Review diagnoses and identify therapeutic objectives

• Patient reports: feeling tired and short of breath

• Therapeutic objectives: Improve ability to self-manage and interact socially; reduce ankle swelling; reduce sedation; reduce falls risk

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

• None

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

• Thiamine – may be redundant if well-nourished in care home.
• Bendroflumethiazide – No longer hypertensive. Potential for withdrawal
• Tramadol – Indication unclear (may have been started after surgery)
• CNS medication (trazodone, amisulpride) – Indication unclear.
  • Consider withdrawal if not agitated (See 3.3)
• Antihistamine and emollient: Required for itch? Clarify cause (i.e. dermatological versus CNS problem or drug side effect). If dermatological problem, non-pharmacological measures e.g. attention to washing powder, natural fabrics, reducing use of perfumed products etc., as well as regular use of emollients in sufficient quantity

• Antimicrobial cream: Should only be used short term so this can be stopped

Identify if therapeutic objectives are being met and whether therapy should be added or intensified

• Thyroid function: Check TFT and correct hypothyroidism if present
• Ankle swelling and shortness of breath: Consider presence of LVSD. Potentially highly effective treatment available (ACEI/ARB, Beta-blocker) if present. Consider ECG, ECHO, BNP
• Reduce falls and fracture risk: Falls risk mainly associated with sedative load; fracture risk modification with osteoporosis prevention (e.g. bisphosphonates) could be considered. Decision to treat needs to be balanced against expected efficacy (See NNT) and ability to comply with treatment.  Dental health needs to be considered if moving to active treatment. Unlikely to have time to benefit if life expectancy felt to be <  1 year

Identify patient safety risks

Identify adverse drug effects

• Actual ADR: Over sedation
• Risk of CVD events: Antipsychotics carry a markedly elevated risk of cardiovascular events in dementia (See Section 3.3)
• Risk of cognitive deterioration: Antipsychotics, antihistamines, tramadol
• Risk of falls and fractures: Antipsychotics, antidepressant (sedative), antihistamines
• Risk of serotonin syndrome: Tramadol and antidepressant
• Risk of steroid adverse effects (topical and systemic): High dose topical steroid
• Risk of acute kidney injury: Stop bendroflumethiazide if dehydrated
• Sick Day Rules guidance: Ensure staff have clear information on prescription to withhold if dehydrated.

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

Ensure prescribing in keeping with current formulary recommendations

Are the outcomes of the review clear?

Are changes the patients preferences?

Agree and communicate plan

• Preferences and understanding: Involve patient where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place
  • Reduce risk of falls and fractures: Reduce trazodone and amisulpride to reduce sedation and falls risk: decision to start bisphosphonate should balance ability to take versus expected benefit.