ABSTRACT
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.
