Medicines Reconciliation and Prescribing in the Elderly

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?

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.
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