When a new symptom may be a medicine problem
A fall. New confusion. Dizziness. Unusual sleepiness. Reduced appetite. A person who is suddenly “not themselves”.
These changes may have many causes and must never be diagnosed from one sign alone. Infection, dehydration, injury, stroke, low blood glucose and other acute illness may need urgent consideration. However, medicines should be part of the picture—especially when the symptom began after something changed.
Recent reporting has again highlighted the potential harm associated with inappropriate polypharmacy in older people. For adult social-care staff, the useful response is not to assume that taking several medicines is automatically unsafe. It is to notice possible patterns, document them well and make sure the person receives an appropriate clinical review.
WHAT DOES POLYPHARMACY MEAN?
Polypharmacy is commonly used to describe a person taking several medicines, often five or more. That number alone does not tell us whether the treatment is right or wrong.
Appropriate polypharmacy may be necessary to manage several conditions and improve a person’s health or quality of life. Inappropriate polypharmacy occurs when the balance of benefit and harm is no longer right, medicines interact, treatment has become unnecessarily complicated, or a medicine is no longer suitable for the person’s circumstances.
The aim is not simply to reduce the number of medicines. It is to make sure that every medicine has a clear purpose, remains beneficial and can be used safely.
CHANGES THAT MAY DESERVE A MEDICINES CHECK
Possible medicine-related changes can include:
- new dizziness, faintness or unsteadiness
- falls or near misses
- unusual drowsiness or reduced alertness
- new or worsening confusion, agitation or delirium
- nausea, vomiting or reduced appetite
- constipation or diarrhoea
- tremor, stiffness or a change in movement
- new urinary symptoms
- unusual bruising or bleeding
- rash, facial swelling or breathing difficulty
- a sudden change in blood pressure, pulse or blood glucose where these are being monitored
None of these proves that a medicine is responsible. The important question is whether the timing and the full clinical picture suggest that a medication review is needed.
ASK: WHAT CHANGED?
Look for a new medicine, stopped medicine, dose change, timing change, different formulation or change of brand. Also consider whether the person has:
- recently returned from hospital
- received more “when required” or PRN doses than usual
- started an over-the-counter remedy, vitamin or herbal product
- used somebody else’s medicine or obtained treatment online
- missed doses or had difficulty swallowing or taking a medicine
- become acutely unwell, dehydrated or unable to eat and drink normally
- experienced a change in kidney or liver function
- received duplicate supplies after moving between services
Over-the-counter and herbal products matter. They can cause side effects and interact with prescribed treatment, so include them when giving information to a clinician.
MAKE THE TIMELINE VISIBLE
Useful documentation connects events without claiming a diagnosis:
“Ramipril dose increased on Tuesday. Since Wednesday, Mrs A has reported dizziness when standing. She was unsteady on transfer this morning and had a near fall at 10:15.”
Record:
- the exact symptom and the person’s own words
- when it began and whether it is constant or intermittent
- what happens before, during and after it
- recent prescriptions, discharge instructions and medication changes
- what has actually been administered, including PRN doses and omissions
- observations taken by trained and authorised staff
- food and fluid intake, vomiting, diarrhoea or signs of infection
- over-the-counter, herbal and self-administered products
- falls, near misses or changes in mobility and function
Check the current MAR and recent instructions, but do not rely on the MAR alone. A complete picture may require discharge paperwork, repeat prescriptions, PRN records, the person’s own supplies and information from family or other professionals.
ESCALATE CLEARLY WITH SBARD
SBARD can help staff explain why a medication review is being requested:
Situation — State the new symptom and immediate concern.
Background — Give relevant diagnoses, allergies, recent discharge, medicines changes and normal baseline.
Assessment — Describe onset, pattern, observations, recent doses, PRN use, hydration, illness and any incident or functional change.
Recommendation — Request the action needed, such as urgent clinical advice or a medication review by the GP, pharmacist or prescriber.
Decision — Record what was agreed, who will act, the timescale and what to do if the person worsens.
Do not write only “GP informed”. Record the information provided, advice received and follow-up plan.
DO NOT STOP OR ALTER PRESCRIBED MEDICINES INDEPENDENTLY
Care staff should not stop, withhold, reduce, crush, alter or change the timing of prescribed medicines unless this is supported by a valid instruction, the person’s care plan or an authorised protocol.
If the person refuses a medicine, follow the refusal process, record it accurately and seek advice in line with the care plan and local policy. Do not disguise the medicine or give it covertly without the required lawful process.
Emergency signs still require emergency action. Call 999 for life-threatening symptoms such as severe breathing difficulty, collapse, unconsciousness, signs of stroke or a suspected severe allergic reaction. Sudden swelling of the mouth, throat or tongue, difficulty breathing, a tight throat, blue or very pale skin, or sudden severe confusion or drowsiness may indicate anaphylaxis.
For urgent concerns that are not immediately life-threatening, follow the person’s care plan and local clinical pathways, including NHS 111 where appropriate.
REQUEST A STRUCTURED MEDICATION REVIEW
NHS England describes a structured medication review as a comprehensive, evidence-based review of a person’s medicines that considers their needs, preferences and circumstances.
A review may be particularly helpful after hospital discharge, after a fall, when new symptoms appear, when PRN use increases, when medicines are difficult to take, or when treatment has become complex.
Useful questions include:
- What is each medicine for?
- Is it still achieving its intended benefit?
- Could the new symptom be a side effect, interaction or withdrawal effect?
- Is the dose still suitable for the person’s age, weight, kidney function and health?
- Is the timing practical and safe?
- Are any medicines duplicating one another?
- Are over-the-counter or herbal products interacting with treatment?
- Can the regimen be simplified without losing benefit?
- What monitoring and follow-up are required?
The person should be involved in the review as far as possible. Their priorities, experience of side effects and ability to manage the regimen are central—not secondary—to the decision.
AFTER HOSPITAL DISCHARGE
Transitions between hospital, community services and social care are a common point of risk. Reconcile the discharge information against the current MAR, medicines supplied and previous regimen. Clarify discrepancies promptly rather than guessing which list is correct.
Make sure staff understand what has started, stopped or changed; the reason where known; the first dose or next dose; required monitoring; and what symptoms should trigger further advice.
YELLOW CARD REPORTING
Suspected adverse drug reactions can be reported to the MHRA Yellow Card scheme. Patients, carers and healthcare professionals can report. Where a carer reports for another person, follow consent, confidentiality and organisational requirements.
A Yellow Card report does not replace clinical advice. Seek medical help first when it is needed, and follow local incident-reporting arrangements as well.
LEARNING DISABILITY AND AUTISM
For people with a learning disability or autistic people, medicines used for behaviour, mood, sleep or mental health should receive person-centred review. NHS England’s STOMP programme promotes stopping over-medication where it is inappropriate, while ensuring that treatment changes are clinically supervised and the right support is available.
THE PRACTICAL MESSAGE
Care staff are not expected to decide which medicine caused a symptom. They are expected to notice a meaningful change, check the timing, record accurately, report the complete medicines picture and request appropriate review.
Do not assume every new symptom is “just ageing”. Sometimes the safest question is: what changed in the medicines?
Safe Skills Training provides practical clinical-skills, first-aid and patient-safety training for adult social-care teams. To discuss training for your service, visit www.safeskillstraining.com.
GUIDANCE AND FURTHER INFORMATION
NHS England: Structured medication reviews and medicines optimisation
https://www.england.nhs.uk/primary-care/pharmacy/smr/
Royal Pharmaceutical Society: Polypharmacy—getting our medicines right
https://www.rpharms.com/recognition/setting-professional-standards/polypharmacy-getting-our-medicines-right
NICE: Medicines optimisation (NG5)
https://www.nice.org.uk/guidance/ng5
NICE: Falls—assessment and prevention (NG249)
https://www.nice.org.uk/guidance/ng249
CQC: Medicines care plans
https://www.cqc.org.uk/guidance-providers/adult-social-care/medicines-care-plans
CQC: When required medicines
https://www.cqc.org.uk/guidance-providers/adult-social-care/when-required-medicines-adult-social-care
MHRA: Yellow Card scheme
https://yellowcard.mhra.gov.uk/
NHS England: STOMP and STAMP
https://www.england.nhs.uk/learning-disabilities/improving-health/stomp-stamp/