After two consecutive years of successfully reducing medication overload in nursing homes, United Hospital Fund is using its expertise to tackle this urgent problem in a particularly vulnerable group: frail adults near the end of life.
On August 23, UHF’s Quality Institute held the first session in its STOPPFrail Learning Collaborative, which will use a tool developed by researchers from Cork University Hospital, Ireland to identify and safely deprescribe inappropriate medications taken by highly dependent frail adults with poor 1-year life expectancy.
The initiative builds on UHF’s Polypharmacy Learning Collaborative, which in 2022 and 2023 partnered with New York-area nursing homes and reduced the number of residents taking 10 or more medications. Polypharmacy, or the prescribing of an inappropriately high number of medications, has been shown to increase adverse outcomes like drug-drug interactions, falls, cognitive impairment, and unscheduled hospitalizations.
The STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy) tool is the first set of explicit guidelines designed to tackle inappropriate polypharmacy in very frail adults approaching end of life, who often have different health priorities than other groups.
“In severely frail older people with poor survival prognosis, the focus of drug therapy should be symptom relief rather than long-term prevention,” one of the STOPPFrail authors, Professor Denis O’Mahony, MD, told learning collaborative participants. “There must be particular attention on symptom relief and quality of life for the individual patient.”
During the UHF project, five nursing homes who participated in the polypharmacy initiative will implement interventions using the STOPPFrail tool in their facilities over a five-month period. The process will include an initial testing phase and an eight-week period to scale up the intervention, along with coaching and learning collaborative sessions as a group.
In their first learning session, participants received an overview of the STOPPFrail tool from Professor O’Mahony and a presentation on the definition of frailty from T.S. Dharmarajan, MD, a learning collaborative faculty member and clinical director of the division of geriatrics at Montefiore Medical Center.
While difficult to define, frailty is understood as a disorder characterized by the decline in functioning among multiple physiological systems and elevated vulnerability to stressors, Dr. Dharmarajan said. It is predominantly a by-product of aging and carries a higher risk of adverse health outcomes, including falls, hospitalizations, and death. In 2021, an estimated 51.5 percent of residents in nursing homes had objective evidence of frailty, compared to 26.8 percent of the general older adult population, according to a 2021 study.
“When you see a frail resident, you can recognize frailty,” Dr. Dharmarajan said. “[But] it took a long time to come to grips with this topic, define it, and make it easy for the practicing physician to understand and manage.”
Participants in the STOPPFrail Learning Collaborative will measure seven criteria to identify frailty in their residents, including fatigue, weight loss, the need for help with activities like dressing, and illness. The criteria are specific to identifying frail residents in a nursing home setting. Residents identified as frail will then be reviewed for deprescribing (i.e. medication curtailment) opportunities, and the participating nursing homes will collect data on any medication changes.
UHF's work to decrease medication overload among frail nursing home residents is supported by the TD Charitable Foundation, who previously supported UHF’s two-year initiative, Reducing Polypharmacy in Nursing Homes.