Key messages

  • Look out for the signs of medication issues among older patients.
  • Assessing a patient’s medications should include taking a medication history.
  • Medicines should be reconciled on admission, discharge and transfer of care to avoid errors.
  • It is important to be aware that an older patient’s medications may be placing them at risk of decline. Consider the signs of medication issues.

Identifying people at risk

A patient is considered at risk of medication issues if they:

  • are aged over 65 years
  • take five or more medicines
  • have conditions that are commonly associated with preventable medication-related hospital admissions – such as asthma/COPD, depression, cerebrovascular event, hip fractures, renal failure, acute confusion, bipolar disorder and hyperkalaemia1.
  • are identified as at risk of falls or have decreased mobility – some medications can alter balance and coordination
  • have a cognitive or sensory impairment – the patient may not be able to follow medication instructions
  • are identified as at risk of under-nutrition – nutrition and hydration play a major role in the absorption of medications
  • are identified as at risk of incontinence – some medications may cause continence problems
  • are identified as at risk of delirium – some medications can cause delirium
  • are identified as at risk of depression – apathy may impact on the patient’s ability to take medications accurately
  • manage their own medications and live alone or are socially isolated. They may be taking medications inaccurately, or they may have difficulty in accessing medication or seeking support regarding their medication. Conversely, social connectedness helps with medication adherence.2
  • have been recently discharged from hospital - this is a high risk time for medication errors due to the number of medication changes that are typically made during a hospital stay
  • have poor literacy or are from a non-English speaking background - this may impact on their understanding of how and when to take medications and what they are for.

Assessment can inform medication management

If a person is identified as being at risk of or as experiencing medication issues, we need to refer them to the pharmacist and treating doctor for a comprehensive assessment. This will inform our intervention plan. In addition, start by completing a Best Possible Medication History.

Best Possible Medication History (BPMH)

This is a complete medication history that should be taken for each patient identified as being at an increased risk of issues with medication management.

Obtain information for the BPMH by interviewing the patient and a family member or carer.

Collect the following information for the BPMH:

  • current dosing schedules
  • duration of treatment
  • current indications
  • allergies and ADRs (including a description of the reaction)
  • current levels of adherence (the extent to which a patient follows the agreed instructions or recommendations for taking a medication as given by the health care provider).

Confirm the information through other sources, such as the patient’s medicine containers and medication list, their family (particularly if the person is quite unwell, has a cognitive impairment or receives assistance from someone to take their medications), GP, community pharmacy and other health services.

Medication reconciliation

To avoid errors in transcription, check that all of the medications the patients should be taking are what they are actually taking.

Repeat this process on admission, discharge and transfer of care between healthcare settings, for example, from the Emergency Department to the General Medical Ward.

To reconcile medications prescribed:

  • verify against medicines ordered on the medication chart
  • compare to admission, transfer and discharge orders
  • resolve any discrepancies with the prescriber.

Reviewing the medications list

When complete, the medications list should be reviewed to focus on medications that are associated with the development of geriatric syndromes.

Targeting medications with the highest risk of causing injury could prevent more adverse drug events and emergency department visits.1,2,3 These medications include Warfarin, Insulin, Digoxin, narcotics, opiates and sedatives. If an older person is taking any of these medications, discuss them with the treating doctor and refer to the ward pharmacist for further assessment. Along with the team’s clinical judgment, use the prescribing appropriateness criteria and the STOPP/START tool to minimise inappropriate prescribing during the review process.


1. Kalisch, L., Caughey, G. E., Barratt, J. D., Ramsay, E., Killer, G., Gilbert, A. L., Roughead E. E., Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm'. International Journal for Quality in Health Care 2012. 24: pp. 239-49.

2. Dimatteo, M.R., Giordani, P.J., Lepper, H.S., Croghan, T.W., Patient adherence and medical treatment outcomes: a meta analysis. Medical Care 2002. 40: pp. 794-811.

3. Fick D., Cooper, J., Wade, W., Waller, J., Maclean, R., Beers, M. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Archives of Internal Medicine 2003. 163: pp. 2716-24.

4. Petty, D. Can Medicines Management Services Reduce Hospital Admissions?, The Pharmaceutical Journal 2008. 280: pp. 123-26.