Appropriate use of medications, prescribed or otherwise, is the cornerstone of good management of medical conditions.

Adverse drug reactions (ADRs) in older people currently re­present a serious and growing public health problem (Scott I, 2010).

Older people, particularly those with frailty, are more likely to have multiple comorbidities and to be taking multiple medications.

This increases the risk of interactions, but additionally they are more likely to experience drug side effects and to have additional prescriptions written to counter such unintended effects .

 

Polypharmacy is a term commonly used in this context though it simply means the patient is on many medications (typically a cut-off of 4 or 5 is accepted as a threshold suggesting increased risk of interactions and complications).

Polypharmacy and inappropriate prescribing (IP) are well-known risk factors for ADRs, which commonly cause adverse clinical outcomes in older people (Onder G, 2013)].

IP encompasses po­tentially inappropriate medications (PIMs) and potential pre­scribing omissions (PPOs) (O'Connor, 2012).

One patient may be taking only 3 medications, all of which are unnecessary or detrimental, while another may be taking 10, completely appropriate medications at optimal doses with evidence-based indications.

 

Medication review is, put simply, a process by which a patient’s use of medication is carefully reviewed to ensure that each medication taken is used appropriately, optimally, and that its benefits outweigh its harms.

It is a key part of a comprehensive geriatric assessment.

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Periodic routine prescribing review for patients on repeat medication is usually conducted by the GP with the individual patient.

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An in-depth evaluation of all of the patient’s medication (prescribed and non-prescribed) should be especially targeted at those older people known to be at higher risk of medicines-related problems :

 

• Being prescribed 4 or more medicines (Polypharmacy)

Polypharmacy is a particular risk factor in older people for adverse drug reactions and for re-admissions of older patients discharged from hospital (Chu IW, 1999)

 

• Post-discharge from hospital

Changes in medication after discharge may be intentional where the GP decides to modify the hospital’s suggested treatment.

However, unintentional discrepancies in medication are found in half of patients after they have left hospital (Duggan C, 1998).

These include patients or the GP practice restarting medicines that were stopped in hospital, and duplication of treatment (for example, a medicine being prescribed by both its generic and branded names).

By simply sending a copy of the discharge prescription to the community pharmacist, as well as the GP practice, the number of such discrepancies can be halved (Duggan C, 1998).

Discrepancies are also reduced when a pharmacist processes discharge medication in general practices (Randles AJ, 1999).

 

• In care homes

A major study of pharmacist-conducted medication review of all medicines showed that modifications to treatment were needed for half of the medicines prescribed; the most frequent recommendation (47%) was to stop medication and in two-thirds of these cases there was no stated indication for the medicine being prescribed (Furniss L, 1998).

Longer-term follow-up showed the number of medicines prescribed for older people can be reduced with no adverse impact on morbidity or mortality (Furniss I, 2000).

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• Where medicines-related problems have been identified through routine monitoring/assessment

 

• Patients aged over 75

Medicine review should form part of their annual health check

 

• Following an adverse change in health.

Following events such as dizzy spells or confusion, medicines should be reviewed to determine whether they may have caused or contributed to the problem

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• Frail adults with limited life expectancy

         who meet ALL of the criteria listed below:

1.      End-stage irreversible pathology

2.      Poor one year survival prognosis

3.      Severe functional impairment or severe cognitive impairment or both

4.      Symptom control is the priority rather than prevention of disease progression

 

It should be noted that a medication review does not imply a large or whole-scale reduction in prescribing (although that is often the case), and in fact some medications may be increased (to more effective doses) or added (if important indications have not been addressed ).