Several conditions and many medicines: reviews, side effects and keeping track

A long list of medicines can be exactly right. Someone with heart failure, type 2 diabetes and arthritis may need a medicine for each, and stopping any of them could do harm. The difficulty is that each medicine is usually started for one condition at a time, often by a different clinic, and the guidance each prescriber follows was written with that one condition in mind. NICE makes this point in its guideline on multimorbidity: the evidence behind single-condition guidance is often drawn from people who do not have several conditions and are taking fewer medicines.

So the combination needs looking at as a whole. The aim is the right medicines for this person now, which can mean fewer, a change of time or form, or adding something that has been missed. If one condition is the main worry, the condition guides go further: heart failure at home and high blood pressure in later life both cover the medicines involved.

A side effect is easy to mistake for a new illness or for getting older. Unsteadiness, tiredness, constipation, a dry mouth, poor sleep or a low mood can all have several causes, and a medicine is one possibility to rule in or out. NICE asks the clinician at a review to find out whether each medicine is helping or causing harm, and where the person is unsure of the benefit or is having harms, to discuss reducing or stopping it and plan a review to see how the change goes.

That is a decision for the prescriber with your relative, never one to make at the kitchen table. If a tablet seems to be the problem, ring the GP surgery or ask the pharmacist, and keep giving it as prescribed unless they say otherwise. If your relative has had a fall, mobility and falls care covers the other things that help reduce the risk of another.

The list matters most when your relative moves between places. NICE guidance on medicines optimisation says that when someone leaves hospital they, and their family or carers where appropriate, should be given a complete and accurate list of their medicines, including any changes made during the stay. It also says the GP practice should check the medicines against that information within a week of receiving it. Bring the new list home, compare it with yours, and ask the ward or the pharmacy about anything that does not match before the old boxes go back in the cupboard. Our guide to what to arrange when someone is leaving hospital covers the rest of the discharge.

Keep one copy beside the medicines, one in your relative’s bag, and a photograph on your phone.

The NHS App can help with the ordering. Through family and carer access, the NHS says you may be able to request and manage another person’s repeat prescriptions, book appointments for them, or see their test results, depending on the access their GP surgery agrees. The surgery sets it up and checks your identity, and the NHS says both of you need to be patients at the same surgery. The NHS page on family and carer access in the NHS App explains how to apply.

If the difficulty is remembering which tablet goes when, packaging can help, and the pharmacist decides what suits. What a dosette box is explains the weekly boxes, and whether blister packs are being phased out explains why pharmacies now offer original packaging first.

In England, NHS England expects clinical pharmacists working in GP practices to lead these reviews, with the GP and the wider practice team helping. Practices are asked to find people who would benefit, and the groups NHS England names include people taking ten or more medicines, people in care homes, people with severe frailty who are housebound or isolated, people who have recently been in hospital or had falls, and people on pain medicines that can be addictive. Its page on structured medication reviews sets this out.

You do not have to wait to be invited. Ring the GP surgery, say that your relative takes a lot of medicines for several conditions, and ask whether they can have a structured medication review with the practice pharmacist. Say why you are asking, plainly: two falls since the spring, more drowsy than usual, or struggling to keep the routine straight. If your relative has had a fall, NICE’s guideline on falls says a structured medication review should be considered to find any medicines that may be adding to the risk.

The review is your relative’s appointment. NICE asks the clinician to check whether, and how, they would like a partner, family member or carer involved. If they would like you there, they can tell the surgery so. The review should start from what matters to them, such as staying steady on their feet, staying out of hospital, or having fewer tablets to swallow, because that shapes which trade-offs are worth making.

What comes out of it, in NICE’s words, is an individualised management plan. It can include starting, stopping or changing medicines, prioritising appointments, and saying who is responsible for coordinating care. NICE also says copies should be shared, with your relative’s permission, with the people involved in their care, including family and carers. Ask for the updated medicines list before you leave.

The New Medicine Service is worth knowing about because it covers several conditions older people live with together. NHS England lists, among others, high blood pressure, type 2 diabetes, COPD, asthma, heart failure, atrial fibrillation, coronary heart disease, stroke, Parkinson’s disease, osteoporosis, gout, glaucoma and epilepsy, and depression for people aged 18 and over. Its page on the NHS New Medicine Service has the full list. If something has just been started and your relative is finding it hard, this is the moment to say so, because the pharmacist can refer back to the prescriber.

The NHS advises taking unwanted medicines back to the pharmacy rather than putting them in the bin. Suspected side effects can be reported through the Yellow Card scheme.

Where the line falls for a particular carer depends on what they have done before and what you agree together. Can a private carer give medication? sets out the difference between prompting, assisting and administering, and what to write down first. If insulin is part of the routine, insulin at home explains who gives it and how a task is delegated.

Every carer on PrimeCarers has had their identity and right to work checked, holds an enhanced DBS check (or PVG in Scotland, Access NI in Northern Ireland) issued within the last 2 years, and has been interviewed online. Carers are insured while they work. PrimeCarers does not check training or qualifications, so anything a carer says about medicines experience is their own account on their profile, and it is worth asking about at interview. When you are ready to look for someone to help with medicines and appointments at home, you can search for carers near you and compare their rates, meet them first, and agree the visit times around the medicines.

Joining up the appointmentsSection titled Joining%20up%20the%20appointments

Several conditions can mean several clinics, each with its own letters and follow-ups. NICE counts the number of appointments as part of the burden of treatment, and asks clinicians to consider other ways of arranging follow-up so that appointments are coordinated, or fewer. At the review, ask whether any checks can be done on the same day, whether a blood test for one clinic can serve another, and whether some follow-ups could be by phone. Ask too who is coordinating your relative’s care, since NICE says the management plan should name who is responsible.

At home, keep one calendar for every appointment beside the medicines list, and write in anything that changed after each visit.