Medication Review in Older Adults

A medication review is a structured, critical examination of all of a person’s medicines to agree an optimised regimen, reduce harm and cut waste. It combines reconciliation, assessment of adherence, clinical appraisal and shared decision making. Regular polypharmacy means 5 or more medicines, and 10 or more is high-risk polypharmacy.

Frequency. At least once a year. Repeat every 6 months with 10 or more medicines or frailty, within 7 days of hospital discharge, and after any fall, delirium, admission or new high-risk drug.

Preparation. Ask the person to bring every container, including over-the-counter, herbal and borrowed medicines.

Steps.

• Reconcile: confirm what is taken against what is prescribed and by whom.
• Indication: confirm each drug still has a clear current indication.
• Effectiveness: check the treatment goal is met.
• Safety: check dose against weight and creatinine clearance, interactions, duplication and adverse effects.
• Adherence: ask about swallowing, cost, beliefs, side effects and dosing complexity.
• Goals: align with the person’s priorities and expected survival.

High-risk drugs to prioritise. Anticoagulants, insulin, opioids, digoxin, diuretics, NSAIDs, benzodiazepines, antipsychotics and methotrexate. Methotrexate must be taken once weekly, never daily, with folic acid 5 mg orally once weekly on a different day.

Omissions. Look for indicated drugs not prescribed: an anticoagulant in atrial fibrillation with a CHA2DS2-VASc score of 2 or more, a statin after myocardial infarction or stroke, an ACE inhibitor in heart failure with reduced ejection fraction, bone protection after fragility fracture, and a laxative when an opioid is prescribed.

Special groups. Care-home residents need a named reviewer and a documented indication for every as-needed drug. Where care is shared across facilities, give the person a patient-held list of current medicines. Ask about herbal products and khat, which raise blood pressure and heart rate and suppress appetite.

Adherence aids. Blister packs, once-daily regimens, pictorial schedules for low literacy, and carer supervision.

Tests. Creatinine and eGFR, sodium, potassium, liver tests, full blood count, HbA1c, thyroid function, vitamin B12 in long-term metformin use, and lying and standing blood pressure.

Drug levels. Digoxin trough 0.5 to 0.9 micrograms/L; check lithium and phenytoin levels when renal function or interacting drugs change.

Renal and hepatic. Recalculate creatinine clearance at each review and compare with every dose threshold.

Follow-up. Reassess 2 to 4 weeks after any change.

Actions. Stop, reduce, switch, start or continue, and record the reason for each. Share the plan with the person, carers and all prescribers, and give written information.

Common errors. Reviewing the list without the containers, changing many drugs at once, and failing to inform the specialist who started a drug.

Referral and escalation. Refer to a clinical pharmacist or geriatrician for 10 or more medicines with frailty, repeated adverse events, uncertain indications or disagreement among specialists.