Anticholinergics: These include antidepressants, overactive bladder meds, antihistamines, anti-emetics.

See: Anticholinergics | Right Decisions (scot.nhs.uk)

• Check that the indication is still relevant.
• These medicines increase the risk of cognitive impairment, blurred vision and drowsiness. Toxicity is often the cumulative effect of several of these medicines.
• Check the full list of medicines that the patient is prescribed, and if an anticholinergic burden (ACB) score has been calculated: ACB calculator

• Consider effectiveness and necessity.
• Optimise emollients for dry, itchy skin.
• Calculate ACB score.
• Discuss rationalising medicines on ward round.

Analgesics

• Check that the indication is still relevant.
• Is pain relief being achieved with the current prescription or is a review required?
• Consider GI protection if NSAIDS are prescribed, and ensure that renal function has been checked.
• If opioids are prescribed, ensure that the duration is limited and laxatives are prescribed.

• Avoid opioids where possible, including tramadol in older adults.
• Stop NSAID if AKI, hypotension or D&V.
• Review on ward round.

Atypical Analgesics:

Eg: amitriptyline, duloxetine, gabapentin, pregabalin.

• Check that the indication is still relevant.
• These medicines can cause neuropsychiatric side effects and hypotension.
• Look for low BP and orthostatic hypotension.

• Consider indication and dose reduction but avoid abrupt withdrawal.
• Ensure review on ward round.

Antibiotics

Eg: gentamicin.

• Risk of vestibular injury.
• Review dose and duration.
• Counsel patients. See PIL: Gentamicin - your hearing and balance (NHS Highland intranet access required)

Anticoagulants

• Check that the indication is still relevant.

• Consider withholding if head injury or active bleeding, unless for metal valve or recent or high risk recurrent PE.

Anticonvulsants

• These medicines can cause sedation, disorientation and impaired balance.

• These are time critical medicines. Do not withhold unless immediate concern.
• Ensure relevance but do not stop abruptly without consultant discussion.

Antidepressants

• Check that the indication is still relevant.
• Check that there has been a timely review with initial prescriber.

• Review on ward round.

Antipsychotics

• Check that the indication is still relevant.
• Check what the indication is, do antipsychotics have a role and have they been regularly reviewed for efficacy?
• Are there symptoms of distress and what are the trigger factors for distress?

• Avoid abrupt withdrawal, but consider clinical need and discuss dose alterations with MHLT.

Benzodiazepines and Z drugs.

• Check that the indication is still relevant.
• Review indication and dose.

• Avoid abrupt withdrawal but review clinical need and benefit on ward round.

Bladder medicines

Eg: tamsulosin, solifenacin, tolterodine.

• Check that the indication is still relevant.
• Look for low BP and orthostatic hypotension.
• Is there evidence of efficacy documented?

• Has patient been catheterised since admission?
  Keep, if planning to remove catheter.

Blood pressure lowering drugs

Eg: ACE Inhibitors, alpha blockers, diuretics.

• Check that the indication is still relevant.
• Look for BP consistently <140/80mmHg.
• Is there evidence of AKI or electrolyte imbalance?
• Obtain a lying and standing BP.
• Does the patient suffer dizziness on standing?

• Consider indication and withhold if possible.
• Review dose if AKI.
• Review on ward round.

Eye treatments

• Risk of blurred vision if not administered.

• Check time of prescribing.

• Check that the indication is still relevant.
• Are BMs <6
• Recent HbA1C

• Withhold sulphonylurea if BMs <6.
• Involve Diabetes Specialist Nurse.
• Review on ward round.

Muscle relaxants

Eg: baclofen.

• Check that the indication is still relevant.
• Review indication and dose.
• If recently started, does this coincide with increase in drowsiness.

• Reduce dose or withhold if possible.
• Review on ward round.

Parkinsonian medicine

• These are time critical medicines.
• Check that the correct dose, formulation and times are prescribed.
• Is the dose too much or too little?
• Be aware of medicines that are contraindicated in Parkinson’s, eg: metoclopramide, prochlorperazine, haloperidol.

• These are time critical medicines. Ensure that all staff caring for the patient are made aware.
• Refer to patients usual Parkinson’s consultant.