CRP06 — Multimorbidity, polypharmacy and iatrogenic harm

ClinicalEdu V1.14 | Adult NHS educational reading | Editorial review

Learning context and original foundational reading

The whole patient is the unit of care

Guideline recommendations for a single condition may be based on trial populations that differ from patients living with multiple chronic diseases, frailty, disability and high treatment burden. NICE NG56 therefore supports an individualised assessment of goals, benefits, harms and coordination. This is not an invitation to ignore evidence, but a reminder to judge how evidence applies to this patient in this context.

Medication harm can mimic disease

A new medicine, dose increase, missed dose, withdrawal, interaction or change in renal function may produce dizziness, delirium, hypotension, falls or metabolic disturbance. Review what was prescribed, what was administered, what the person actually took, and recent changes across care settings. Avoid assuming that a medication list is accurate because it appears in a discharge document.

Assess prescribing in context

Consider the indication, expected time to benefit, competing risks, kidney function, anticholinergic and sedative burden, duplicate treatment and adherence barriers. Acute illness can temporarily change the risk-benefit balance, but any medicine change should follow the appropriate prescribing competence and local medicines policy; record the reason, review date and who will restart or discontinue it.

Frailty is dynamic and specific

Frailty informs physiological reserve and recovery expectations, yet acute illness can distort physical performance assessments. Functional baseline, mobility before the episode, cognition, nutrition, swallowing and care support may matter as much as the nominal disease count. A comprehensive clinical approach seeks reversible causes without assuming that every decline is inevitable.

Shared priorities and practical care

Ask what matters to the patient: independence, comfort, avoiding repeated travel, maintaining cognition or receiving a potentially burdensome intervention. Describe the expected benefit and possible harm of each plausible pathway. An individualised plan needs a named coordinator and communication with the multidisciplinary team. A decision to reduce treatment burden can be an active, evidence-informed clinical decision.

Worked clinical scenario

An older person develops a fall, new confusion and renal impairment after a change in regular medicines. Produce a medication-centred differential without overlooking infection or structural injury.

Multimorbidity, frailty and medication-related harm

In older adults, the unit of clinical reasoning is the person living with several interacting conditions, not a single guideline pathway. A medicine that improves one disease outcome may worsen falls, renal function or cognition in another context. The first step is to obtain an accurate medicine history, including recent starts, dose changes, omitted medicines, non-prescription products and who administers the treatments. Medication reconciliation is an investigative task: discrepancies can explain deterioration or reveal important risk.

Frailty describes vulnerability to stressors, but must not be used as a shortcut for declining clinically appropriate treatment. Ask about baseline mobility, cognition, continence, eating, independence and the patient's own priorities. A small physiological insult may produce a disproportionate functional decline; the inverse is also important, because new severe deterioration must not be dismissed as “just frailty”. Assess dehydration, constipation, pain, infection, renal function and drug effects as potentially interacting mechanisms rather than competing single answers.

When several disease-specific recommendations conflict, explain options and burdens in relation to realistic goals. Medicines optimisation may include starting, stopping or adjusting treatment but requires appropriate assessment, monitoring, shared decisions and prescribing responsibility. A discussion about treatment burden must not become an unsupported assumption that the patient prefers minimal care. Record what matters to the person and which clinician will review the plan after acute illness.

Extended worked cases and reasoning prompts

Case discussion 1

An 88-year-old resident experiences falls, drowsiness and worsening kidney function after a change to medicines. The admission list differs from the GP list. Build a medication-reconciliation plan, identify classes of medicine that might contribute to hypotension or confusion, and state what prescribing authority and monitoring are needed before changing treatment.

Case discussion 2

Next compare a patient with advanced multimorbidity who values remaining at home with a patient who wants active hospital investigation. Explain how those priorities alter the options without changing the obligation to assess reversible problems.

Structured practice and reflection

1. Write a two-sentence problem representation separating observed facts from assumptions.

2. Name two important alternatives and one potentially harmful missed condition.

3. What is the safest immediate action before a definitive diagnosis is available?

4. Which finding or change would cause you to revise your plan?

5. What would you document or communicate to make responsibility and follow-up explicit?

Further reading — primary organisations

NICE multimorbidity NG56: https://www.nice.org.uk/guidance/ng56

NICE medicines optimisation NG5: https://www.nice.org.uk/guidance/ng5

Editorial verification: only selected central documents have been checked live this session; the complete module reference list requires individual date/version checking and clinical reviewer sign-off before public release.

Educational boundary: an online completion record is not evidence of independently assessed clinical competence or accredited BLS/ALS provider certification.

Clinical decision and professional scope

Understand interacting harms is the central theme of this chapter. The case begins with: frail adult with recurrent falls, renal impairment and multiple long-term medicines. The educational aim is to practise structured reasoning, seek timely senior help and revisit early judgements as the patient changes. It is not a substitute for individual assessment, escalation policy, approved practical training or independent clinical supervision.

Reasoning in the first clinical encounter

Medication reconciliation compares the prescription, what the patient actually takes, recent changes and administration records. Include over-the-counter products where relevant.

Ask what must be recognised now, what is uncertain, which risks cannot wait and what professional or practical resources are available. This is especially important in the following scenario: Frail adult with recurrent falls, renal impairment and multiple long-term medicines.

Evidence, bias and contradictory information

The burden of treatment can itself produce harm: falls, reduced intake, hypotension, renal injury, interactions and limited ability to follow complex regimens.

Distinguish reliable measurements, recalled history, inferred mechanisms and assumptions. Identify a genuine contradictory fact and explain how it changes the plan. This is especially important in the following scenario: Frail adult with recurrent falls, renal impairment and multiple long-term medicines.

A worked bedside narrative

Discuss the patient’s goals; do not simply apply every single-condition target to a frail individual without reviewing the balance of benefit and harm.

Treat the first impression as provisional. Explain the immediate actions, an alternative explanation and the findings that would determine escalation. This is especially important in the following scenario: Frail adult with recurrent falls, renal impairment and multiple long-term medicines.

Follow-up and safety net

Medication reconciliation compares the prescription, what the patient actually takes, recent changes and administration records. Include over-the-counter products where relevant.

Specify who repeats observations, the interval dictated by local protocols and what will trigger additional clinical review. This is especially important in the following scenario: Frail adult with recurrent falls, renal impairment and multiple long-term medicines.

Communication and record quality

The burden of treatment can itself produce harm: falls, reduced intake, hypotension, renal injury, interactions and limited ability to follow complex regimens.

Show that the documentation allows a colleague to see the decision, uncertainty, response and accountable next action. This is especially important in the following scenario: Frail adult with recurrent falls, renal impairment and multiple long-term medicines.

Teaching exercise

Discuss the patient’s goals; do not simply apply every single-condition target to a frail individual without reviewing the balance of benefit and harm.

Pause at each stage to write a short problem representation and a concrete decision before looking at the proposed reasoning. This is especially important in the following scenario: Frail adult with recurrent falls, renal impairment and multiple long-term medicines.

Extended case discussion

Initial contact: Frail adult with recurrent falls, renal impairment and multiple long-term medicines. The clinician has incomplete handover details. Record the physiological observations, compare the current presentation with baseline and decide whether urgent response is warranted. This stage is about recognising the need for action, not guessing the final diagnosis.

At the first review: Ask whether the patient can supply a reliable history; consult relevant carers and records; reconcile medication changes; and interpret findings in the context of frailty and multimorbidity. The team must not allow uncertainty about cause to hide objective deterioration.

New information: A colleague reports that the change began earlier than originally thought. The clinician must revise the time course and identify whether this shifts the prioritised differential, appropriate investigation, monitoring frequency or destination of care.

Decision point: Reconcile medication exposure, treatment burden and person-centred goals. Explain a decision that is justified now, a competing option and the circumstances in which it would be appropriate. Clearly distinguish what you know, what you suspect and what needs confirmation.

After the intervention: Arrange reassessment and document the response. A settled score, a single laboratory result or a temporary symptom improvement should not erase the need to review the full trajectory.

Practice lens 1: time and trajectory

Medication reconciliation compares the prescription, what the patient actually takes, recent changes and administration records. Include over-the-counter products where relevant. Consider how this principle is affected by imperfect staffing, overnight cover or limited site resources; distinguish a desirable ideal response from what can actually be delivered safely.

Write a structured clinical note using the headings: observed findings; baseline; current concern; differential and important alternatives; agreed actions; accountable reviewer; and explicit reassessment or transfer triggers. Highlight any unresolved question instead of silently closing it.

Practice lens 2: uncertainty and corroboration

The burden of treatment can itself produce harm: falls, reduced intake, hypotension, renal injury, interactions and limited ability to follow complex regimens. Consider how this principle is affected by imperfect staffing, overnight cover or limited site resources; distinguish a desirable ideal response from what can actually be delivered safely.

Write a structured clinical note using the headings: observed findings; baseline; current concern; differential and important alternatives; agreed actions; accountable reviewer; and explicit reassessment or transfer triggers. Highlight any unresolved question instead of silently closing it.

Practice lens 3: next decision and ownership

Discuss the patient’s goals; do not simply apply every single-condition target to a frail individual without reviewing the balance of benefit and harm. Consider how this principle is affected by imperfect staffing, overnight cover or limited site resources; distinguish a desirable ideal response from what can actually be delivered safely.

Write a structured clinical note using the headings: observed findings; baseline; current concern; differential and important alternatives; agreed actions; accountable reviewer; and explicit reassessment or transfer triggers. Highlight any unresolved question instead of silently closing it.

Reading and source-check register

Core reference: NICE NG56. The reference supports its own clinical or professional recommendations; the case examples, reflective prompts and teaching structure are original educational synthesis, not direct source quotations. Check the operative full guidance and local policy before applying recommendations.

Reflective practice

What did I first assume? Which finding would most quickly falsify that assumption? Was I influenced by site capability or workload? What did I communicate, to whom, and when should that decision be reviewed? Do not include patient-identifiable information in submitted reflections.

Boundary with BLS and ALS

Early recognition, timely escalation, clinical reasoning and team communication support later BLS/ALS theoretical learning. This chapter does not teach or certify CPR, defibrillation, airway procedures or accredited resuscitation competence. Use current Resuscitation Council UK guidance and approved supervised practical training for those skills.