PS-057 Pharmaceutical care for chronically hospitalised elderly patients

BackgroundPolypharmacy is a risk factor for geriatric syndrome, increasing morbidity and mortality.PurposeTo determine the prevalence of potentially inappropriate medications (PIMs) and potential prescription omissions (PPOs) in older people with polypharmacy.Material and methodsProspective and descriptive study (February–August 2015) with the following inclusion criteria: patients older than 65 years admitted to the internal medicine unit (IMU), pluripathologic (>5 chronic diseases), polypharmacy (>6 drugs/day) and >2 readmissions/year. Studied variables were: age, sex, patient diagnosis, Charlson comorbidity index (CCI), prescribed drugs, PIMs (according to STOPP 2008, Beers 2012 and Priscus 2010 criteria) and PPOs (according to START 2008 criteria). Circuit: (1) IMU informs the hospital pharmacist (HP) everyday about new patients admissions; (2) HP reviews electronic patient records and electronic prescription programme; (3) evaluation of prescribed drugs at admission and during hospital stay with the programme Check-the-meds; and (4) HP prepares a report to inform the doctor of the identified PIMs and PPOs.Results64 patients were included (56.2% male), mean-age was 77.9 ± 12.1 years and mean CCI was 7.5. Mean medical diagnoses (at hospital admission) and drugs (during hospitalisation) per patient were 8.6 ± 4.3 and 10.2 ± 3.5, respectively.The following PIMs were identified: 76 STOPP criteria (60.9% of patients), 107 Beers criteria (67.2% of patients) and 19 Priscus criteria (23.4% of patients). The following PPOs were identified: 144 START criteria (70.3% of patients). The most frequent PIMs and PPOs were: (1) STOPP criteria: use of beta-blockers in patients with diabetes mellitus (DM) with frequent episodes of hypoglycaemia (14.5%) and proton pump inhibitors for peptic ulcer disease at full therapeutic doses >8 weeks (9.2%); (2) START criteria: starting treatment with angiotensin converting enzyme inhibitor if the patient has congestive heart failure (13.2%) and starting treatment with antiplatelet agents in patients with DM and cardiovascular risk factors (11.8%); (3) Beers criteria: acetylsalicylic dose 2 mg/day and long acting benzodiazepines (21.1% both cases).ConclusionThis tool was useful to easily identify PIMs and PMOs. In our study their prevalence was high. Implementation of a pharmaceutical c