Doctors need to take holistic view of patient medications

The Royal Australasian College of Physicians (RACP) is encouraging doctors to take a
holistic view of medication use with research revealing Australians over 65 take 5.6
medications each year on average* – a potentially risky amount according to multiple

According to the RACP, medication-related harm in elderly patients rises once the number of
regular medicines they take exceeds five and rises exponentially at eight or more.
RACP President, general physician and geriatrician Dr Catherine Yelland says although
medications are a crucial part of patient care, there are a variety of risks around
polypharmacy in the elderly including increased incidence of falls, increased frailty, and
increased mortality.**

“A large proportion of elderly patients will have three or more diagnosed chronic illnesses
making simultaneous management of these conditions and symptoms incredibly
challenging,” explained Dr Yelland.

“It is important doctors take a holistic of view of all medications that the patient is on – not
just those associated with the specific issue that the patient is seeing them for. This should
also consider over-the-counter and complementary medicines.

“It’s only when we have a complete picture of each patient that we can weigh up the benefits
and risks of each drug, how each interacts with others, and the risks and benefits of stopping
a particular medication.

“As older Australians are likely to be seeing multiple doctors, open conversations and shared
decision-making between doctor and patient regarding medications is vital.
“It’s also equally important that there is effective communication across the various clinical
disciplines. Every one of our patients should know and be reassured that their doctors are
talking to each other.”

Medicines that deserve particular attention are benzodiazepines and other sedativehypnotics,
anti-psychotics, hypoglycaemic agents, antithrombotic agents, anti-hypertensives,
and anti-anginal agents.

The recommendation is one of five made as part of the Internal Medicine Society of Australia
and New Zealand’s (IMSANZ) Evolve list. Evolve is a partnership between the RACP and its
affiliated Specialty Societies which aims to improve patient care by identifying and reducing
tests, interventions and procedures that are overused, inappropriate or of limited

The full list of IMSANZ recommendations are below.

  1. Avoid medication-related harm in older patients (>65 years) receiving five or more
    regularly used medicines by performing a complete medication review and
    deprescribing where appropriate.
  2. Don’t request daily full blood counts, erythrocyte sedimentation rate (ESR) or Creactive
    protein (CRP) as measures of response to antibiotic treatment if patients are
    clinically improving.
  3. Once they have become afebrile and tolerant of oral antibiotics, don’t continue
    prescribing intravenous antibiotics to patients with uncomplicated infections and no
    high-risk features.
  4. Don’t request Holter monitoring, carotid duplex scans, echocardiography,
    electroencephalograms (EEGs) or telemetry in patients first presenting with
    uncomplicated syncope and no high-risk features.
  5. Don’t request computerised tomography pulmonary angiography (CTPA) as the firstchoice
    investigation in patients with low risk of venous thromboembolism (VTE) by
    Well’s score. Instead request D-dimer and perform imaging only if levels are
    elevated, after adjusting for age.

*Britt H, Miller GC, Henderson J, Bayram C, Harrison C, Valenti L, Wong C, Gordon J,
Pollack AJ, Pan Y, Charles J. General practice activity in Australia 2014–15. General
practice series
no. 38. Sydney: Sydney University Press, 2015.
**Gnjidic D, Hilmer SN, Blyth FM, et al. Polypharmacy cutoff and outcomes: five or more medicines
were used to identify community-dwelling older men at risk of different adverse outcomes, The
Journal of Clinical Epidemiology, 2012; 65: 989–995

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