Frailty, Polypill and Quality of Life in Elderly

Abstract

Frailty is an age-related state of increased susceptibility of functional decline that may be reversed or at least slowed progressiveness. It is characterized by impairments in a number of physiological systems and is linked to a higher risk of morbidity or unexpected hospitalization. It is a newly recognized geriatric syndrome in clinical practice, and excess healthcare expenses from consultations, polypill use, and hospitalization are some of its correlations. When under stress, frailty results in a loss of autonomy in everyday activities and death. Elderly adults frequently have many comorbid ailments, which exposes them to multiple medications or polypill therapy. This is linked to a higher chance of negative drug reactions, which leads to more hospitalizations, high morbidity, mortality, and higher healthcare system costs. It’s crucial to recognize these conditions in order to offer primary care patients early intervention and/or interdisciplinary management, which fits well with the physical and psychosocial model for their well-being.

1. Introduction

The cutoff age for elderly is 60 years in the majority of nations, including India. Our society today considers the “young old” to be between 60 and 74 years old, the “middle old” to be between 75 and 84 years old, and the “old old” to be over 85 years old [1].

According to WHO, currently 1 in 10 people are 60 years or older; by 2050, that number will increase to 1 in 5 and 1 in 3 by 2150 [2]. One in five Europeans and one in every twenty Africans are 60 years of age or older. There will be less time to adapt to the effects of population ageing in developing countries because aging occurs more quickly there than in industrialized ones. Current global life expectancy is 66 years; however, in the least developed areas, males can expect only 14 years and women 16 years of additional life, respectively, while in the more developed areas, life expectancy at 60 is 18 years and 22 years, respectively [3]. India is home to more than 100 million senior people, according to the most recent census. Even though the number could rise to 170 million by 2025 and life expectancy would grow from the present 66–72 years, little is known about the health of this population and its medical needs. In the years 2009–2013, women had a life expectancy at birth of 69.3 years compared to men’s 65.8 years [4].

Frailty is a reduced physiological reserve of several organs that makes elderly people more vulnerable to shocks and more likely to experience negative outcomes [5]. The term “frail” is used to describe frail old individuals who are highly susceptible to unfavourable outcomes, such as falls, deteriorating disabilities, hospitalization, and mortality. Frailty, however, is not the same as old age or illness. When under stress, frailty results in a loss of autonomy in everyday activities and death. Physical weakness is thought to be potentially recoverable at this time. Due to the fact that frailty indices are beneficial for risk classification, forecasting the need for institutional care, and planning for necessary services, it is important to objectively detect frailty in aged individuals [2, 3].

In clinical practice and research, several frailty definitions and evaluation techniques have been created, and this has been the subject of many reviews and comparative studies [4, 5]. Particularly, Fried et al.’s frailty phenotype has gained recognition on a global scale. The fundamental benefit of Fried’s approach is that it just calls for the evaluation of five factors: physical activity, grip strength, tiredness, and weight loss [4]. Although this is reasonable in terms of primary care, there is a problem with the way the measure was put together as non-frail, pre-frail, and frail.

The cumulative deficit model, which is based on a variety of factors including symptoms, signs, diseases, disabilities, and abnormal test values, together known as deficits, determines frailty [6]. The initial model had 92 variables, but later research has shown that this may be cut down to around 30 more manageable variables without losing predictive validity [7]. The variables can be used to create a frailty index (FI) score, which is a straightforward computation of each variable’s presence or absence as a percentage of the whole.

In order to manage cases at the primary care level based on the concept of frailty, which fits well with the physical and psychosocial model, research should be conducted with the goal of identifying at-risk groups of elderly people in order to provide early intervention and/or multidisciplinary case management [8]. This ideal has, however, made it clear that there aren’t any frailty measurements that are suitable for use in basic care. In fact, general practitioners still require simple tools for detecting frailty.

The biopsychosocial factors are also associated with complexities of the frailty that interrelate and lead to clinical and functional manifestations in older adults. These factors are interlaced with each other as shown in Figure 1. In biological component, physical health, disability, genetic vulnerability and poor sleep quality account for major factors. In social component- family circumstances, friends, relationships. And in psychological, self-esteem and anxiety are important factors.

Figure 1.

Biopsychosocial factors associated with fraility.

2. Frailty: definition and pathophysiology

The term “frail” is used to describe frail old individuals who are highly susceptible to unfavorable outcomes, such as falls, deteriorating disabilities, hospitalization, and mortality. Frailty, however, is not the same as old age or illness. Therefore, even for patients with advanced single- or multi-organ disease processes, frailty, as a way to summarize health status, could provide additional relevant clinical information. Frailty is characterized by a need for assistance with daily living activities (ADLs), such as dressing, feeding, bathing, using the restroom, and moving around. Frailty and impairment usually coexist, and the likelihood is higher as age rises. The scenario could get more complex due to cognitive impairment [9].

Fried et al.’s definition of frailty syndrome, which includes three or more of the following symptoms: weakness, slow walking speed, self-reported weariness, limited physical activity, and unintended weight loss, is the most frequently accepted [2].

Abnormalities in numerous physiological and biochemical systems have been linked to fragility. These include low levels of insulin-like growth factor-1 and dehydroepiandrosterone-sulfate, anemia, low albumin, higher levels of inflammatory markers, particularly interleukin-6 and tumour necrosis factor, high hemoglobinA1c, and nutritional deficiencies. However, new research has shown that rather than a single biomarker, frailty is most closely linked to a mix of immunological and physiological abnormalities. This is in line with the theory that aging is the result of a complex system suffering a cumulative loss of redundancy over time. The likelihood of frailty appears to depend more on a critical mass of anomalies than on any single mechanism.

3. Elderly and disability

Although aging is largely a reflection of people living longer and generally in better health, it is also linked to chronic and degenerative diseases, which are more prevalent as people get older. Disability can negatively affect elderly people’s quality of life and is a significant health marker that can have a huge social impact due to recurrent institutionalization and higher medical care. Additionally, as age increases, their chances of becoming disabled increases, and their chances of recovering from disability diminish [10]. The phrase “disability and elderly” covers a wide range of conditions, each with their own specific needs.

The International Classification of Functioning, Disability and Health (ICF) classifies impairments, activity limitations, and participation restrictions under the general heading of disability [11]. A constraint or lack of capacity to do a task in the manner or within the parameters deemed typical for a human being has been classified as a disability [12]. “Types of disability” are frequently characterized using just one component of disability, such as sensory, physical, mental, or intellectual impairments. Other times, health issues are confused with disability [12, 13].

Elderly people with disabilities can be divided into three categories: those who can manage their daily activities with the aids, those who have multiple health issues and severe limitations in their mental and/or physical functioning and need very high levels of care, and those who are functionally disabled in one or two activities of daily lifes or have mild cognitive impairments [14]. There is proof that older populations are more likely to experience several comorbidities, which can result in disability [15]. It has been well established in numerous studies from India that morbidity affects the physical functioning and psychological well-being of elderly populations; the necessity “to develop geriatric health care services in developing countries on the basis of existing morbidity profile” must be emphasized [16, 17]. Elderly people have been found to exhibit a variety of morbidity patterns, including hypertension, diabetes, arthritis, constipation, cataracts, and hearing loss, dyspepsia/heartburn, backache, dyspnoea, syncope, altered bowel habits, and blurring of vision. However, studies had lacked a clear definition of disability and were unable to quantify the impact of advancing age and associated morbid conditions as its main etiologies [16].

4. Frailty and falls

Any geriatric condition is more likely to manifest in weak older persons, and there is growing evidence that links frailty especially to falls. A framework for examining why and how the frail older person is at danger of falling is provided by viewing frailty as the breakdown bipedal ambulation, which requires neurological control of different muscles on joints with sensory feedback signals and commands from the motor cortex. Therefore, it should not come as a surprise when weak people (who are equivalent to a system that has lost redundancy) experience falls because they become unable to integrate various inputs in the face of seemingly insignificant stressors.

It is important to note that the fall is not a diagnosis but can be a manifestation of “multiple underlying disease like visual impairment (cataract, corneal opacity), postural hypotension, degenerative joint disease, giddiness, and depression, the effects of certain medications on homeostasis, and/or environmental hazards or obstacles that interfere with safe mobility” [17].

5. Measurement of frailty in general practice

Frailty is recognized by a number of techniques as a clinical syndrome or phenotype (a group of symptoms that frequently co-occur to define a certain medical disease). Summative impairment lists and algorithms that are based on clinical judgment are typical of them. Frailty is defined by a number of factors, including physical inactivity and weight loss, gait speed, hand grip, visual impairment, fatigue, resistance, ambulation, as well as the inability to get up from a chair without using arms five times and a decreased energy level. Slow gait speed has been utilized alone as a frailty indicator despite its high correlation with functional decline and impairment. Presence of three or more of the five criteria like weight loss, tiredness, weak grip strength, slow walking speed, and low physical activity has been described as frailty phenotype is the most well-known and frequently used one originally defined by Fried et al. [2]. This phenotype was recently utilized to describe frailty as the most common condition causing death in community-dwelling older individuals. It has been validated as a predictor of unfavourable outcomes in major epidemiological investigations. The Fried et al. model is very strong since it recognizes frailty as a wasting condition and is clinically consistent and reproducible. On inpatient wards, however, a large number of very ‘vulnerable’ elderly patients are unable to take performance-based assessments and cannot be categorized by phenotypic measurements [3].

The fundamental benefit of Fried’s approach is that it just calls for the evaluation of five factors: physical activity, grip strength, fatigue, and weight reduction [2]. Although this is reasonable in terms of primary care, there is a problem with the way the measure was put together. According to Fried’s definition, frailty can be divided into three groups based on the total number of individual criteria that are met in each group (0: non-frail, 1 or 2: pre-frail, and 3, 4 or 5: frail). Retrospectively, using the lowest twentieth percentile criterion, individual criteria that are measured on a continuous scale (such as grip strength, walking speed, and physical activity) are dichotomized. There are also further stratifications. This calls for extensive statistical knowledge. Primary care physicians are not usually equipped with the necessary statistical knowledge or a reference sample, both of which are necessary for this. It is debatable if impairments of cognition and mood are left out of these models because frailty in the clinical world encompasses more than just weakness, slowness, and waste [4, 5].

Frailty can be measured as a multidimensional risk state that can be determined by the quantity rather than the type of health issues by seeing aging as the accumulation of impairments. The Frailty Index (FI) model develops an index as a percentage of deficits using a well-defined approach [13]. They have received strong validation in large, community-based research as a method of quantifying health state, with strong correlations to institutionalization, deteriorating disability, and death. A measure of frailty status can be obtained from data normally gathered during the examination of an older person because FIs can be created from various numbers and types of impairments. There are now studies looking into the clinical applicability and predictive validity of a FI produced from Comprehensive Geriatric Assessment.

6. Screening tools for frailty

One technique for detecting frailty is the Frailty Index (FI) which is a collection of health weaknesses, such as symptoms, signs, impairments, and diseases. The patient’s FI score, which ranges from zero to one, is determined by the percentage of deficiencies present [18]. Different numbers and types of deficits may be employed in a FI with at least 30 deficits without significantly affecting the FI’s features, allowing for use in and comparison of various datasets. Other frailty instruments, including the Tilburg Frailty Indicator, are more promising, according to other writers, who claim that the FI hasn’t been validated in this context, is of limited utility due to its perceived complexity, and has only moderate discriminative power [19]. Others have asserted that the FI is a substantial predictor of unfavourable health outcomes, that it includes all crucial frailty indicators, that it is simple to calculate from regular administrative healthcare data, and that further research is needed to determine the FI’s benefits in primary care [19].

7. Do we know how to detect and measure frailty?

At the turn of the century, a variety of models, explanations, and tools were put forth to operationalize the concept of frailty and identify those who were feeble. Two strategies were developed as a result of prospective, quantitative research on sizable samples of community-dwelling individuals; both strategies were presented in seminal publications released in 2001. The multisystem loss of physiological reserve that distinguishes frailty as a risk for a variety of unfavourable outcomes is referred to as the frailty phenotype and was first described by Fried et al. [20].

Fried’s frailty phenotype may have a wide diffusion because it has a good face validity and only a few measurement-required factors. However, it has come under fire for limiting frailty to the physical components of health and ignoring mental health issues, which are common in old age and may heighten frailty, such as mood disorders or cognitive impairments [6]. But the five measures suggested by Fried et al. are probably also reflective of mental health: weariness is measured using items from a depression screening questionnaire, and new studies have shown links between frailty and cognitive impairments.

The “accumulation of deficits” concept, as defined by Mitnitski and Rockwood, is based on a frailty index that is calculated from numerous health-related indicators [11]. It alludes to the idea of advanced biological age in relation to the danger of passing away. The Canadian Study of Health and Aging data used in the development of this model included more than 90 distinct variables, including medical diagnoses, self-reported health issues or symptoms, physical manifestations, lab test outcomes, and functional challenges with ADLs. The frailty index, which is defined as their arithmetic total, is a variable-neutral measure. The selection of variables is based on three guiding principles: they point to health issues whose prevalence rises with age, they address multiple systems, and they do not reflect conditions that are always present in old age (and thus would not distinguish between people of the same chronological age). As long as there are enough factors included—at least 30 to 40—the set of variables chosen to compute the index of frailty may theoretically vary between different samples [13]. The “accumulation of deficits” hypothesis does not offer any hints as to the physiological processes producing frailty. But the wide variety of health deficiencies used to calculate the frailty index accommodate for the complexity of frailty, including its physical and psychological components.

All current frailty assessment tools were fundamentally validated by showing their potential correlation with unfavourable outcomes in population-based cohort studies. The frailty index generally predicts death better than the frailty phenotype. However, because it contains impairment indicators in its definition, it cannot be used to forecast the likelihood of functional deterioration.

The definition and validation of screening tools have received a lot of attention, but despite this, we still know very little about these two features outside of the frequently noted greater levels of frailty in women and in low socioeconomic groups [6, 15]. As a result, socioeconomic factors should be researched separately as susceptibility factors since they may interact with frailty to cause unfavourable health consequences. Early phases of frailty should be the most appropriate focus for intervention since they correspond to preclinical (or undetected) chronic diseases and functional decline and are more likely to be reversed.

The ability of frailty screening tools to properly predict negative outcomes at the individual level is still an open subject. These tools have been validated in population-based research and indicate prospective relationships with unfavourable outcomes. Frailty screening tools used in clinical practice to determine treatments must be specific and sensitive in order to avoid denying appropriate care to healthy individuals who are mistakenly labelled as pre-frail or frail [20]. The tools that are now in use often have excellent sensitivity but low specificity. Once age, sex, and chronic illnesses were taken into consideration in the population, it was discovered that a group of the most prevalent frailty markers had very little predictive value. Although it is appealing to use primary care data to quantify frailty, current evidence suggests that the frailty index is only weakly capable of forecasting unfavourable outcomes [21].

8. How we can prevent frailty?

The difference between an older person’s chronological age and biologic age—and the requirement to treat older patients adequately by taking the second into account rather than the first—are at the core of geriatrics clinical practice. Although one or more chronic conditions are typically present in older patients, their number, combinations, severity, and impact on functional capacities are very diverse at any given age. As a result, although the prevalence of chronic diseases is highest in older age, chronological age does not always correspond to the risk of disability and death. An older person’s fragility is frequently portrayed as a degree of inherent vulnerability. Although it tends to rise with age, it is unrelated to chronological age.

Many dependent older people are both frail and impaired because frailty can be the beginning of a developing dependency in activities of daily living (ADL). Frailty, however, does not always lead to old age infirmity, and not everyone who is fragile is always functionally dependent.

Although there are no known methods to reverse frailty, epidemiological research into the causes linked to its onset provide light on potential interventional methods. Because co-morbidities such cerebrovascular, chronic renal, and cardiovascular disease are linked to frailty, preventing these diseases early on may help to lower the prevalence of frailty in old life [22]. Quitting smoking in particular may offer advantages over simply preventing one disease. Smoking has been directly associated with the development of frailty because it is a potent inflammatory stimulation that brings on the inflow and activation of inflammatory cells. Despite the well-established link between inflammation and frailty, anti-inflammatory medications or foods with anti-inflammatory properties do not appear to be able to stop or delay the onset of frailty, according to observational and epidemiological research conducted to far [23].

Additionally, obesity and, in particular, the buildup of abdominal fat, are linked to greater frailty, as well as larger waist circumference are more likely to be fragile, as compared to older adults who are underweight [24]. Therefore, abdominal obesity in elderly individuals with low BMIs may be a new area of management. Physical activity may improve function without affecting weight loss due to decreased belly adiposity and enhanced oxidative activity [24]. Because they are sophisticated therapies that have the potential to change the accumulation of deficiencies across numerous systems, exercise, healthy eating, and improved education are of special interest as therapeutic methods for frailty. More research should be done to determine whether elderly patients who are frail would benefit from lengthier rehab stays in facilities that provide individualized exercise programs and nutritional assistance.

9. Prescribing in frail older people

The cost and quantity of prescription pharmaceuticals have increased as a result of the introduction of recommendations for the management of chronic diseases. The bioavailability of prescription drugs is impacted by altered pharmacokinetic responses that are related to frailty. Drug distribution is impacted by increases in body fat and decreases in lean body mass; low albumin levels diminish drug binding and hinder the activity of enzymes involved in drug metabolism [18]. Older persons also have pharmacodynamic changes that raise their risk of adverse drug reactions (ADRs), such as greater sensitivity to benzodiazepines and warfarin [19, 20].

Although co-morbidity or disability are not the same thing as frailty, many elderly persons who are frail have a number of chronic illnesses, functional impairment, and are given extensive prescription regimens. The drawbacks of polypill go beyond the dangers of taking individual medications. A greater chance of non-compliance and a noticeably increased risk of adverse drug reactions are linked to the use of more drugs. Regardless of the medication’s reasons, older persons taking five or more drugs had a noticeably greater risk of delirium and falls. It has been demonstrated that when frailty is expressed as a co-morbidity index, ADRs rise in elderly people who are fragile. More research is needed to understand the independent impacts of frailty, although it is likely that a more robust person with a number of co-morbidities will tolerate ADRs better than a frailer person with a comparable list of co-morbidities. When prescribing drugs for elderly patients who are frail, goals of care should be carefully examined, even if the fundamental approach and concepts behind drug prescription should be identical for all patients. In people with short life expectancies, the hazards of secondary prevention can outweigh their advantages.

10. Are polypill necessary?

The shift in the elderly population’s demographics poses a considerable challenges among physicians because older age is linked to a number of chronic ailments as hypertension, diabetes mellitus, arthritis, chronic heart disease, renal diseases, etc. Because of this, elderly people frequently take several drugs throughout the course of the day, a practice known as polypill. It can be characterized as the administration of more prescriptions than are clinically required and/or the usage of several medications, typically referred to as five or more prescribed drugs per day, which represents needless or undesirable drug use. Numerous research conducted worldwide have revealed that older persons often take 2–9 drugs each day. It was discovered that between 11.5 and 62.5% of older adults took improper medications [25].

Unfortunately, the signs and symptoms of polypill are typically demented and include: fatigue, sleepiness, or decreased alertness; constipation, diarrhoea, or incontinence; loss of appetite; confusion; falls; depression; or lack of interest in daily activities. They can also include: weakness; tremors; visual or auditory hallucinations; anxiety; or excitability; and/or dizziness.

In order to prevent any potential negative consequences, a patient who is older should have their polypill evaluated. To identify polypill and its negative effects, an interdisciplinary team should conduct a thorough medication review and risk assessment. Several tools, including Assess Review Minimize Optimize Reassess, Screening Tool to Alert Doctors to the Right Treatment, and Screening Tool to Older Person’s Potentially Inappropriate Prescriptions, can be used to carry it out. Evaluation of the cause and effect of medication errors leading to ADRs is aided by the ADR probability scale and the Trigger tool for monitoring Adverse Drug Events in Nursing Homes. According to studies, Comprehensive Geriatric Assessment can help individuals take fewer prescriptions and daily medication doses overall.

The drug regimens of older people should be reviewed periodically in order to decrease the incidence and negative effects of polypill. If possible, a single agent or medication should be provided rather than a number of medications to address a particular condition. Where clinically warranted, medication dosages should be begun at a lower level and increased gradually as needed. Drugs that may be administered once or twice a day are preferable to those that must be administered three times a day. Drugs that are thought to be problematic should be stopped. If a medicine is used and neither a therapeutic benefit nor a clinical indication can be shown, the drug should be stopped. When many healthcare professionals prescribe the same medication for the same condition or disease, unnecessary medications should be discovered and removed. safer medications should drugs should be substituted with the higher risk medications.

Finding and avoiding polypill can assist elderly patients have better results and improve their quality of life. To prevent the negative consequences that polypill may have on an aged patient, medication review is crucial.

Increased risk of medication nonadherence, negative drug responses, drug interactions, and geriatric syndromes (falls, urine incontinence, cognitive impairment) are all consequences of polypill.

11. The prescription rules

1. Is it appropriate?

   Taking care of a new symptom as some symptoms (such as constipation—laxatives; vertigo—meclizine) appear to prompt a reflex prescription.

   However, take into account the following before beginning a medication:

2. Is something reversible?

   Dizziness brought on by a reduction in postural blood pressure so check for antihypertensive treatment, rather than starting new prescription for dizziness. Constipationmay be brought on by opioid analgesia, insist on any non-drug interventions (Example: increasing fibre to treat constipation). Before subjecting the patient to a number of medications, diagnosis must be confirmed, and disease-modifying therapies should not be withheld only to prevent polypill. Tight and meticulous treatment should not be considered to reduce disease-related mortality if the patient already has a short life expectancy (for example, cholesterol medicine in a patient with severe dementia or decreasing cholesterol and controlling blood sugar). The patient must be aware of the purpose of the treatment.

3. Do any conditions preclude its use where encounters likely to occur?

   Review the medication list and request information regarding the use of herbal and over-the-counter drugs. Computer prescribing, which automatically warns to potential concerns, is helpful in preventing drug-drug interactions.

4. What dosage should be started?

   Start low and go slow. Drug dosages are often better tolerated at lower doses and can be increased if there are no unfavourable side effects. For instance, 1.25 mg of ramipril is better than 10 mg with a postural drop in blood pressure when taking ACE inhibitors for heart failure. The benefits continue to rise as the dose is optimized.

5. How will the impact’s evaluation be done?

   Plan a follow-up appointment and look for medication’s effectiveness (e.g., has a dopamine agonist helped bradykinesia? Setting up precise therapy goals and carefully interviewing the patient and their family or carers are necessary when administering medication for less objective conditions (such as pain or cognition). When taking a statin, for example, check blood tests to determine effectiveness by lipid panel. Any negative side effects that the patient reports voluntarily, that are elicited by direct questions (such as a headache caused by dipyridamole), or that are necessary should be checked by blood tests (such as thyroid function while taking amiodarone). Side effects can be imperceptible and simple to miss. For instance, a patient with dementia may experience decreased hunger or attention for many different reasons. Even seemingly safe drugs like aspirin or iron can have an impact on hunger, and an antidepressant that was once successful can have a dulling effect on attention. A careful re-evaluation and a trial without the medicine are frequently beneficial.

6. Do not use it as a general rule.

   In geriatric medicine, a lot of prescribing is based on practical judgment and personally tailored assessments. There are always situations where it is necessary to break the rules in the best interests of the particular patient, even though most of what is detailed in the preceding pages is acceptable for most people.

   Prescription cascades should be identified to prevent inappropriate polypill as shown in Figure 2.

Figure 2.

Example of prescription cascade to avoid polypill. Non steriodal anti inflammatory drugs (NSAIDS), Calcium channel blockers (CCB).

First question should be thought of, “Is the patient reporting a symptom that could represent an adverse drug event?”. Furthermore, “Is a new drug being considered to address an adverse event that may be related to a previously prescribed drug therapy?” “Could the initial drug be substituted for a safer alternative or could the dose be reduced, potentially eliminating the need for the subsequent drug therapy?”. If so, “Does the patient need the initial drug therapy or could it be stopped?”

Experience is necessary for this method, and the patient should always be monitored to determine how the decision affected them.

Although polypill has drawbacks, it is not universally viewed as a bad thing. It can also be harmful to deny individuals access to medicines because they are too old or already on too many medications.

Co-prescribing a medication to treat the anticipated bad impact may be justified when side effects are very probable but the treatment is unquestionably indicated, for instance: Opiates and laxatives, Steroids and bisphosphonates, An ACE inhibitor or furosemide together with a potassium-sparing diuretic, Nonsteroidal medications and a stomach-protecting substance.

Drug interactions for some diseases should be avoided since they are highly likely, but they may be tolerated for other diseases. For instance:

Although beta-blockers should not be used without caution in cases of asthma because of their positive effects on lowering cardiovascular risk, these warnings should not be taken as gospel. Since COPD frequently masquerades as “asthma” and has low beta-receptor responsiveness, cautious beta-blockade that is started in the hospital while keeping an eye on lung function may be suitable. Cardiovascular disease is common in diabetics, and the advantages of beta-blocker typically outweigh the risks. Although fludrocortisone (for postural blood pressure drop) will increase hypertension and produce ankle edema, it may be reasonable to accept the risk of hypertension if the postural drop is so severe that the patient is unable to move. If this is the best treatment option for a patient with chronic venous insufficiency, amlodipine may make their ankle edema worse.

12. Conclusion

Long life is not always equal to quality and good living, so focus should be on the health span, rather than the lifespan to decrease the burden of old age. WHO defines healthy aging as the “process of developing and maintaining the functional ability that enables wellbeing in oldage.” Understanding the decline in functional ability of each biological system and identifying common biological targets and strategies based on the hallmarks of aging are key to delay in gage-associated decline. Identifying and avoiding the polypill can lead to better outcomes in the elderly patients and also helps in improving the quality of life by frequent prescription review to avoid adverse effects thence frailty.