B.8. Frailty

Guidance on Polypharmacy/high risk of Harm

The Ageing Well patient leaflets developed by the STP can be found here 

https://www.healthierfuture.org.uk/ageing-well/living-well-with-moderate-frailty 

https://www.healthierfuture.org.uk/ageing-well/living-well-with-severe-frailty 

The Ardens guidance for completing the core contract requirement for practices to create a frailty register and review patients living with severe frailty can be found here. 

https://ardens.freshdesk.com/support/solutions/articles/31000120368-frailty 

Polypharmacy medication reviews

To support deprescribing and reduce problematic polypharmacy the IMPACT tool from PrescQIPP (Improving Medicines and Polypharmacy Appropriateness Clinical Tool).  This tool incorporates the STOPPSTART tool and is a ‘one stop shop’ to support polypharmacy reviews.  A webinar and user guide to support use is also available from this page.

The polypharmacy review toolkit can be found here. The supplementary files provide advice on items that should be reviewed with a view to stopping and where there is an indication to add a medication. 

Step 1

See Ardens Manager ‘Rules’ tab relating to the relevant indicator for full details relating to coding.

Ardens will apply the code “Eligible for polypharmacy medication review” (968141000000105) added to their electronic patient record for those patients who fulfilled the criteria for review on 1st April 2025.

Practices are required to continue to identify further/new patients eligible for polypharmacy utilising appropriate Ardens report (see below) throughout the year and should put a process in place to intermittently review Ardens and code patients as above.

Step 2

Polypharmacy medication review completed

When a polypharmacy medication review has been undertaken the following code should be added to the patient’s record. Polypharmacy medication review (^ARD-000-001-145),

NB The code group Polypharmacy medication review (^ARD-000-001-145) contains two codes (Polypharmacy Medication review  (870661000000100) and Polypharmacy medication review done by clinical pharmacist (2010011000006106)) both of which can be used to code for the polypharmacy ECF indicator payment.

Please note that if a patient is identified as moderately frail, taking 8 or more medicines and codes as eligible for a polypharmacy review they will remain in the denominator cohort for this indicator if their frailty score changes post the eligibility code being applied.

 Step 3

 Anticholinergic burden scoring

 Patients with moderate or severe frailty and/or living in a care home will have:

• An Anticholinergic burden score recorded. NB To ensure consistency of scoring across the system practices should use the ACB Calculator to calculate scores

• A documented deprescribing plan for patients with an ACB score of 3+

 Using clinical systems to achieve these indicators

 EMIS

As above practices should use the ACB Calculator link to calculate scores that should then be added into the clinical system. 
The ACB score can be entered by entering the term anticholinergic burden in the search bar and entering the code directly from there. By adding the score the code Anticholinergic Burden Scale score (XagBE) (SNOMED: 761882000) will be added to the patient’s record.(*Picture1: below)

SystmOne

SystmOne has an Ardens Template that can be used to identify medicines with an anticholinergic burden.  The ACB Scale template is accessed from the polypharmacy tab of the drug review template.  The clinician carrying out the review must manually enter the manually calculated total score into the system.  By adding the score, Ardens will apply the code Anticholinergic Burden Scale score (XagBE) (SNOMED: 761882000) to the patient’s record. (**Picture 2: below)

Deprescribing plan

Where a patient has an ACB score of 3 or more entered and a deprescribing plan put in place the following code should be added to the clinical system: Optimisation of medication (713838004)

Nutrition and hydration 

If on completion of MUST or Patients Association Nutrition Checklist a patient is identified as at risk of malnutrition, a goal should be agreed with the patient and support provided to enable the patient to manage their risk of malnutrition – see additional information. The goal identified should be what matters to the patient rather than what the clinician thinks they should be trying to achieve, and so will not always equate to weight gain or a significant increase in nutritional intake.  For example -the pts goal may be maintaining or improving their functional ability or quality of life which could be achieved by minimising additional weight loss or optimising nutritional intake. If additional nutritional intake is suggested, this should be advised in line with local guidance and should focus primarily on food. In addition, activity should be encouraged if possible in addition to nutritional intake to optimise retention of muscle mass and strength. 

Dehydration is extremely difficult to diagnose in older adults as evidence demonstrates that no commonly used tests are accurate or appropriate to use in this age group. Research into this area concludes that all dependent older adults should be assumed to be at risk of low intake dehydration and therefore all opportunities to encourage fluid intake should be optimised. 

The reasons for low food or fluid intake and how these can be managed or mitigated e.g. social care issues (difficulty accessing or preparing food); financial issues; dental issues; concerns regarding continence; lack of awareness of thirst connected with increasing age; impact of polypharmacy on appetite and food intake; impact of health conditions on appetite and intake; mobility. Support from organisations like Herts Help, Hospital and Community Navigators or practice/PCN based social prescribers should be encouraged. 

Measuring outcomes is important but can be challenging, as many systems do not lend themselves to coding more than weight change or MUST score, neither of which is usually what pts want to achieve. Using quality of life questions or even a Likert scale may be more meaningful and demonstrate an impact on the pts quality of life.