Review diagnoses and identify therapeutic objectives

• Reduce potential for harms from drugs
• Ameliorate effects of dementia
• Minimise potential for future episodes of delirium
• Maintain physical function and minimise symptoms 

Review need for essential drugs (only stop with expert advice)

• Levothyroxine to treat hypothyroidism, but check for overtreatment

Review the need for unnecessary drugs – consider stopping or reducing dose (deprescribe)

• Huge medication burden
• Review need: bisphosphonate, sedation, antidepressant, PPI and oxybutynin
• Clopidogrel plus rivaroxaban is rarely indicated
• Trimethoprim prophylaxis – no evidence beyond 6 months

Identify if therapeutic objectives are being met

• Target control: Pursuing surrogate targets (BP, HbA_1C, cholesterol) may not be appropriate in this case, and causing harm
• Symptoms and daily function likely to assume greater importance
• COPD: Check FEV1 and review treatment – ensure correct inhaler technique

Identify patient safety risks

Identify adverse drug effects

• Risk of lactic acidosis: On high dose metformin and tight HbA1_c Reduce dose (deprescribe) as eGFR 38, and consider stopping
• Risk of hypoglycaemia: Gliclazide should be stopped
• Risk of acute kidney injury: Review ACE + diuretic + metformin
• Risk of paracetamol intoxication: weight <50 kg reduce dose
• Risk of falls: sedation (mirtazapine, zopiclone); anticholinergic (oxybutynin); hypoglycaemia (antidiabetics); hypotension (antihypertensives)
• Risk of Fractures: reduced by bisphosphonate and calcium plus vitamin D supplementation, but decision to continue should be in context of NNT
• Risk of bleeding: either stop DOAC or clopidogrel. Dose reduction of rivaroxaban required (creatinine clearance 19 ml/min)
• Risk of myalgia: review statin dose
• Sick Day Rules guidance

Opportunities for cost minimisation (e.g. generic substitution) should be explored

Ensure prescribing in keeping with current formulary recommendations

Does the patient understand the outcomes of the review?

Ensure drug therapy changes are tailored to patient preferences

Agree and Communicate Plan

• Patient Preferences and understanding:
  • COPD management: Check symptom control and inhaler acceptance
  • Consider whether patient has capacity to engage with review process
  • Ensure that carer views and expectations are heard and balanced, especially if carer has power of attorney
  • Discuss the effort required for the existing regimen
  • Consider narrowing medication to most effective agents and check understanding of risk versus benefit
  • Incorporate review into wider anticipatory care planning discussions
  • Consider adherence. If tablets are being missed and blood sugar control is tight, there is a severe risk of hypoglycaemia if compliance suddenly improves