During a practice audit of patients over 75 years taking 10 or more regular medications, you identify several patients who would benefit from structured medication reviews. You are prioritising which patients to review first based on risk stratification. According to best practice guidance on medication reviews in primary care, which patient characteristic indicates HIGHEST priority for urgent structured medication review?

A patient recently discharged from hospital with five new medications added to their existing regimen

A patient taking 15 medications who has been stable on the same regimen for 3 years with no recent adverse events

A patient taking multiple high-risk medications including warfarin, methotrexate, and lithium who attends regular monitoring

A patient who has reached the age of 75 and is now eligible for routine medication review under the Quality and Outcomes Framework

A patient with declining renal function (eGFR decreased from 68 to 54 over 12 months) taking eight regular medications

A 75-year-old man with COPD (post-bronchodilator FEV1 42% predicted), ischaemic heart disease, atrial fibrillation, and type 2 diabetes attends for medication review. He is on multiple inhalers: tiotropium, salmeterol/fluticasone 25/250 twice daily, and salbutamol as needed. Other medications include apixaban, bisoprolol, ramipril, atorvastatin, and metformin. He has had two exacerbations requiring oral steroids in the past year, the last one being 8 months ago. His current COPD symptoms are well-controlled with no exacerbations recently. Sputum cultures from his last exacerbation grew Pseudomonas aeruginosa. Which change to his inhaler therapy is MOST appropriate?

Switch from salmeterol/fluticasone to a triple therapy inhaler (LABA/LAMA/ICS combination)

Add a regular azithromycin prophylaxis regimen due to previous Pseudomonas infection

Stop inhaled corticosteroids and continue bronchodilators only, given limited recent exacerbations

Reduce fluticasone dose to minimise steroid-related adverse effects including pneumonia risk

Add regular nebulised colistin for Pseudomonas suppression in COPD

You are conducting a structured medication review for an 80-year-old man with heart failure (NYHA class II), type 2 diabetes, chronic kidney disease stage 3b (eGFR 38 ml/min/1.73m²), and benign prostatic hyperplasia. He lives alone and manages his medications independently using a dosette box filled by his daughter. He takes 13 different medications at various times throughout the day. He mentions he sometimes forgets his evening doses and finds the regimen 'complicated'. Which approach BEST addresses medication adherence in this context according to principles of medicines optimisation?

Simplify the regimen by switching to once-daily preparations where possible and aligning administration times

Arrange for a district nurse to visit twice daily to supervise medication administration

Provide detailed written instructions about each medication and the importance of adherence

Reduce the total number of medications by stopping those not providing immediate symptom relief

Arrange urgent assessment of his cognitive function as non-adherence suggests early dementia

A 70-year-old woman with rheumatoid arthritis, osteoporosis, hypertension, and gastro-oesophageal reflux disease attends for review. She takes: methotrexate 15mg weekly, folic acid 5mg weekly (taken day after methotrexate), prednisolone 5mg daily, alendronic acid 70mg weekly, omeprazole 20mg daily, amlodipine 10mg daily, and calcium/vitamin D daily. Blood tests show: Hb 102 g/L (MCV 88 fL), WCC 3.8 × 10⁹/L, platelets 156 × 10⁹/L, ALT 68 U/L (previously 32), eGFR 58 ml/min/1.73m². Which aspect of her medication regimen requires MOST urgent attention?

The elevated ALT indicating methotrexate hepatotoxicity requiring dose reduction or cessation

The alendronic acid and omeprazole combination reducing bisphosphonate absorption

The low haemoglobin suggesting methotrexate-induced bone marrow suppression requiring urgent cessation

The combination of prednisolone and alendronic acid requiring additional osteoporosis monitoring

The declining renal function requiring methotrexate dose adjustment or alternative DMARD

A practice pharmacist is conducting a quality improvement project on anticholinergic burden in elderly patients with multimorbidity. She identifies a 73-year-old man taking 12 medications with a total Anticholinergic Cognitive Burden (ACB) score of 6. His medications include amitriptyline 50mg nocte for neuropathic pain, tolterodine 4mg for overactive bladder, lansoprazole 30mg, co-codamol 30/500, atorvastatin, ramipril, bisoprolol, aspirin, and metformin. He reports feeling 'foggy-headed' and has had two falls. Which intervention would have the GREATEST impact on reducing anticholinergic burden?

Address both amitriptyline and tolterodine simultaneously by switching to alternatives

Switch tolterodine to mirabegron, a beta-3 agonist with no anticholinergic activity

Replace amitriptyline with duloxetine for neuropathic pain management

Stop lansoprazole as proton pump inhibitors contribute to cognitive impairment

Reduce co-codamol dose as opioids can contribute to cognitive impairment

A 76-year-old woman with dementia (MMSE 18/30), Parkinson's disease, type 2 diabetes, and recurrent falls is brought by her daughter for medication review. Current medications include: co-careldopa 25/100 three times daily, ropinirole 8mg three times daily, quetiapine 25mg twice daily, metformin 500mg twice daily, gliclazide 40mg twice daily, alendronic acid 70mg weekly, calcium/vitamin D, and PRN paracetamol. She has had three falls in the past two months. Her daughter reports increasing confusion and hallucinations. Blood glucose monitoring shows values between 4.8-8.2 mmol/L. Which medication intervention should be prioritised?

Reduce ropinirole as dopamine agonists cause hallucinations and should be withdrawn first

Reduce co-careldopa dose as dopaminergic medications contribute to hallucinations and falls

Stop quetiapine immediately as antipsychotics worsen Parkinson's disease motor symptoms

Review and rationalise diabetes medications given risk of hypoglycaemia contributing to falls

Stop alendronic acid as bisphosphonates increase fall risk in elderly patients

A 68-year-old man with ischaemic heart disease, permanent atrial fibrillation, type 2 diabetes, and osteoarthritis takes: aspirin 75mg, apixaban 5mg twice daily, bisoprolol 5mg, atorvastatin 80mg, metformin 1g twice daily, gliclazide 80mg twice daily, and paracetamol as required. He has no history of stenting or acute coronary syndrome in the past 12 months. His most recent echocardiogram shows LVEF 55% with no wall motion abnormalities. His CHA₂DS₂-VASc score is 5. Which medication change is MOST appropriate?

Stop aspirin as dual antiplatelet and anticoagulation increases bleeding risk without additional benefit

Stop apixaban and continue aspirin alone for cardiovascular protection

Continue both medications as dual therapy is indicated in atrial fibrillation with ischaemic heart disease

Stop both aspirin and apixaban and commence warfarin for better control

Reduce apixaban to 2.5mg twice daily when used in combination with aspirin

During a structured medication review using the STOPP/START criteria for a 71-year-old woman, you identify she takes co-codamol 30/500 four times daily for chronic lower back pain, alongside atorvastatin, ramipril, and bisoprolol. She mentions she has been constipated for several weeks and also takes senna tablets daily. She has no history of major surgery or inflammatory spinal disease, and her back pain has been present for 18 months. Her renal function and liver function are normal. Which action represents BEST practice according to deprescribing principles?

Gradually reduce and stop codeine while optimising non-opioid analgesia and addressing pain holistically

Switch co-codamol to tramadol to reduce constipation while maintaining analgesia

Add a stimulant laxative such as sodium picosulfate to manage opioid-induced constipation

Continue current regimen but refer for specialist pain management assessment

Switch to modified-release morphine for more consistent pain control

A 74-year-old man attends for medication review. He has heart failure (LVEF 32%), atrial fibrillation, type 2 diabetes, stage 3b CKD (eGFR 36 ml/min/1.73m²), and benign prostatic hyperplasia. Current medications: bisoprolol 10mg, ramipril 10mg, furosemide 40mg, spironolactone 25mg, apixaban 5mg twice daily, metformin 1g twice daily, empagliflozin 10mg, finasteride 5mg, tamsulosin 400mcg, atorvastatin 80mg. Blood tests show potassium 5.4 mmol/L, sodium 134 mmol/L, urea 12.8 mmol/L, creatinine 168 μmol/L (stable). He reports good symptom control but occasional dizziness on standing. Which represents the BEST management approach?

Continue current regimen with close monitoring as benefits outweigh risks

Stop spironolactone due to hyperkalaemia risk and continue other heart failure medications

Reduce ramipril to 5mg daily to decrease potassium and improve renal function

Stop empagliflozin as it may be contributing to hyperkalaemia and renal impairment

Stop tamsulosin as it may be causing orthostatic hypotension and reduce polypharmacy

According to the Beers Criteria for potentially inappropriate medication use in older adults, which of the following medications should be avoided in elderly patients regardless of diagnosis or condition?

Long-acting benzodiazepines such as diazepam and chlordiazepoxide

Non-selective beta-blockers in patients with peripheral vascular disease

First-generation antihistamines in patients with cognitive impairment

Proton pump inhibitors when used for longer than 8 weeks

Thiazide diuretics in patients with a history of gout

Multimorbidity for UKMLA AKT: High-Yield General Practice & Primary Care Lessons

Quick Overview

Multimorbidity is defined as the presence of ≥2 long-term health conditions (NICE NG56). Affects >50% of patients >65 years and 25% of adults overall in UK primary care. Creates consultation complexity, polypharmacy risks, and treatment burden. NICE NG56 emphasizes individualized care over single-disease guidelines, prioritizing patient goals and reducing treatment burden.

Core Facts & Concepts

Definition & Prevalence

Multimorbidity: ≥2 chronic conditions (physical/mental health)
Prevalence: 25% all adults; >50% over 65 years; >65% over 75 years
Socioeconomic gradient: Occurs 10-15 years earlier in deprived areas

Impact on Healthcare

Accounts for 50% of GP consultations
Average 6-8 medications per patient with multimorbidity
Treatment burden: Multiple appointments, monitoring, medication regimens

NICE NG56 Core Principles

Focus on patient priorities and quality of life
Consider treatment burden vs benefit
Review medications regularly (polypharmacy risk)
Use individualized care approach over disease-specific guidelines
Address social determinants and support needs

Figure 1: Diagram showing overlapping circles of multiple chronic conditions with central patient priorities

Common Condition Clusters	Examples
Cardiometabolic	HTN + T2DM + CKD + IHD
Mental-physical	Depression + chronic pain + COPD
Frailty-related	Osteoporosis + falls + dementia + incontinence

Problem-Solving Approach

NICE NG56 Structured Approach

Identify patient priorities - What matters most to them?
Review ALL conditions - Not isolated disease management
Assess treatment burden - Appointment load, medication complexity, monitoring
Medication review - STOPP/START criteria, deprescribing opportunities
Coordinate care - Single care plan, named coordinator
Set realistic goals - Symptom control may trump guideline targets

Red Flags for Review 🚩

≥10 medications (high polypharmacy)
≥15 appointments/year (high treatment burden)
Conflicting treatment goals (e.g., tight glycemic control in limited life expectancy)
Poor adherence (may indicate treatment burden)
Falls/cognitive impairment (medication-related risk)

⭐ Clinical Pearl: Single-disease guidelines may conflict (e.g., beta-blockers for IHD vs COPD concerns). Patient priorities break the tie.

Analysis Framework

Individualized Care vs Guideline-Based Care

Aspect	Traditional Approach	NICE NG56 Approach
Focus	Disease-specific targets	Patient priorities & QoL
Medications	Add per guideline	Review burden vs benefit
Goals	Guideline-driven (e.g., HbA1c <53)	Individualized (symptom control)
Monitoring	Per each condition	Rationalized, combined visits
Decision-making	Clinician-led	Shared, patient-centered

Key Discriminators for Care Planning

Frailty status - Rockwood scale guides intensity
Life expectancy - Time to benefit vs treatment burden
Patient capacity - Cognitive/physical ability to manage regimen
Social support - Caregiver availability, isolation risk

Visual Aid

Key Points Summary

✓ Multimorbidity = ≥2 long-term conditions; affects >50% over 65 years

✓ NICE NG56: Individualized care prioritizing patient goals over guideline targets

✓ Key approach: Assess treatment burden, review polypharmacy, coordinate care with single plan

✓ Red flags: ≥10 medications, ≥15 appointments/year, conflicting treatment goals

✓ Medication review mandatory: Use STOPP/START criteria, consider deprescribing

✓ Social gradient: Multimorbidity occurs 10-15 years earlier in deprived populations

✓ Avoid single-disease tunnel vision: Holistic assessment prevents iatrogenic harm and treatment burden

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Multimorbidity