This guide supports health professionals undertaking medication reviews with people living with frailty.
It highlights issues for frail older people within the framework of a standard comprehensive medication review.
This guide can be used within the emergency department and all hospital and community healthcare settings.
If a person living with frailty is considering surgery or other procedures, a targeted medication review is required. This may involve the proceduralist and anaesthetist.
For people from culturally and linguistically diverse backgrounds, use interpreters to establish goals, gather information and communicate the outcomes of the review directly with the person.
Align the medication review with the person's goals
- Identify the objectives of the medication therapy by asking the person, ‘What matters to you?’
- Establish realistic treatment objectives through shared decision making.
- Consider all short and long-term, specific therapeutic and medication management goals.
- Assess all diagnoses, geriatric syndromes, current and recent nutrition and physical activity.
- Review a reconciled list of all current medications (including vitamins, supplements and immunisation history), considering overall risk of medication-related harm.
- Number of medications (prescribed or non-prescribed).
- Medication interactions with other medications, diseases, nutrients or geriatric syndromes.
- Cumulative risk from specific medication combinations, for example anticholinergic and sedative medications, medications with similar side effects (such as nausea, vomiting, dry mouth, taste disturbances, altered bowel habits) and medications contributing to falls, sarcopenia, osteopenia, and reduced exercise tolerance.
- Adherence to medicines, including use of devices, cost and accessibility, and reasons for non-adherence if present.
- History of previous adverse medication reactions.
Review each medication on the person’s reconciled medication list
- Is there a valid current indication?
- Does it help the person achieve what matters to them?
- Is it essential for symptom control or physiological replacement?
- Is there enough time to benefit from preventative medications?
- Is there a better non-pharmacological or pharmacological alternative?
- Is the person achieving the desired therapeutic effect?
- Is the person experiencing, or at high risk of, adverse effects?
- Is the medication being used to treat an adverse effect of another medication?
Decide whether to continue or deprescribe each medication
- If the medication should be continued, then:
- review the dose, considering pharmacokinetic or pharmacodynamic changes in frailty
- consider changes in dietary intake, supplements, or exercise to improve tolerability.
- If the medication should be deprescribed, then plan to cease or wean it, with close monitoring. Replace with non-pharmacological therapy, if warranted (for example exercise with anxiolytic, sedative hypnotic or antidepressant deprescribing).
Address potential undertreatment
- Is there an untreated condition that may benefit from non-pharmacological treatment or a trial of medication to help the person achieve what matters to them?
- Align the person’s problem list with the reconciled medication list.
Simplify overall regimen, optimise formulations, advise on adherence aids if required
- Consider long-acting formulations.
- Consider combination formulations.
- Minimise total number of times for medication administration.
- Think about the person’s ability to cut tablets and to swallow them.
Clearly communicate the outcomes to the relevant people, in writing and verbally
- Relevant people are the person, caregivers and other healthcare providers (such as doctors, pharmacists, nurses and allied health professionals).
- Where possible, adjust medications incrementally to assess effect of each change.
- It is possible to make changes, more rapidly, with close clinical supervision. For example as an urgent response to adverse medication effects or after comprehensive review in hospital.
- Ensure that relevant people involved in the person’s care understand the outcomes of the review, including:
- changes made
- reasons for changes
- monitoring plans
- follow-up appointments required.
- Document the changes and subsequent outcomes, so the information is available to all healthcare providers involved in the person’s care.
- Ensure that the person is willing and able to take medication therapy as intended. If adherence with medication therapy is an issue, then consider administration aides and/or supervision with medications.
Published September 2021