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?



  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: 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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