Populations are ageing fast worldwide, including in Africa and Asia. With age come more long-term conditions, and with those, more medicines. Many older adults take five or more medicines a day (often called polypharmacy). When combined with frailty, this can lead to falls, confusion, kidney injury, bleeding, and hospital admissions. Nurses often know the patient best and are in a strong position to spot problems.
What is frailty?
Frailty is a state of reduced physical and mental reserve, so that a minor stressor (a urinary infection, a new medicine, a change in environment) can cause a major decline. It’s not the same as age: some 90-year-olds are robust, while some 60-year-olds are frail.
Signs of frailty
- Slow walking, weakness, unintentional weight loss, exhaustion, low activity.
- Falls, new incontinence, confusion (delirium) or sudden loss of mobility, sometimes called “frailty syndromes”.
- Needing help with daily activities.
The Clinical Frailty Scale (CFS) rates people from 1 (very fit) to 9 (terminally ill) based on function in the two weeks before illness. It’s widely used in emergency and inpatient settings to guide decisions.
Why medicines cause more harm in older people
- Reduced kidney and liver function means drugs accumulate.
- More body fat and less water change drug distribution.
- The brain is more sensitive to sedatives and anticholinergic drugs.
- Interactions multiply with each extra medicine.
- Prescribing cascades: a side effect is mistaken for a new condition and treated with another drug.
High-risk medicines to watch
- Sedatives: benzodiazepines, “Z-drugs” (zopiclone), some antipsychotics: falls and confusion.
- Anticholinergics: some antihistamines (e.g. chlorphenamine), bladder medicines (oxybutynin), tricyclic antidepressants: confusion, constipation, urinary retention.
- Opioids: sedation, constipation, falls.
- NSAIDs: kidney injury, stomach bleeding, heart failure.
- Antihypertensives and diuretics: postural hypotension, falls, dehydration, kidney injury.
- Anticoagulants and antiplatelets: bleeding (but often very beneficial; balance carefully).
- Diabetes medicines (insulin, sulfonylureas): hypoglycaemia; targets are often relaxed in frail older adults.
Tools such as the STOPP/START criteria and the Beers Criteria help clinicians identify potentially inappropriate medicines in older adults.
What nurses can do
- Accurate medicine history: include over-the-counter medicines, herbal and traditional remedies, and medicines from multiple prescribers.
- Ask how they actually take them: many older adults skip doses, double up, or share medicines.
- Observe for side effects: dizziness on standing (check lying and standing blood pressure), drowsiness, confusion, constipation, falls.
- Raise concerns and request a structured medication review, especially after a fall or admission.
- Support deprescribing: carefully stopping or reducing medicines that no longer help, with the patient’s involvement. Some need gradual tapering (e.g. benzodiazepines, beta-blockers, antidepressants).
- Simplify regimens: fewer doses per day, blister packs or dosette boxes where appropriate.
- Involve carers and community pharmacists.
Beyond medicines
- Keep people moving: bed rest causes rapid muscle loss in older adults.
- Nutrition and hydration support.
- Prevent and recognise delirium.
- Falls prevention.
- Comprehensive geriatric assessment where available.
- Discuss what matters most to the person, and advance care planning.
Based on the Clinical Frailty Scale (Rockwood), STOPP/START criteria v3, the American Geriatrics Society Beers Criteria, NICE NG56 (Multimorbidity) and WHO guidance on medication safety in polypharmacy. Educational content.