One-Minute Read… 

Medicines Reconciliation and Prescribing in the Elderly

By @clairemchale

• Polypharmacy

Appropriate: ‘prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence.’

Problematic: ‘The prescribing of multiple medicines inappropriately, or where the intended benefit of the medicines are not realised.’

• We should demonstrate ‘a person centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines’
• Shared decision making is an important part of this- the decision about whether to take a medication or not is different for each person. We need to ensure patients are informed about their medication.
• We should share relevant information about the person and their medicines when a person transfers from one care setting to another.
  • What this means in the ED:
    • Notify GP if there is a change in medication OR if medication list is complex, note that there has been NO CHANGE to medications
    • Check allergy status is up to date on Symphony
    • What information has been given to the patient
    • Any other information: if review is required, monitoring
  • One group for which this is particularly relevant is the elderly
    • Medications often interact and/or cause significant side effects which may be poorly tolerated.
    • The STOPP/START tool has been devised with this in mind
      • List of 92 potentially inappropriate prescriptions (STOPP)
        • Particular emphasis on:
          • Loop diuretics
          • Aspirin, warfarin
          • TCAs
          • NSAIDS
          • Antimuscarinics
        • List of 40 medications which are important to minimize side effects
          • Good cardiovascular preventative measures e.g. ACEi in CHF
          • Warfarin or aspirin for AF
          • Osteoporosis prevention/treatment(1, 2)
        • We should share information ideally within 24 hours of the person being transferred
        • Medicines reconciliation should be carried out by a trained and competent health profession with the necessary knowledge, skills and expertise including
          • Effective communication skills,
          • Technical knowledge of processes for managing medicines
          • Therapeutic knowledge of medicines use(3)

What does this mean in the ED?

• We should ensure we ask about medication history and note doses and frequency
• Think about possible medication (iatrogenic) causes for presentation
• Consider stopping harmful medication BUT ensure there is adequate safety netting e.g. ask GP to review and tell patient to make an appointment to see GP within a timeframe for example 1 week.

**Always ask senior colleagues if unsure about a particular course of action**

• NB if medication is in a dosset box this more complicated – sometimes medication can be removed but ask HRDT +/- pharmacy for advice
• If not immediately problematic ask GP to stop/start a medication

We are not pharmacists BUT prescribing safely is an essential part of our job.

Interested in learning more about GEM?

• Check out the MDTea podcasts: https://itunes.apple.com/gb/podcast/the-mdtea-podcast/id1073719746?mt=2
• RCEMLearning have featured a mini series on GEM in their recent podcasts: https://www.rcemlearning.co.uk
• If you are super keen the RCP has a diploma in elderly medicine:

https://www.rcplondon.ac.uk/diploma-geriatric-medicine

References:

1. O’MAHONY D, O’SULLIVAN D, BYRNE S, O’CONNOR MN, RYAN C, GALLAGHER P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing. 2014;2015(44):213-8.
2. Ryan C. The basics of the STOPP/START criteria [Available from: http://www.pcne.org/upload/ms2011d/Presentations/Ryan pres.pdf.
3. NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes 2015. Contract No.: NG5.