Links Between Polypharmacy, Clinical Frailty Seen in UK Critical Care Admissions

Identifying patients with combined polypharmacy and frailty can help recognize ICU patients with high risk of hospital readmission, the authors said.

Polypharmacy and frailty are very common among older emergency critical care patients in the United Kingdom, according to a study published in European Journal of Hospital Pharmacy.

The study also found an association between the degree of polypharmacy and the patient Clinical Frailty Scale (CFS), a 7-point scale that measures fitness from 1 (very fit) to 7 (severely frail).

The authors said they conducted the study because not much is known about certain aspects of polypharmacy as it relates to clinical frailty in patients admitted to critical care units, where additional medication is typically what they receive, or about the impact of polypharmacy and frailty on care pathways at discharge.

This retrospective single-center study evaluated 762 patients aged 70 years and older who were admitted as emergencies to the general critical care units of a UK academic hospital. The study covered a 2-year period from March 2016 to February 2018.

At the time of admission, CFS and current medications were recorded. At admission, a little more than 80% of patients had a degree of polypharmacy (5 medications or more); hyperpolypharmacy (10 medications or more) was seen in 43.2% of the patients.

Overall, patients were taking a median of 9 medicines at admission, of which a median of 3 were high-risk medicines, and there was a significant increase at discharge compared with the preadmission period.

In addition, the median CFS was 4, with 45.7% of patients classified as “vulnerable to mildly frail,” while 20% were identified as “moderately to severely frail,” with a CFS score of 6 or 7.

There were statistically significant differences in median CFS among the polypharmacy groups (no polypharmacy, polypharmacy, and hyperpolypharmacy), with median CFS increasing by 1 as the polypharmacy category changed.

A representative sample of 77 patients from the cohort were followed up to hospital discharge to analyze any medication changes and documentation of care transitions. There were no significant differences in polypharmacy at admission. However, most patients discharged from critical care lacked detailed care documentation compared with patients discharged from the hospital. Overall, however, most patients were not provided with detailed care plans at discharge.

In addition, patients discharged from clinical care left with significantly more new medicines and fewer discontinued medicines compared with patients discharged from the hospital.

The extent of medicine changes after critical care and hospital stay were notable. Older patients admitted to critical care taking a median of 9 medicines had a median of 6 changes to their medication at discharge, compared with 5 drug changes on hospital discharge.

A greater understanding of the issues raised by frailty and polypharmacy or hyperpolypharmacy can help patients, their families, and medical staff understand the associated risks, said the authors, noting that hyperpolypharmacy can predict functional decline and is linked with an increase in unplanned hospital admissions.

“The acute hospital admission created extensive changes in patients medication therapy and documentation of these changes was often inadequately detailed at transitions in care,” the study authors concluded. “More work is required to understand the risks this presents to ongoing patient care and healthcare resource utilisation, to then inform need for targeted interventions.”

Reference

Bourne RS, Ioannides CP, Gillies CS, Bull KM, O Turton EC, Bryden DC. Clinical frailty and polypharmacy in older emergency critical care patients: a single-centre retrospective case series. Eur J Hosp Pharm. Published online June 2, 2021. doi:10.1136/ejhpharm-2020-002618