Frailty among older adults has been a common cause for concern for decades. The arrival of modern medicine has, to an extent, eased this worry and improved physical weaknesses among senior citizens. However, could there be something exacerbating this infirmity?

According to a recent editorial co-authored by Dr. Paula Rochon, a professor at U of T’s Department of Medicine and Institute of Health policy, Management and Evaluation, the answer may be yes, due to the relationship between the intake of a cocktail of prescription drugs and frailty among older adults.

The Varsity spoke to Rochon, who also serves as the vice-president of research at Women’s College Hospital, a geriatrician, and as the The Retired Teachers of Ontario/Les enseignantes et enseignants retraités de l’Ontario chair in geriatric medicine at the U of T. She has a longstanding interest in improving the health and wellness of older adults, particularly women, who make up most of this demographic.

One area which she has studied extensively is the optimization of drug therapies for older adults in order to maximize their benefits and minimize harm.

What came first, the chicken or the egg?

Frailty is a geriatric syndrome characterized by “age-related decreases in physiologic reserves, resulting in vulnerability to health declines following even minor stressor events,” according to the co-authors. Polypharmacy is a situation in which patients take a combination of prescription drugs — or a drug cocktail, as it’s commonly called.

While both frailty and polypharmacy are known to be linked and have co-existed for quite some time, little is known about the extent of their relationship. Scientists are unable to discern whether drug therapies manage frailty and accompanying chronic medical illnesses, or whether they prompt health declines characterized as frailty.

Similar to the philosophical question of the chicken and the egg, we are unsure which factor causes what.

Unravelling the mystery of the relationship

To determine the type of association between frailty and polypharmacy, two longitudinal studies were published in Journal of the American Geriatrics Society, in order to further explore the question.

Shahar Shmuel, a researcher at the University of North Carolina, and colleagues conducted a longitudinal study of older adults. Their study notes the high prevalence of frailty and polypharmacy in older adults, and suggests that there is a relationship between polypharmacy and frailty.

The researchers note that further research can be conducted to see whether lowering the number of prescriptions would reduce frailty.

Dr. Andrew Bergen at the Oregon Research Institute and his colleagues conducted a longitudinal analysis of more than 1,400 community-dwelling older adults. Their study found that the prescription of drugs for sleep and pain was associated with increased frailty.

In both studies, a relationship was found between prescription drugs and frailty, even though one was looking at polypharmacy and the other was looking at specific drug classes for pain and sleep. However, while both studies established a relationship, the chicken-and-egg scenario still remains.

For this reason, Rochon believes that the association between frailty and polypharmacy is extremely difficult to entangle. Scientists need to be able to study the sequence of events in order to determine if polypharmacy causes frailty, or whether it is the frailty that leads to polypharmacy, she noted.

Future steps of research

Rochon suggested that researchers investigate and conduct medication reviews on all pre-frail and older adults to identify the possibility of ‘deprescription’ — decreasing the dose of the prescription or even possibly discontinuing the prescription. She wrote that identifying drugs that could make frailty worse should be the first step.

Identifying cascades is also an important priority, she added. In other words, drug therapies that lead to the growth of medical conditions and additional drug cocktails to treat these conditions also make frailty worse.

Lastly, in the usage of drug therapy for an individual, course of life must also be considered. In many cases frailty is associated with death and this association or connotation must be accounted for when making prescriptions. A patient’s life expectancy and a drug’s lag time should also be accounted for, she further noted.

While both Shmuel and Bergen’s studies provide useful information, none are able to completely solve the puzzle. The current conclusion is that polypharmacy and frailty have an effect on each other, but this relationship remains ambiguous.

It is possible that we may never know the answer to the chicken-and-egg question. But in the meantime, there are steps that we can take to answer this one — one of them being to focus on optimizing drug therapy for frail or pre-frail adults.