Best practice in pragmatic prescribing for older people with moderate to severe frailty

Polypharmacy is common among older people. Optimal prescribing balances medicine-related benefits and potential harms. People with moderate to severe frailty, as defined by the Clinical Frailty Scale, are infrequently included in drug clinical trials. For this group, prognostic benefits of medicines are likely to be diminished by reduced life expectancy. They are also at increased risk of harm from medicines due to a combination of problems, including the characteristic vulnerability of people with frailty, drug-drug interactions, drug-disease interactions and therapeutic burden. In modern healthcare, medicine-related harm is a major contributor to reduced well-being, including provocation of hospital admissions. In the absence of definitive clinical trial data for this population, optimising care is challenging. A pragmatic approach balances risks and benefits of prescribing for a person with frailty alongside the individual's circumstances and goals. A recently developed guideline aims to help reduce medicine-related harm for people with moderate to severe frailty. In this best practice article, we will make a case for the need for change and outline a pragmatic approach to balance medication risks and benefits, with reference to the recent guidance.