Frailty modifies the effect of polypharmacy and multimorbidity on the risk of death among nursing home residents: Results from the SHELTER study

Abstract

BackgroundFrailty, disability, and polypharmacy are prevalent in nursing home (NH) residents, often co-occurring with multimorbidity. There may be a complex interplay among them in terms of outcomes such as mortality. Aims of the study were to (i) assess whether nursing home residents with polypharmacy (5–9 medications) or hyperpolypharmacy (≥10 drugs), have an increased risk of death and (ii) whether any association is modified by the co-presence of frailty or disability.MethodsCohort study with longitudinal mortality data including 4,023 residents from 50 European and 7 Israeli NH facilities (mean age = 83.6 years, 73.2% female) in The Services and Health for Elderly in Long Term care (SHELTER) cohort study. Participants were evaluated with the interRAI-LongTerm Care assessment tool. Frailty was evaluated with the FRAIL-NH scale. Hazard ratio (HR) of death over 12 months was assessed with stratified Cox proportional hazards models adjusted for demographics, facilities, and cognitive status.Results1,042 (25.9%) participants were not on polypharmacy, 49.8% (n = 2,002) were on polypharmacy, and 24.3% (n = 979) on hyperpolypharmacy. Frailty and disability mostly increased risk of death in the study population (frailty: HR = 1.85, 95%CI 1.49–2.28; disability: HR = 2.10, 95%CI 1.86–2.47). Among non-frail participants, multimorbidity (HR = 1.34, 95%CI = 1.01–1.82) and hyperpolypharmacy (HR = 1.61, 95%CI = 1.09–2.40) were associated with higher risk of death. Among frail participants, no other factors were associated with mortality. Polypharmacy and multimorbidity were not associated with mortality after stratification for disability.ConclusionsFrailty and disability are the strongest predictors of death in NH residents. Multimorbidity and hyperpolypharmacy increase mortality only in people without frailty. These findings may be relevant to identify patients who could benefit from tailored deprescription.

Number of medically prescribed pharmaceutical agents as predictor of mortality risk: a longitudinal, time-variable analysis in the EPIC-Heidelberg cohort

“…Other studies have also shown that among elderly individuals with high prevalence of medication use, most medications belonged to a very restricted number of ATC classes [22][23][24][25][26] . Furthermore, it has been reported that among elderly individuals (residents of nursing facilities) the association of polypharmacy with mortality risk may be modified by other health conditions such as frailty, and that risk of death was increased mostly by frailty and disability, whereas (hyper-)polypharmacy was associated with higher risk of death only among non-frail study participants 27 .…”

Concepto y manejo práctico de la fragilidad en neurología

“…La intervención sobre la prescripción adecuada y el tratamiento de síndromes geriátricos y comorbilidades es básico. Los ancianos frágiles generalmente se asocian a un mayor número de fármacos [ 39 ], con mayor riesgo de efectos secundarios por sus interacciones. La prescripción farmacológica tiene que ser cuidadosa, evitando medicamentos inapropiados y valorando bien su beneficio.…”

Functional and Psychosocial Profile of Older People Living in Nursing Homes: Findings from the European Survey of Health, Ageing and Retirement in Europe (SHARE)

“…In particular, multimorbidity, as defined by the co-presence of two or more chronic conditions (e.g., heart failure/disease, stroke, diabetes, cancer, dementia, depression), is indeed prevalent in nursing home residents, and often it is, in turn, co-occurring with frailty, disability and polypharmacy. Moreover, older residents with multimorbidity and with hyper-polypharmacy have, respectively, a 35% and a 29% increased risk of mortality when compared to those not experiencing these conditions [92]. These older people need appropriate healthcare services, and nursing homes, however, representing a possible care solution in their daily living [93,94].…”