OBJECTIVES Older people approaching end of life are commonly prescribed multiple medications, many of which may be inappropriate or futile. Our objective was to examine the effect of applying the STOPPFrail, a recently developed deprescribing tool, to the medication regimens of older patients with advanced frailty. DESIGN Randomized controlled trial. SETTING Two acute hospitals in Ireland. PARTICIPANTS Adults 75 years or older (n = 130) with advanced frailty and polypharmacy (five or more drugs), transferring to long‐term nursing home care. INTERVENTION A STOPPFrail‐guided deprescribing plan was presented to attending physicians who judged whether or not to implement recommended medication changes. MEASUREMENTS The primary outcome was the change in the number of regular medications at 3 months. Secondary outcomes included unscheduled hospital presentations, falls, quality of life, monthly medication costs, and mortality. RESULTS Intervention (n = 65) and control group (n = 65) participants were prescribed a mean (plus or minus standard deviation [SD]) of 11.5 (±3.0) and 10.9 (±3.5) medications, respectively, at baseline. The mean (SD) change in the number of medications at 3 months was −2.6 (±2.73) in the intervention group and −.36 (±2.60) in the control group (mean difference = 2.25 ± .54; 95% confidence interval [CI] = 1.18‐3.32; P < .001). The mean change in monthly medication cost was –$74.97 (±$148.32) in the intervention group and –$13.22 (±$110.40) in the control group (mean difference $61.74 ± $26.60; 95% CI = 8.95‐114.53; P = .02). No significant differences were found between groups for any of the other secondary outcomes. CONCLUSION STOPPFrail‐guided deprescribing significantly reduced polypharmacy and medication costs in frail older people. No significant differences between groups were observed with regard to falls, hospital presentations, quality of life, and mortality, although the trial was likely underpowered to detect differences in these outcomes. J Am Geriatr Soc 68:762–769, 2020

Frail older adults commonly experience multiple co-morbid illnesses and other risk factors for potentially inappropriate prescribing. However, determination of frailty varies depending on the frailty instrument used. Older people's degree of frailty often influences their care and treatment priorities. Research investigating the association between frailty and potentially inappropriate prescribing is hindered by a wide variety of frailty definitions and measurement tools. We undertook a narrative review of selected articles of PubMed and Google Scholar databases. Articles were selected on the basis of relevance to the core themes of frailty and potentially inappropriate prescribing. We identified observational studies that clearly link potentially inappropriate prescribing, potential prescribing omissions, and adverse drug reactions with frailty in older adults. Equally, the literature illustrates that measured frailty in older adults predisposes to inappropriate polypharmacy and associated adverse drug reactions and events. In essence, there is a bi-directional relationship between frailty and potentially inappropriate prescribing, the underlying substrates being multimorbidity and inappropriate polypharmacy. We conclude that there is a need for consensus on rapid and accurate identification of frailty in older people using appropriate and user-friendly methods for routine clinical practice as a means of identifying older multimorbid patients at risk of potentially inappropriate prescribing. Detection of frailty should, we contend, lead to structured screening for inappropriate prescribing in this high-risk population. Of equal importance, detection of potentially inappropriate prescribing in older people should trigger screening for frailty. All clinicians undertaking a medication review of multimorbid patients with associated polypharmacy should take account of the important interaction between frailty and potentially inappropriate prescribing in the interest of minimizing patient harm.

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Background Older people with advanced frailty are among the highest consumers of prescription medications. When life expectancy is limited, the use of multiple medications may be unnecessary or burdensome. STOPPFrail criteria were recently developed to assist clinicians with deprescribing decisions in frail older people approaching end-of-life. The aim of this study was to examine whether long-term medications could be safely discontinued in frail older people using STOPPFrail criteria. Methods We recruited hospitalized adults aged ≥75 years with polypharmacy (≥5 long-term medications) that were transitioning to nursing home care. Participants were eligible if their Clinical Frailty Scale score was ≥7 and if their attending physician indicated that he/she “would not be surprised if the patient died in the next 12 months”. Patients were randomized to single time point pre-discharge STOPPFrail-guided deprescribing or routine pharmaceutical care. The primary outcome was change in the number of regular medications at 3 months. Secondary outcomes included emergency hospital transfers, incident falls, fractures and mortality. Results Results are presented for the first 100 enrolled patients. The mean (±standard deviation [SD]) age of study participants was 85.1 (±5.7) and 61% were female. Intervention (n = 49) and control group (n = 51) participants were prescribed a mean (±SD) of 11.5 (±3.0) and 10.9 (±3.5) regular medications, respectively, at baseline. The mean (±SD) change in the number of regular medications at 3 months was -2.7 (±2.8) in the intervention group and -0.6 (±2.6) in the control group (estimated difference 2.1 ±0.6, 95% confidence interval 0.8 -3.3, p=0.001). Ten intervention participants and 14 control participants died within 3 months of randomization (20.4% vs 27.4%, p=0.49). There was no significant difference between groups for emergency hospital transfers, incident falls or fractures. Conclusion STOPPFrail-guided deprescribing significantly reduced medication burden in frail older people without adversely affecting clinical outcomes in the prospective 3 months.