Medication management

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Medicines are considered the most common intervention in healthcare. Medicines can contribute to patient harm due to adverse and unintended effects. This may include increased risk of falls, delirium, hypotension, bleeding, constipation, urinary retention, sedation, and impaired mobility.

Older people and people taking multiple medicines are particularly vulnerable to adverse medicines events and medicines interactions.

Minimise harm from medicines

To minimise harm from medicines:

  • conduct a Best Possible Medication History and medication reconciliation on admission and transfer/s of care
  • medication reviews should be conducted throughout admission (as appropriate)
  • monitor for side effects
  • consider the risks and benefits of each medicine during prescribing and administration
  • prescribe the lowest effective dose
  • avoiding initiating psychotropic medicines where possible, and consider non-pharmacological approaches to managing sleep disturbances, anxiety and depression
  • make sure patients and families understand any medicine changes
  • look for opportunities to deprescribe
  • document all medication reviews conducted, interventions made and outcomes of intervention.

Sedating medications that can lead to harm

Antipsychotics

Common examples Adverse effects that increase risk of harm Other points to consider Cease abruptly versus taper slowly
haloperidol
olanzapine risperidone 		orthostatic hypotension, confusion, sedation, extra-pyramidal side effects, blurred vision.
  • For the management of Behaviours of Concern and Psychological Symptoms associated with Dementia or delirium (sometimes referred to as responsive behaviours and changed behaviours), non-pharmacological strategies should be used as first-line management and continued throughout treatment.
  • Antipsychotics should only be considered if these measures are unsuccessful, and prescribed at the lowest effective dose for the shortest period of time.
 Withdraw slowly to avoid relapse and withdrawal symptoms (tachycardia, sweating and insomnia).

Antidepressents

Common examplesAdverse effects that increase risk of harmOther points to considerCease abruptly versus taper slowly
amitriptyline duloxetine
sertraline		orthostatic hypotension, dizziness, weakness, drowsiness, confusionWeigh up risks to patient (e.g. falls) against benefit to patient’s quality of life.Do not cease abruptly. Taper over several weeks and monitor patient closely to minimise the risk of relapse and withdrawal.

Sedatives or hypnotics

Common examplesAdverse effects that increase risk of harmOther points to considerCease abruptly versus taper slowly
oxazepam
temazepam
zolpidem		dependence, confusion, ataxia, impaired alertness, oversedation, blurred vision, light headedness
  • Avoid where possible. If indicated, limit to short-term, intermittent use due to risk of physical and psychological dependence.
  • Benefits of benzodiazepines are short lived; hypnotic effect is lost after 14 consecutive nights; however side effects persist, thus increasing fall risk.
  • Consider why it has been prescribed, i.e. if for anxiety, consider an alternative.
  • Where such medicines are prescribed, consider whether the medicine should continue after discharge, and cease before discharge if possible.
  • Should not be initiated during a hospital admission.
Do not cease abruptly due to risk of withdrawal (insomnia, anxiety, irritability, sweating and GI symptoms)
Taper slowly to avoid rebound effects. When tapering: - ensure effective communication with GP for monitoring and review of patient - address concerns by providing information on the benefits of stopping the medicine, such as improved cognition, alertness and sleep quality.

Opioids

Common examples Adverse effects that increase risk of harm Other points to consider Cease abruptly versus taper slowly
oxycodone
morphine
fentanyl 		orthostatic hypotension, sedation, cognitive impairment, dizziness
  • If commenced during admission for acute pain or post-surgery, give clear direction about expected duration of therapy.
  • If newly prescribed, consider possible medicine-medicine interactions with patient’s pre-existing medications.
  • Review the patient’s needs for opioids regularly, consider reducing the dose and/or tapering, particularly if initiated for acute pain or post-surgery.
  • If required long-term, discuss with GP and consider referral to pain team or specialist.

See opioid stewardship for acute pain management principles.

 Physical dependence is common; if taken long term, opioids should not be ceased abruptly due to the risk of withdrawal symptoms occurring (nausea, vomiting, sweating, anxiety).1

Read our fact sheet on reducing the use of sedative medicines

References

  1. Australian Medicines Handbook (AMH) electronic version, accessed via CIAP 17/8/17.
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