Station 24 · Medication review

Candidates: do not open until you have consulted.

Persona and manner

• Edna Pargeter, 86; alert, polite, a little deaf, inclined to let Carol speak; you have views when asked directly and a dry humour. You are tired of the tablets and would “happily throw half of them in the bin”, but you will not say so in front of Carol unless asked.
• Carol, 58, her daughter and carer; devoted, anxious, organised; she fills the dosette box and keeps a list; she believes every tablet is keeping her mother alive and fears that stopping any of them is giving up.

Opening line (verbatim)

• “Carol: “The pharmacist said Mum's kidneys are going down and someone needs to look at her tablets. I've brought the list. I don't want anything stopped that's keeping her well, though. She's done brilliantly on these for years.””

The story

• Edna, if asked directly: “I'm dizzy when I stand. Every morning, and after my dinner. I've gone over twice. I hold on to the furniture.”
• Edna: “I'm not hungry. Carol does lovely food and I push it round the plate. My mouth's dry. I'm up three times a night.”
• If asked about hypos: “I go shaky and sweaty before lunch if I'm late with it. Carol gives me a biscuit.” Three or four times a month.
• If asked about pain: the knees ache; the co-codamol “makes me woozy and bungs me up”; you take it because it is in the box.
• If asked about the alendronic acid: you take it standing up on Mondays; it gives you heartburn; you have taken it for nine years.
• If asked about memory: “Not what it was, but I know what's what.” Carol: “She's sharp as a tack.”
• Carol, if the doctor proposes a change: “But her blood pressure's been perfect.” “The diabetes nurse said the sugar must stay down.” “My dad had a stroke; that's why she's on the blood thinner.”
• If asked what matters most: Edna: “Not falling. Staying here with Carol. Getting to the garden.” Carol: “Keeping her safe.”
• If asked, Edna would like fewer tablets; Carol would accept changes if she understood why and if the doctor took the responsibility.

Ideas, concerns and expectations

• Idea: Carol's: the tablets are keeping her mother alive and the kidneys are a separate problem. Edna's: “It's the tablets that make me dizzy.”
• Concern: Carol's: that stopping tablets means giving up on her mother; a stroke like her father. Edna's: falling again; a care home; being a burden.
• Expectation: Carol's: reassurance and the list kept as it is. Edna's: fewer tablets and the dizziness gone.

Impact

• Home: Edna lives with Carol; Carol fills the box; the garden is Edna's pleasure.
• Falls: two this year; the kitchen at night and standing from the chair.
• Food: appetite gone; weight down six kilograms; a dry mouth.

Red flags

• Present: Dizziness on standing with two falls on four blood-pressure-lowering drugs at 118/66; hypos on gliclazide with an HbA1c of 50 at 86; an eGFR of 34 on metformin, ramipril and a thiazide with a potassium of 5.1; an opioid causing drowsiness; nine years of alendronic acid; six kilograms lost.
• Absent: No chest pain, breathlessness or syncope; no bleeding on apixaban; no confusion or delirium; no fracture; no new neurological symptoms.

Hidden facts and their triggers

• The hypos before lunch — released only only if asked directly about shaking, sweating or funny turns; Carol calls them “a bit wobbly”
• That Edna would happily throw half the tablets in the bin — released only only if Edna is asked directly, and what matters most to her is asked
• The heartburn on alendronic acid and the nine years — released only if asked about the bone tablet
• That Carol's father died of a stroke — released only if the doctor raises the apixaban or asks why the blood thinner matters to Carol
• That Carol would accept changes if the doctor took the responsibility — released only if the doctor asks Carol what would make a change acceptable

Behaviour

• Minute 1: Carol presents the list; Edna smiles and says nothing.
• Minute 3, if Edna is asked directly: “I'm dizzy when I stand.”
• Minute 6, if a change is proposed: Carol: “But her blood pressure's been perfect.”
• If the doctor asks Edna what matters most, examines her lying and standing, links the dizziness and the falls to the blood-pressure tablets and the hypos to the gliclazide, explains each change as a way of keeping her at home and in the garden, reduces in steps with a date, keeps the apixaban and explains why, and gives Carol a role and a plan she can follow in the box: Edna: “Thank goodness.” Carol, after a pause: “If you'll write it all down, and we see you again.”
• If the doctor keeps everything because Carol objects: Edna looks at the floor.
• If the doctor stops everything at once: Carol: “That's half her tablets. Are you sure?”
• If the doctor speaks only to Carol: Edna stops answering.

Examination findings, if the candidate states what they would examine and why

• If the candidate explains and asks: blood pressure lying 126/70, standing at one minute 96/58 with dizziness; pulse 54, irregular; weight 52 kg; dry mouth; no ankle swelling; chest clear; heart sounds normal; capillary glucose 6.1 at 11 a.m.; she needs her hands to rise from the chair; a timed up-and-go of 19 seconds.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Reviewing the list with Carol and never asking Edna what matters most or how she feels when she stands (statement R3)
• Keeping every medicine because Carol objects, so that the dizziness, the hypos and the kidneys continue (statement C5)
• Stopping the apixaban because she falls, while the four blood-pressure drugs that cause the falls continue (statement D8)

What the examiner is listening for in the last four minutes

By 8:00 the working assessment should have been stated: the medicines are causing the dizziness, the falls and the hypos, and the kidneys are being over-treated. The examiner is listening for: each change with its reason and its date (the thiazide, the ramipril, the gliclazide, the metformin dose, the co-codamol, the alendronic acid); the apixaban and the bisoprolol kept and why; the bloods in two weeks and the falls referral; the written plan for the box and Carol's role; a safety-net for a fall, a hypo, confusion or bleeding; the review in two weeks; and Edna's own words, then Carol's, on what will change this week.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Offer a structured medication review to people with multimorbidity who are taking many regular medicines, using the person's goals and preferences; consider stopping medicines where the burden outweighs the benefit, particularly in frailty and limited life expectancy, and agree the changes with the person and their carer. NICE — NG56 Multimorbidity: clinical assessment and management, section 1.6, reviewing medicines and other treatments, September 2016, checked 10 Oct 2026
2. In people aged 80 and over, a clinic blood pressure target below 150/90 mmHg applies; in frail older people, consider the person's frailty, co-morbidity and postural hypotension when deciding treatment; measure standing blood pressure in people with symptoms of postural hypotension and treat to the standing reading. NICE — NG136 Hypertension in adults: diagnosis and management, section 1.4, treatment targets; section 1.1, measuring blood pressure: postural hypotension, 2019, last updated February 2026, checked 10 Oct 2026
3. In adults with type 2 diabetes, individualise the HbA1c target and relax it for people who are frail, older or at risk of hypoglycaemia; avoid sulfonylureas where hypoglycaemia is a particular risk; review metformin dose when eGFR is below 45 and stop it below 30. NICE — NG28 Type 2 diabetes in adults: management, section 1.6, HbA1c targets; section 1.7, drug treatment: metformin and renal impairment, 2015, last updated February 2026, checked 10 Oct 2026
4. Do not withhold anticoagulation in atrial fibrillation solely because of a risk of falls; apixaban is reduced to 2.5 mg twice daily when two of age 80 or over, weight 60 kg or less, or creatinine 133 micromol/L or more are present; a woman of 86 weighing 52 kg meets two criteria. NICE — NG196 Atrial fibrillation: diagnosis and management, section 1.6, anticoagulation: falls; (dose from the BNF apixaban monograph), 2021, last updated June 2021, checked 10 Oct 2026
5. Alendronic acid: review the need for continued treatment after five years (three years for zoledronic acid); in people at lower risk consider a treatment break with reassessment of fracture risk; in people at high risk continue up to ten years and then review. NICE CKS — Osteoporosis: prevention of fragility fractures, management: duration of bisphosphonate treatment and treatment breaks, current online version, checked 10 Oct 2026
6. Opioids are not recommended for osteoarthritis pain and cause drowsiness, constipation and falls in older people; when withdrawing a long-term opioid, reduce gradually and agree the plan with the person; offer paracetamol and a topical NSAID for knee pain. NICE — NG226 Osteoarthritis in over 16s: diagnosis and management, section 1.4, pharmacological management, October 2022, checked 10 Oct 2026
7. The STOPP criteria list, among others: a thiazide with hypokalaemia or hyponatraemia, a sulfonylurea with recurrent hypoglycaemia, an ACE inhibitor with hyperkalaemia, any drug that causes postural hypotension in a person with falls, and long-term opioids as first-line for mild to moderate pain; the START criteria list what should be added. O'Mahony D et al. (European Geriatric Medicine) — STOPP/START criteria for potentially inappropriate prescribing in older people: version 3, STOPP sections B, J and K, 2023, checked 10 Oct 2026
8. Offer a multifactorial falls assessment to older people who have had two or more falls, including a medication review targeting drugs that lower blood pressure or sedate, strength and balance training, and a home hazard assessment. NICE — NG249 Falls: assessment and prevention in older people and people 50 and over at higher risk, section 1.2, multifactorial falls risk assessment; section 1.3, interventions, April 2025, checked 10 Oct 2026
9. The ADA Standards of Care (2025), Older adults, set glycaemic goals by health status: for older adults in good health an HbA1c below 7.0 to 7.5 per cent (53 to 58 mmol/mol); for complex or intermediate health (several coexisting conditions, mild cognitive impairment or impaired instrumental activities of daily living) below 8.0 per cent (64 mmol/mol); for very complex or poor health, avoid reliance on HbA1c and avoid hypoglycaemia. Sulfonylureas are avoided because of hypoglycaemia; over-treatment is common, and de-intensification is recommended where it reduces hypoglycaemia and polypharmacy. ADA — Standards of Care in Diabetes 2025: section 13, Older adults, glycaemic goals by health status; treatment de-intensification and simplification, 2025, checked 10 Oct 2026
10. NG5 defines a medication review as a structured, critical examination of a person's medicines, with the aim of reaching agreement with the person about treatment, optimising the impact of medicines, minimising medication-related problems and reducing waste; it is offered to people taking multiple medicines, people with long-term conditions and older people. The review covers the person's and carer's views and understanding, every prescribed and over-the-counter medicine, whether each remains clinically appropriate, monitoring needed and adverse effects; the outcome is recorded and shared. NICE — NG5 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, section 1.3, medication review, March 2015, checked 10 Oct 2026
11. An eGFR of 30 to 44 is CKD category G3b. Accelerated progression is a sustained fall in eGFR of 25 per cent or more with a change in category within a year, or a sustained fall of 15 or more a year; a fall from 44 to 34 in a year approaches the first threshold and is repeated with a urine albumin-to-creatinine ratio. On an ACE inhibitor, potassium and eGFR are monitored: not started if potassium exceeds 5.0 mmol/L, stopped at 6.0 or more. NICE — NG203 Chronic kidney disease: assessment and management, section 1.1, classification and defining progression; section 1.6, pharmacotherapy: ACE inhibitors and potassium, August 2021, checked 10 Oct 2026
12. NG56 says that when assessing for frailty in primary care the GP may use an informal assessment of gait speed (more than five seconds to walk four metres, or below 0.8 metres a second), self-reported health status, a validated tool such as PRISMA-7 (a score of 3 or more), or the timed up-and-go test (more than 12 seconds); a woman who needs her hands to rise from a chair and takes 19 seconds meets this threshold, and frailty so identified is the basis for the tailored approach NG56 describes. NICE — NG56 Multimorbidity: clinical assessment and management, section 1.2, identifying people who may benefit from a tailored approach: frailty, September 2016, checked 10 Oct 2026
13. The Older adults Topic Guide expects the GP to recognise and grade frailty, to lead a structured medication review and deprescribe safely with a sequence and a date for each step, to assess falls and postural hypotension, to keep the older person's own priorities at the centre while involving the carer, to assess capacity where a decision is in doubt, and to arrange monitoring and follow-up after any change in medicines. RCGP — GP curriculum: Older adults, Topic Guide: frailty; polypharmacy and medication review; falls; working with carers, 2025 curriculum (Being a GP), checked 10 Oct 2026

Working references for this station

13 statements, 774 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-24