A medication list is a record of what was prescribed. The brown bag - everything the patient actually has at home, including what the neighbour recommended, what a previous doctor started, the over-the-counter sleep aid and the ayurvedic preparation - is a record of what is being taken. The two diverge more in older patients than in any other group, and the gap is where most drug-related harm lives.
Ask for the bag at the first visit and at every annual review, and then ask a separate question: not 'are you taking these?' but 'which of these did you take yesterday, and at what time?'. The first question gets a yes; the second gets the truth, and reveals the doses being skipped, doubled or taken at the wrong time of day.
Pay particular attention to the things that never appear on a prescription record: antihistamines, oral decongestants, anticholinergic bladder drugs bought or continued indefinitely, sleep aids, and any preparation whose ingredients are not listed in a language the patient reads. These carry much of the anticholinergic load and none of the visibility.
- Ask for every medicine in the house, not the printed list, at the first visit and annually
- Ask what was taken yesterday and when, rather than whether the list is being followed
- Specifically ask about over-the-counter antihistamines, sleep aids and bladder drugs
- Include traditional and herbal preparations without judgement - they will not be volunteered otherwise
- Stop what nobody can name a current indication for, and record the stop date
Why it matters
The drugs doing the most harm in older patients are usually the ones that never appear on the prescription record.
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