Beyond Disease-Centred Care: Frailty, Polypharmacy and What Matters Most

A conversation with Professor Mirko Petrovic (Part 2)

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Interviewers: Sirin Zelal Sahin Tirnova & Ezgi Pinar (ECGI Blog co-leaders)

Interviewee: Prof. Mirko Petrovic

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Welcome to the second part of our conversation with Professor Mirko Petrovic. In this section, we explore some of the themes that have shaped Professor Petrovic’s work over many years, including polypharmacy, frailty, interdisciplinary collaboration, and the future of personalized prescribing in older adults. As always, his reflections combine scientific insight with a deeply patient-centred perspective.

The third and final part of this interview, Building a Career in Geriatrics: Advice for the Next Generation, will be published next week—stay tuned!

ECGI Blog: Do you feel your work on polypharmacy and appropriate prescribing has had the clinical impact you initially hoped for, or do you think there is still a significant gap between evidence and real-world practice? In particular, how important is collaboration with other specialties in improving awareness and implementation?

Professor Petrovic: I think it's a very good question and also I'm pleased with the question because it is also something that belongs to my interest for many years. I think we have clearly made progress. Twenty or thirty years ago, inappropriate prescribing in older adults was often seen as inevitable, whereas today medication appropriateness, structured medication review, and deprescribing have become integral components of mainstream geriatric practice. Structured medication review tools, including STOPP/START and others, have helped move the field forward significantly.

That said, there is still a substantial gap between evidence and real-world practice. We know that inappropriate prescribing contributes to falls, delirium, hospitalizations, and loss of function, yet implementation remains inconsistent across healthcare systems and even between hospitals in the same region. One challenge is that prescribing decisions are often fragmented across multiple specialties, each focused understandably on disease-specific guidelines.

This is exactly why collaboration with other specialties is so important. Polypharmacy cannot be addressed by geriatricians alone, because our patients, older patients, frequently visit other specialties too. The most successful initiatives I have seen are those where geriatric principles are integrated into multidisciplinary care pathways rather than added afterwards as an external recommendation.

I believe education is one of the most important drivers of change. Twenty or twenty-five years ago, geriatric pharmacotherapy was not part of the medical curriculum. Today, however, it has become an established component of training, at least at our university, and I hope this is increasingly the case elsewhere as well. As a result, medical students and young physicians are introduced early in their careers to the challenges of polypharmacy, implementation gaps, and the importance of interdisciplinary collaboration. Compared with two decades ago, awareness and education in this area have improved considerably.

We need to move from the idea that deprescribing is “stopping treatment” to recognizing it as active, patient-centered prescribing. The future lies in collaborative models where medication appropriateness is embedded across specialties and becomes a shared responsibility throughout the healthcare system.

ECGI Blog: In settings where subacute care is not available, how can clinicians establish effective care pathways for older adults presenting to the emergency department? Do you think tools such as the Clinical Frailty Scale (CFS) or ISAR are feasible for use by emergency department personnel? Would you recommend any additional tools?

More broadly, how can a relatively small geriatric team contribute to hospital-wide identification and management of frailty? What models have you found effective in integrating geriatric expertise across departments?

Professor Petrovic: Even in settings without dedicated subacute care, it is still possible to create more geriatric-friendly emergency pathways. The key is early identification of vulnerable older adults combined with streamlined multidisciplinary assessment and discharge planning.

I think frailty screening should not be viewed as an isolated intervention, but as part of a broader process. In practice, there are three essential steps: screening, assessment, and implementation of person-centred care. If a screening test identifies a patient as potentially frail, this should be followed by geriatric assessment. Based on that assessment, individualized interventions and care pathways can then be developed.

For this reason, emergency departments should be aware of the value of frailty screening from the moment older adults enter the hospital. Screening helps clinicians move beyond disease-centred decision-making and consider the broader context of the individual patient. It allows treatment decisions to be tailored according to frailty status, functional reserve, care dependency, and overall goals of care.

Tools such as the Clinical Frailty Scale and ISAR are certainly feasible in emergency departments because they are relatively quick and practical. The Clinical Frailty Scale, in particular, has gained wide acceptance because of its simplicity and clinical relevance. However, no tool should replace clinical judgment.

Frailty screening is valuable only when it triggers a defined assessment and management pathway. Identifying frailty has limited value unless it leads to medication review, mobility assessment, delirium prevention, or improved care coordination.

For example, an older patient presenting with a cardiac condition may be considered for invasive investigations and interventions under a traditional disease-focused approach. However, if a comprehensive geriatric assessment reveals severe frailty and significant care dependency, a different strategy may be more appropriate. In such cases, the focus may shift toward supportive, adapted, or even palliative care rather than pursuing interventions that are unlikely to improve outcomes. Frailty assessment therefore helps ensure that care is both appropriate and aligned with the patient’s needs and priorities.

To make this approach successful, hospitals need access to geriatric expertise. This begins with the recognition of geriatric medicine as a specialty and the presence of a geriatric team capable of coordinating these processes. Importantly, many older adults with a geriatric profile are admitted to non-geriatric wards, where their needs may be overlooked if staff are not familiar with geriatric principles.

For smaller geriatric teams, embedding geriatric principles throughout the hospital is often more sustainable than trying to directly manage every frail patient. Effective models include liaison geriatrics, embedded consultation services, frailty pathways in surgery and emergency medicine, and education programs for non-geriatric teams.

In Belgium, one effective model has been the development of geriatric liaison teams. These teams work across the hospital and become involved when frailty screening is positive. They perform further assessment and provide individualized recommendations for patient management. In some cases, they may recommend additional interventions; in others, they may advise against unnecessary investigations or treatments that are unlikely to provide meaningful benefit.

In many hospitals, the greatest impact comes when geriatricians act as system enablers rather than solely as consultants. Building partnerships across departments allows geriatric expertise to influence care far beyond the capacity of the geriatric team itself.

ECGI Blog: Given your unique background in both geriatrics and clinical pharmacology, how do you see the future of personalized prescribing in older adults?

Professor Petrovic: I believe personalized prescribing in older adults will increasingly move beyond disease-based prescribing toward function-based and goal-oriented prescribing. Prescribing in older adults has already improved considerably over the past decades. Better education, closer collaboration with clinical pharmacists, structured medication reviews, and greater awareness of deprescribing have all contributed to more appropriate medication use. However, there is still significant room for further progress.

Chronological age alone tells us very little. What matters is frailty, cognition, functional status, life expectancy, treatment burden, and patient priorities. Two patients of the same age may require completely different prescribing approaches. A medication may be considered appropriate according to guidelines, but that does not necessarily mean it remains meaningful for a particular patient. As health status changes, treatment goals may also change. For example, medications that were beneficial earlier in life may no longer provide meaningful benefit for a patient with advanced disease or limited life expectancy.

Advances in pharmacogenomics, digital decision support, artificial intelligence, and real-world data analytics may help improve prescribing precision, but technology alone will not solve the problem. The challenge in geriatrics is not simply predicting drug response—it is balancing competing priorities in complex patients.

I think the future lies in integrating biological, functional, and patient-centered data into prescribing decisions. Medication appropriateness should become dynamic and continuously reassessed as patients’ conditions evolve.

Most importantly, personalized prescribing must remain grounded in what matters to the patient. In older adults, the best prescription is not always the one that maximizes disease-specific outcomes, but the one that best preserves function, independence, and quality of life.