Audit clinique ciblé sur la prise en charge médicamenteuse chez le sujet âgé hospitalisé en psychiatrie - 05/02/16
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Résumé |
Le risque d’iatrogénie médicamenteuse est majoré chez les personnes âgées. Dans une unité de soins gériatrique d’un hôpital psychiatrique s’est déroulée une évaluation des pratiques professionnelles sous forme d’audit clinique ciblé (ACC) sur le thème des « prescriptions médicamenteuses chez le sujet âgé de 75ans et plus ». Cet audit a conduit à définir trois axes d’amélioration sur les associations de neuroleptiques, les médicaments ayant des propriétés anticholinergiques et la prescription des benzodiazépines, ce dernier faisant l’objet d’une autre communication. Lors de la réévaluation, les ordonnances de sortie ont alors été analysées en regard des axes d’améliorations définis. Entre les deux évaluations, le pourcentage d’ordonnance avec au moins deux neuroleptiques est resté stable. Néanmoins, on a observé que le second était prescrit de manière conditionnelle et anticipée à des posologies inférieures ou égales à celles préconisées chez le sujet âgé. La proportion des patients qui ne prenaient pas de médicaments anticholinergiques est passée de 30 % à 60 % (p≤0,01). Cependant, les référentiels utilisés pour notre évaluation n’étaient pas faciles à respecter, notamment sur l’utilisation des neuroleptiques. En effet, il s’agit de patients dont les troubles ont conduit à une hospitalisation en établissement psychiatrique, ce qui peut nécessiter l’association de deux neuroleptiques.
Le texte complet de cet article est disponible en PDF.Summary |
Background |
The elderly are particularly vulnerable to the iatrogenic effects of drugs that are a major public health problem. In a geriatric care unit of a psychiatric hospital, the pharmacist, in close cooperation with the various health professionals, takes part in the optimization of drug therapy of these patients during cross-professional consultation meetings. From 2009 to 2011, an evaluation of professional practices was run through a targeted clinical audit on the theme of “prescription drugs at the age of 75 and over”. The main objective of this study is to measure the differences between the practices and the guidelines for prescription drugs concerning the elderly, and then to analyze and amend these differences. The secondary objective is to gather data on the prescription drugs for the elderly in the particular context of a psychiatric unit.
Methods |
The evaluation was performed using two standards: the evaluation chart of prescriptions of the Professional College of French Geriatrics (CPGF) and the French National Authority for Health and the list of Laroche et al. In the first round, after analyzing the prescriptions of 105 patients, the gap between practice and accepted standards led to the definition of three areas of improvement on the associations of neuroleptics, on the use of anticholinergic drugs and on the prescription of benzodiazepines, the latter being subject of another communication. After reassessment, the prescriptions of 101 patients were thereafter analyzed in relation to the identified areas of improvement.
Results |
Patient samples of both phases were statistically homogeneous. Between the two evaluations, the percentage of prescriptions with at least two neuroleptics remained stable, the decline was not significant (18.1% to 13.9%, P≥0.05). However, it was observed that the second suggested a “conditional” decline with dosages less than or equal to those recommended for the elderly dosages. The proportion of patients who did not take anticholinergic drugs increased from 30% to 60% (P≤0.01). In parallel to the improvement of these criteria, it was noted that the average number of psychotropic drugs prescribed was significantly reduced (from 3.3 to 2.79 psychotropic/patients, P=0.078).
Discussion |
The involvement of a pharmacist in cross-professional meetings of a care unit of psychiatry for the elderly has contributed in setting up a clinical audit focused on the drug management of these patients. This work enabled measurement of the progress made in the use of anticholinergic drugs, following the guidelines. In the mean time, it has been highlighted that the standards used are difficult to comply with regarding some criteria. For instance, the use of neuroleptics in the case of elderly patients hospitalized in the unit of psychiatry and not in the unit of geriatrics requires specific adjustments. Indeed, there are patients whose disorders have led to psychiatric hospitalization, which may require a combination of two neuroleptics. This paved the way for us to develop, within a working group representative of all professionals involved, a list fitting our medical practice and integrated into a guidebook adapted to the drug therapy management of elderly patients in psychiatry. The approach being successful, this targeted clinical audit will be extended to patients aged 75 years and over, hospitalized in other care units of the hospital.
Le texte complet de cet article est disponible en PDF.Mots clés : Psychiatrie du sujet âgé, Audit clinique, Médicaments potentiellement inappropriés, Psychotropes
Keywords : Psychiatry in the elderly, Clinical audit, Potentially inappropriate medications, Psychotropic medication
Plan
Vol 42 - N° 1
P. 14-23 - février 2016 Retour au numéroBienvenue sur EM-consulte, la référence des professionnels de santé.
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