Vega E, 1) F-CgA (2013) Searching for an operational definition of frailty: a Delphi method based consensus statement: the frailty operative definition-consensus conference project. J Gerontol A Biol Sci Med Sci 68(1):62–67. https://doi.org/10.1093/gerona/gls119

    Article  PubMed  Google Scholar 

  3. Luo H, Lum TYS, Wong GHY, Kwan JSK, Tang JYM, Chi I (2015) Predicting adverse health outcomes in nursing homes: a 9-year longitudinal study and development of the FRAIL-Minimum Data Set (MDS) Quick Screening Tool. J Am Med Dir Assoc 16(12):1042–1047. https://doi.org/10.1016/j.jamda.2015.09.006

    Article  PubMed  Google Scholar 

  4. Kojima G (2016) Frailty as a predictor of nursing home placement among community-dwelling older adults: a systematic review and meta-analysis. J Geriatr Phys Ther 41:42–48. https://doi.org/10.1519/JPT.0000000000000097

    Article  Google Scholar 

  5. Buckinx F, Reginster JY, Petermans J, Croisier JL, Beaudart C, Brunois T, Bruyère O (2016) Relationship between frailty, physical performance and quality of life among nursing home residents: the SENIOR cohort. Aging Clin Exp Res 28(6):1149–1157. https://doi.org/10.1007/s40520-016-0616-4

    Article  PubMed  CAS  Google Scholar 

  6. de la Rica-Escuín M, González-Vaca J, Varela-Pérez R, Arjonilla-García MD, Silva-Iglesias M, Oliver-Carbonell JL, Abizanda P (2014) Frailty and mortality or incident disability in institutionalized older adults: the FINAL study. Maturitas 78(4):329–334. https://doi.org/10.1016/j.maturitas.2014.05.022

    Article  PubMed  Google Scholar 

  7. Veronese N, Stubbs B, Noale M, Solmi M, Pilotto A, Vaona A, Demurtas J, Mueller C, Huntley J, Crepaldi G, Maggi S (2017) Polypharmacy is associated with higher frailty risk in older people: an 8-year longitudinal cohort study. J Am Med Dir Assoc 18(7):624–628. https://doi.org/10.1016/j.jamda.2017.02.009

    Article  PubMed  PubMed Central  Google Scholar 

  8. Saum KU, Schottker B, Meid AD, Holleczek B, Haefeli WE, Hauer K, Brenner H (2017) Is polypharmacy associated with frailty in older people? Results from the ESTHER Cohort Study. J Am Geriatr Soc 65(2):e27–e32. https://doi.org/10.1111/jgs.14718

    Article  PubMed  Google Scholar 

  9. Merchant RA, Chen MZ, Tan LWL, Lim MY, Ho HK, van Dam RM (2017) Singapore Healthy Older People Everyday (HOPE) Study: prevalence of frailty and associated factors in older adults. J Am Med Dir Assoc 18(8):734.e739–734.e714. https://doi.org/10.1016/j.jamda.2017.04.020

    Article  Google Scholar 

  10. Maher RL, Hanlon J, Hajjar ER (2014) Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf 13(1):57–65. https://doi.org/10.1517/14740338.2013.827660

    Article  PubMed  Google Scholar 

  11. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D (2008) STOPP (Screening Tool of Older person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 46(2):72–83

    Article  PubMed  CAS  Google Scholar 

  12. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P (2015) STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 44(2):213–218. https://doi.org/10.1093/ageing/afu145

    Article  PubMed  Google Scholar 

  13. Kojima G (2015) Prevalence of frailty in nursing homes: a systematic review and meta-analysis. J Am Med Dir Assoc 16(11):940–945. https://doi.org/10.1016/j.jamda.2015.06.025

    Article  PubMed  Google Scholar 

  14. Cherubini A, Corsonello A, Lattanzio F (2016) Polypharmacy in nursing home residents: what is the way forward? J Am Med Dir Assoc 17(1):4–6. https://doi.org/10.1016/j.jamda.2015.07.008

    Article  PubMed  Google Scholar 

  15. García-Gollarte F, Baleriola-Júlvez J, Ferrero-López I, Cruz-Jentoft AJ (2012) Inappropriate drug prescription at nursing home admission. J Am Med Dir Assoc 13(1):83.e89–83.e15. https://doi.org/10.1016/j.jamda.2011.02.009

    Article  Google Scholar 

  16. Kuijpers MA, van Marum RJ, Egberts AC, Jansen PA, Group OS (2008) Relationship between polypharmacy and underprescribing. Br J Clin Pharmacol 65(1):130–133. https://doi.org/10.1111/j.0306-5251.2007.02961.x

    Article  PubMed  Google Scholar 

  17. Meid AD, Quinzler R, Freigofas J, Saum KU, Schottker B, Holleczek B, Heider D, Konig HH, Brenner H, Haefeli WE (2015) Medication underuse in aging outpatients with cardiovascular disease: prevalence, determinants, and outcomes in a prospective cohort study. PLoS One 10(8):e0136339. https://doi.org/10.1371/journal.pone.0136339

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  18. Lefebvre MC, St-Onge M, Glazer-Cavanagh M, Bell L, Kha Nguyen JN, Viet-Quoc Nguyen P, Tannenbaum C (2016) The effect of bleeding risk and frailty status on anticoagulation patterns in octogenarians with atrial fibrillation: the FRAIL-AF study. Can J Cardiol 32(2):169–176. https://doi.org/10.1016/j.cjca.2015.05.012

    Article  PubMed  Google Scholar 

  19. Perera V, Bajorek BV, Matthews S, Hilmer SN (2009) The impact of frailty on the utilisation of antithrombotic therapy in older patients with atrial fibrillation. Age Ageing 38(2):156–162. https://doi.org/10.1093/ageing/afn293

    Article  PubMed  Google Scholar 

  20. Martínez-Velilla N, Herce PA, Herrero ÁC, Gutiérrez-Valencia M, Sáez de Asteasu ML, Mateos AS, Zubillaga AC, Beroiz BI, Jiménez AG, Izquierdo M (2017) Heterogeneity of different tools for detecting the prevalence of frailty in nursing homes: feasibility and meaning of different approaches. J Am Med Dir Assoc 18(10):898.e891–898.e898. https://doi.org/10.1016/j.jamda.2017.06.016

    Article  Google Scholar 

  21. Mahoney FI, Barthel DW (1965) Functional evaluation: the Barthel index. Md State Med J 14:61–65

    PubMed  CAS  Google Scholar 

  22. Salva A, Coll-Planas L, Bruce S, De Groot L, Andrieu S, Abellan G, Vellas B, Bartorelli L, Berner YN, Corman B, Domingo A, Egger TP, de Groot L, Guigoz Y, Imedio A, Planas M, Porras C, Rovira JC, Salvà A, Serra JA, Task Force on Nutrition and Ageing of the IAGG and the IANA (2009) Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA. J Nutr Health Aging 13(6):475–483

  23. Lobo A, Ezquerra J, Gómez-Burgada F, Sala J, Seva-Díaz A (1979) El Mini-Examen Cognoscitivo: Un test sencillo y práctico para detectar alteraciones intelectuales en pacientes médicos. Actas Luso-Esp Neurol Psiquiatr 7:189e202 189–202

    Google Scholar 

  24. Martínez de la Iglesia J, Onís Vilches M, Dueñas Herrero R, Aguado Taberné C, Albert Colomer C, Luque Luque R (2002) Versión española del cuestionario de Yesavage abreviado (GDS) para el cribado de depresión en mayores de 65 años: Adaptación y validación. Medifam 12(10):26-40 http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1131-57682002001000003&lng=es. 

  25. Martínez-Velilla N, Cambra-Contin K, Ibáñez-Beroiz B (2014) Comorbidity and prognostic indices do not improve the 5-year mortality prediction of components of comprehensive geriatric assessment in hospitalized older patients. BMC Geriatr 14:64. https://doi.org/10.1186/1471-2318-14-64

    Article  PubMed  PubMed Central  Google Scholar 

  26. WHO (2018) Collaborating Centre for Drug Statistics Methodology. ATC/DDD Index. https://www.whocc.no/atc_ddd_index/ Accessed 18 February 2018

  27. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE (2017) What is polypharmacy? A systematic review of definitions. BMC Geriatr 17(1):230. https://doi.org/10.1186/s12877-017-0621-2

    Article  PubMed  PubMed Central  Google Scholar 

  28. Jokanovic N, Tan EC, Dooley MJ, Kirkpatrick CM, Bell JS (2015) Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review. J Am Med Dir Assoc 16(6):535.e531–535.e512. https://doi.org/10.1016/j.jamda.2015.03.003

    Article  Google Scholar 

  29. Bonaga B, Sánchez-Jurado PM, Martínez-Reig M, Ariza G, Rodríguez-Mañas L, Gnjidic D, Salvador T, Abizanda P (2017) Frailty, polypharmacy, and health outcomes in older adults: the frailty and dependence in Albacete study. J Am Med Dir Assoc 19:46–52. https://doi.org/10.1016/j.jamda.2017.07.008

    Article  PubMed  Google Scholar 

  30. Thai M, Hilmer S, Pearson SA, Reeve E, Gnjidic D (2015) Prevalence of potential and clinically relevant statin-drug interactions in frail and robust older inpatients. Drugs Aging 32(10):849–856. https://doi.org/10.1007/s40266-015-0302-9

    Article  PubMed  CAS  Google Scholar 

  31. Ballew SH, Chen Y, Daya NR, Godino JG, Windham BG, McAdams-DeMarco M, Coresh J, Selvin E, Grams ME (2017) Frailty, kidney function, and polypharmacy: the atherosclerosis risk in communities (ARIC) study. Am J Kidney Dis 69(2):228–236. https://doi.org/10.1053/j.ajkd.2016.08.034

    Article  PubMed  Google Scholar 

  32. Bennett A, Gnjidic D, Gillett M, Carroll P, Matthews S, Johnell K, Fastbom J, Hilmer S (2014) Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: a prospective cohort study. Drugs Aging 31(3):225–232. https://doi.org/10.1007/s40266-013-0151-3

    Article  PubMed  Google Scholar 

  33. Herr M, Robine JM, Pinot J, Arvieu JJ, Ankri J (2015) Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people. Pharmacoepidemiol Drug Saf 24(6):637–646. https://doi.org/10.1002/pds.3772

    Article  PubMed  Google Scholar 

  34. Hasan SS, Kow CS, Verma RK, Ahmed SI, Mittal P, Chong DWK (2017) An evaluation of medication appropriateness and frailty among residents of aged care homes in Malaysia: a cross-sectional study. Medicine 96(35):e7929. https://doi.org/10.1097/md.0000000000007929

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kelly A, Conell-Price J, Covinsky K, Cenzer IS, Chang A, Boscardin WJ, Smith AK (2010) Length of stay for older adults residing in nursing homes at the end of life. J Am Geriatr Soc 58(9):1701–1706. https://doi.org/10.1111/j.1532-5415.2010.03005.x

    Article  PubMed  PubMed Central  Google Scholar 

  36. Cullinan S, O’Mahony D, O’Sullivan D, Byrne S (2016) Use of a frailty index to identify potentially inappropriate prescribing and adverse drug reaction risks in older patients. Age Ageing 45(1):115–120. https://doi.org/10.1093/ageing/afv166

    Article  PubMed  Google Scholar 

  37. Poudel A, Peel NM, Nissen LM, Mitchell CA, Gray LC, Hubbard RE (2016) Adverse outcomes in relation to polypharmacy in robust and frail older hospital patients. J Am Med Dir Assoc 17(8):767.e769–767.e713. https://doi.org/10.1016/j.jamda.2016.05.017

    Article  Google Scholar 

  38. Lang PO, Hasso Y, Dramé M, Vogt-Ferrier N, Prudent M, Gold G, Michel JP (2010) Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities. Age Ageing 39(3):373–381. https://doi.org/10.1093/ageing/afq031

    Article  PubMed  Google Scholar 

  39. Parsons C, Lapane K, Kerse N, Hughes C (2011) Prescribing for older people in nursing homes: a review of the key issues. Int J Older People Nursing 6(1):45–54. https://doi.org/10.1111/j.1748-3743.2010.00264.x

    Article  Google Scholar 

  40. Sloane PD, Gruber-Baldini AL, Zimmerman S, Roth M, Watson L, Boustani M, Magaziner J, Hebel JR (2004) Medication undertreatment in assisted living settings. Arch Intern Med 164(18):2031–2037. https://doi.org/10.1001/archinte.164.18.2031

    Article  PubMed  Google Scholar 

  41. Romero-Ortuno R, O’Shea D (2013) Fitness and frailty: opposite ends of a challenging continuum! Will the end of age discrimination make frailty assessments an imperative? Age Ageing 42(3):279–280. https://doi.org/10.1093/ageing/afs189

    Article  PubMed  Google Scholar 

  42. van den Heuvel PM, Los M, van Marum RJ, Jansen PA (2011) Polypharmacy and underprescribing in older adults: rational underprescribing by general practitioners. J Am Geriatr Soc 59(9):1750–1752. https://doi.org/10.1111/j.1532-5415.2011.03548.x

    Article  PubMed  Google Scholar 

  43. Lozano-Montoya I, Velez-Diaz-Pallares M, Delgado-Silveira E, Montero-Errasquin B, Cruz Jentoft AJ (2015) Potentially inappropriate prescribing detected by STOPP-START criteria: are they really inappropriate? Age Ageing 44:861–866. https://doi.org/10.1093/ageing/afv079

    Article  PubMed  Google Scholar 

  44. Lang P, Petrovic M, Dalleur O, Ferahta N, Benetos A, Boland B (2016) The exercise in applying STOPP/START.v2 in vulnerable very old patients: towards patient tailored prescribing. Eur Geriatric Med 7(2):176–179. https://doi.org/10.1016/j.eurger.2015.12.013

    Article  Google Scholar 

  45. Gill TM, Gahbauer EA, Allore HG, Han L (2006) Transitions between frailty states among community-living older persons. Arch Intern Med 166(4):418–423. https://doi.org/10.1001/archinte.166.4.418

    Article  PubMed  Google Scholar 

  46. Hubbard RE, O’Mahony MS, Woodhouse KW (2013) Medication prescribing in frail older people. Eur J Clin Pharmacol 69(3):319–326. https://doi.org/10.1007/s00228-012-1387-2

    Article  PubMed  Google Scholar 

  47. Sinclair A, Abdelhafiz A, Dunning T, Izquierdo M, Rodriguez Manas L, Bourdel-Marchasson I, Morley J, Munshi M, Woo J, Vellas B (2017) An International Position Statement on the Management of Frailty in Diabetes Mellitus: Summary of Recommendations. J Frailty Aging. https://doi.org/10.14283/jfa.2017.39

  48. Lavan AH, Gallagher P, Parsons C, O’Mahony D (2017) STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age Ageing 46(4):600–607. https://doi.org/10.1093/ageing/afx005

    Article  PubMed  Google Scholar 

  49. Caballero-Mora MA, Rodriguez-Mañas L (2017) STOPPFrail: a misleading name for a potentially useful tool. Age Ageing 46(5):874–875. https://doi.org/10.1093/ageing/afx139

    Article  PubMed  CAS  Google Scholar 

Download references

Funding

This project has been funded by the TransPyrenean Biomedical Research Network (REFBIO) for the establishment of a network of stable collaboration among biomedical research centers in the Pyrenees Area (European Program INTERREG IV POCTEFA-A; REFBIO13/BIOD/002). The funder had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

Author information

Authors and Affiliations

  1. Department of Geriatrics, Complejo Hospitalario de Navarra, C/Irunlarrea 3, 31008, Pamplona, Spain

    Marta Gutiérrez-Valencia, Itxaso Marín-Epelde, María Fernanda Ramón-Espinoza, Thamara Domene-Domene, Álvaro Casas-Herrero & Nicolás Martínez-Velilla

  2. IdiSNa, Navarra Institute for Health Research, Pamplona, Navarra, Spain

    Marta Gutiérrez-Valencia, Álvaro Casas-Herrero & Nicolás Martínez-Velilla

  3. Health Science Department, Public University of Navarra, Pamplona, Navarra, Spain

    Mikel Izquierdo

  4. CIBER of Frailty and Healthy Aging, Madrid, Spain

    Mikel Izquierdo & Nicolás Martínez-Velilla

  5. Pharmacy Department, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain

    Esther Lacalle-Fabo

  6. Navarrabiomed-Departamento de Salud-UPNA, Pamplona, Spain

    Arkaitz Galbete

  7. Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain

    Arkaitz Galbete

Authors
  1. Marta Gutiérrez-Valencia
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mikel Izquierdo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Esther Lacalle-Fabo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Itxaso Marín-Epelde
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. María Fernanda Ramón-Espinoza
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Thamara Domene-Domene
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Álvaro Casas-Herrero
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Arkaitz Galbete
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Nicolás Martínez-Velilla
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Gutiérrez-Valencia M and Martínez-Velilla N have contributed to conception and design, acquisition, analysis and interpretation of data, drafting the article, and final approval of the version to be published. Izquierdo M, Lacalle-Fabo E, Marín-Epelde I, Ramón-Espinoza MF, Domene-Domene T, Casas Herrero Á, and Galbete A have contributed to conception and design, analysis and interpretation of data, revising the text, and final approval of the version to be published.

Corresponding author

Correspondence to Marta Gutiérrez-Valencia.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Electronic supplementary material

ESM 1

(DOC 23 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gutiérrez-Valencia, M., Izquierdo, M., Lacalle-Fabo, E. et al. Relationship between frailty, polypharmacy, and underprescription in older adults living in nursing homes. Eur J Clin Pharmacol 74, 961–970 (2018). https://doi.org/10.1007/s00228-018-2452-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00228-018-2452-2

Keywords

Search

Navigation