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?
AA patient taking 15 medications who has been stable on the same regimen for 3 years with no recent adverse events
BA patient recently discharged from hospital with five new medications added to their existing regimen
CA patient taking multiple high-risk medications including warfarin, methotrexate, and lithium who attends regular monitoring
DA patient who has reached the age of 75 and is now eligible for routine medication review under the Quality and Outcomes Framework
EA 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?
AAdd a regular azithromycin prophylaxis regimen due to previous Pseudomonas infection
BSwitch from salmeterol/fluticasone to a triple therapy inhaler (LABA/LAMA/ICS combination)
CStop inhaled corticosteroids and continue bronchodilators only, given limited recent exacerbations
DReduce fluticasone dose to minimise steroid-related adverse effects including pneumonia risk
EAdd 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?
ASimplify the regimen by switching to once-daily preparations where possible and aligning administration times
BArrange for a district nurse to visit twice daily to supervise medication administration
CProvide detailed written instructions about each medication and the importance of adherence
DReduce the total number of medications by stopping those not providing immediate symptom relief
EArrange urgent assessment of his cognitive function as non-adherence suggests early dementia
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