Multimorbidity

Polypharmacy

Prescribing in the Elderly

You are a primary care pharmacist working in a GP practice.

You are seeing a patient for a routine medication review.

The patient has several long-term conditions and is currently taking multiple medications.

The patient has just had routine blood tests and BP checked, which are all satisfactory.

Your task is to:

1. Review the patient's current medications

2. Identify any medication-related issues

3. Determine whether any medicines may need to be changed, deprescribed, or optimised

4. Discuss and agree a management plan with the patient

You have 10 minutes.

You have access to the BNF.

You have access to the patient’s repeat prescription list: 

• Ramipril 10mg tablet once daily

• Amlodipine 10mg once daily

• Metformin 1g twice daily

• Gliclazide 80mg twice daily

• Apixaban 5mg twice daily

• Simvastatin 40mg at night

• Omeprazole 20mg once daily

• Zopiclone 7.5mg at night 

You are Margaret Thompson (MAR-grit TOM-son)

You have attended the GP practice for a routine medication review with the pharmacist.

You generally trust your doctors but sometimes feel overwhelmed by how many tablets you take.

Opening statement: “The receptionist said you wanted to review my medications. I do take quite a lot of tablets.”

Patient information: 

• Name: Margaret Thompson 

• Age: 78 

• Past medical history:  

• High blood pressure

• Type 2 diabetes

• If asked: “My blood sugars are under control.”

• Arthritis

• If asked what type: “I don’t know.”

• Atrial fibrillation

• Chronic insomnia

• If asked, “I’ve had it for 3 years, since my husband died.”

• Medication History:  

• • “I don’t know the names of my medications off the top of my head, but I can recognise them. And don’t try asking me about a dose, I don’t have a clue.”

  • “I take two tablets a day for blood pressure.”

    • “I’ve been on them years. Not had any issues.”

  • “I take two tablets twice a day for my diabetes.”

    • “I’ve been on them for years. Not had any issues.”

  • “I take a blood thinner twice a day for my heart problem.”

    • “I’ve been on it for 20 odd years. Not had any issues”

  • “I take a sleeping tablet and a cholesterol tablet at night.”

    • “I’ve been on them for years. Not had any issues.”

  • If asked about over-the-counter medicines: “I take Nurofen for my knee pain sometimes - maybe a couple of times a week.”

• Allergies:  None

• Symptoms: 

• • “I don’t have any symptoms. Just the arthritis pain sometimes.”

  • If asked: “No falls.”

  • If asked: “No, I don’t get heartburn or reflux.”

• Lifestyle: 

• Smoking: “I smoked for a bit when I was 15. Those were the good old days.”

• Alcohol: “Maybe one glass of wine on Sundays.”

• Exercise: “Not much since my knees got worse.”

• Living situation: “I live alone but my daughter visits once a week.”

• Diet: “I try to eat healthy but sometimes it’s easier to have ready meals.”

• Weight: “I’m about 70 kg.”
  
  

If asked about medication burden: “Sometimes I wonder if I really need all of them.”

If asked about adherence: “I take all my medications as prescribed. But sometimes I forget when I’ve taken them.”

If asked about omeprazole: “Oh, I try to remember that one, but for some reason I forget it all the time. I’m not even sure what it’s for.”

If asked about zopiclone: “I’ve been taking it for 3 years. I can’t sleep without it.”

If asked about STOPPING zopiclone: “I can try cutting down maybe?”

If asked about STOPPING ibuprofen/Nurofen: “I haven’t tried anything else. I know it works well, but I’m happy to try other things.”

1. Joint Formulary Committee (2026) Prescribing in the elderly. British National Formulary. Available at: https://bnf.nice.org.uk/medicines-guidance/prescribing-in-the-elderly/ (Accessed: 7 March 2026).

2. Clinical Geriatric Assessment Toolkit (n.d.) STOPP/START criteria for potentially inappropriate prescribing in older people. Available at: https://www.cgakit.com/m-2-stopp-start (Accessed: 7 March 2026).