Older adult pharmacy resources

Signposting
i
Authors:
British Geriatrics Society
Topics:
Prescribing and medication management
Date Published:
24 September 2024
Last updated: 
24 September 2024

The BGS Pharmacy Group have assembled a list of helpful resources to guide clinicians on medicines management and deprescribing in older adults.

General polypharmacy guidance

Within this section you will find links to guidance for conducting effective polypharmacy reviews.

Explicit tools

These provide background, context and evidence-based framework for optimal use of medicines to support safe reviews (criterion based).

Implicit tools (judgement based)

Implicit tools require judgement, which means they can be subjective and demand more time and clinical expertise.

  • Medication appropriateness index 
    Lists 10 criteria that evaluate various aspects of medication appropriateness (e.g. indication, effectiveness, dose).
     
  • GARFINKEL'S PROCEDURE in Nursing Departments (drugstop.co.il)

    Geriatric palliative methodology study aiming to identify and stop medication in frail patients and assessing intervention vs control group for reduction in mortality rates and referrals to acute care facilities, costs and quality of living.
     

  • ARMOR
    The ARMOR tool (Assess, Review, Minimize, Optimize, Reassess) is an interactive tool which aims to combine recommendation from Beers’ criteria and patient’s functional state and clinical state aiming to balance evidence-based practice with altered physiological reserves.
     
  • NO TEARS 
    The NO TEARS tool goes through process of medication review covering need and indication, open questions, tests and monitoring, evidence and guidelines, adverse events, risk reduction or prevention and simplification and switches.

Prescribing cascades

Prescribing cascades occur when a drug is prescribed to manage side effects of another drug, typically when a side effect is misinterpreted as a new condition.

Shared decision making

Shared decision-making ensures that individuals are supported to make decisions that are right for them. It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment. The conversation brings togethert the clinician’s expertise (such as treatment options, evidence, risks and benefits) with what the patient knows best (their preferences, personal circumstances, goals, values and beliefs).

  • Choosing Wisely 
    Choosing Wisely campaign aims to spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.
     
  • Me & My Medicines, Medicines Communication Charter, It's OK to Ask
    ‘Me and My Medicines’ is a campaign led by patients and supported by clinical staff to help people raise concerns and use their medicines better.
     
  • Realistic Medicine
    Realistic medicine aims to encourage meaningful conversations between health and social care professionals and their service users to base care around what matters most to people, with a shared understanding of what healthcare might realistically contribute to this.

Medicines and falls resources

Medication review forms an essential part of multifactorial falls risk assessment. Below are useful resources for health care professionals undertaking this activity.

Fracture risk assessment and bone health

Fracture risk assessment and management of bone health forms an integral part of frailty care. Below are useful tools and guidance to aid decision making and treatment choice.

  • FRAX ®Fracture Risk Assessment Tool
    UK calculator used to estimate 10-year major osteoporotic fracture risk and hip fracture risk based upon demographic, lifestyle and clinical data.
  • Clinical Guideline for the prevention and treatment of osteoporosis from National Osteoporosis Guideline Group
    This guideline is used to review the assessment and diagnosis of osteoporosis, the therapeutic interventions available and the approaches for the prevention of fragility fractures, in postmenopausal women, and in men aged 50 years or older.
     
  • Management of osteoporosis and the prevention of fragility fractures (sign.ac.uk)
    This guideline provides recommendations based on current evidence for best practice in the management of osteoporosis and prevention of fractures. It addresses risk factors for fracture, commonly used tools for fracture risk assessment, approaches to targeting therapy, pharmacological and non-pharmacological treatments to reduce fracture risk in different patient groups, treatment of painful vertebral fractures and systems of care.
     
  • QFracture
    You can use this calculator to work out your risk of developing any osteoporotic (i.e. hip, wrist, shoulder or spine) fracture or hip fracture alone by answering some simple questions intended for use in the UK.

End of life

Preparing for the end of life and jointly making decisions about treatment choices are important aspects of care of the older person. The following resources may be useful when undertaking this task.

  • Medication Review and Rationalisation of Medicines for Adult Patients with a Limited Prognosis 
    This guidance is intended for use by healthcare professionals in any care setting when conducting a structured medication review and optimising medication for patients  with a limited prognosis (days to short years) due to advanced age, frailty, comorbidity and/or disease, where the goals of care are moving towards optimising symptoms and quality of life rather than prolonging survival.

Opioid review

Historically, opioids have been prescribed to manage chronic pain; however, the clinical evidence shows limited effectiveness and patient safety concerns due to the risks associated with long-term use of opioids such as fractures and falls, endocrine abnormalities, immunomodulation, opioid induced hyperalgesia and dependence.

  • NHS Greater Manchester Integrated Care - Opioid Prescribing for Chronic Pain: Resource Pack
    This document brings together several resources clinicians can use to support the appropriate use and review of opioids used for chronic pain.  The information in this document does not apply to palliative care and end of life care where use of opioids should follow the World Health Organisation (WHO) pain ladder and relevant guidance.
     
  • Live Well with Pain
    Resources aimed at patients who are living with pain and clinical practitioners managing those living with pain.
     
  • Improving the management of non cancer pain – reducing harm from opioids
    Management of ‘chronic non-cancer pain’ requires personalised care and shared decision making at its core with patients requiring a mixture of biopsychosocial support. A whole system approach is proposed to support people to live well with their ‘chronic non-cancer pain’ - this website shares impact and outcomes.

Reviewing antipsychotics

In some people antipsychotics can eliminate or reduce the intensity of certain symptoms. However, they also have serious side effects for people living with dementia. There is concern over the high rates of antipsychotic prescribing in people with dementia due to the associated risks often outweighing the benefits.  As such, antipsychotics should only be considered as a last resort in dementia.

Reviewing antidepressants

Antidepressants have an important role in the therapeutic management of depression and anxiety, when used appropriately in line with the NICE guidelines. However, antidepressant use can become inappropriate which may lead to patient harm from problematic polypharmacy, adverse-effects, or both.

Supporting adherence

Resources aimed at healthcare professionals to help them discuss options for medicines management (to support adherence) with patients.

Anticholinergic burden

Many of the medications that we commonly prescribe have anticholinergic properties. In patients over 65 years of age these can cause adverse events, such as confusion, dizziness and falls.

Monitoring specific medicines/groups of medicines

As part of effective medicines optimisation care, it is important to note monitoring requirements and in particular how these may change in older patients. The following resources provide further information on this subject.

Cardiovascular risk and medication

Useful references when assessing cardiovascular risk and considering polypharmacy in frailty patients is listed below.

Swallowing difficulties

Patients who have swallowing difficulties are commonly encountered in frailty. Resources below offer advice on managing medication in this cohort.

Enteral feeding

Use of enteral feeding and administration of medicines via enteral tubes resources.

  • Enteral feeding and medicines administration - CQC
    CQC advice on considerations to note with regards to medicines administration via enteral tubes.
     
  • Handbook of Drug Administration via Enteral Feeding Tubes
    The information provided in this resource is intended to support healthcare professionals in the safe and effective prescribing and administration of drugs via enteral feeding tubes. It is a comprehensive guide covering the legal, practical and technical aspects that healthcare professionals should consider before attempting to prescribe or administer drugs via an enteral feeding tube.
     
  • Rosemont
    Catalogue of liquid medication available including licenced and special preparations.

Inhalers

Multiple inhaler options and combinations are available for treatment of respiratory conditions – the following are useful resources for patients and prescribers.

  • How to use a pMDI inhaler with a spacer – tidal breathing | Asthma + Lung UK (asthmaandlung.org.uk)
    Asthma UK guide on correct use methodology for inhalers with a spacer.
     
  • RightBreathe
    There are over 120 inhaler device & drug combinations licensed for the treatment of respiratory disease in the UK and it can be challenging for clinicians and patients to identify the product which best meets individual needs. RightBreathe is a web-based resource which provides detailed information on all UK-licensed inhaler products. It is designed to support joint decision-making about product choice and to facilitate appropriate prescribing.

Medication withdrawal

Useful references to aid shared decision making when deprescribing in frailty.

Sleep

Sleep problems are commonly reported by patients. Below is a list of resources aimed at healthcare professionals and patients on addressing insomnia.

Medication podcasts on care of the older adult

Podcasts are available discussing issues of polypharmacy, deprescribing and care of older patients.

Treatment targets

Treatment targets in guidelines do not always account for frailty state and how diminished reserves affect response to treatment. The following articles provide some guidance around treatment targets in frailty.

Related BGS resources

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