Impact of Medication Reconciliation at Discharge on Potentially Inappropriate Medications in the Elderly : Community-hospital Coordination

The geriatric population is exposed to poly-medication. Furthermore, old people have important pharmacodynamic and pharmacokinetic changes that expose to much drug iatrogenic. Adverse drug effects are a great cause for hospitalization that is why the knowledge of the complete list of medications taken by the patient is necessary. The poly-medication in elderly can lead to extremely serious clinical consequences and significant costs. Reference documents specific to geriatrics guide the doctor in therapeutic choices. On the one hand, the Laroche's criteria lists all PIM of the French pharmacopoeia in elderly. On the other hand, STOPP/START criteria are a tool for detect PIM listing inappropriate drugs and criteria of potentially drug omissions. This has been validated in French language. It is important that any changes proposed by the geriatrician resulting in just prescription is sustainable beyond the hospitalization to prevent the recurrence of adverse effects. Effective community-hospital coordination is essential.

Medication reconciliation is defined as the formal process of checking the complete, accurate list of a patient's previous medication - including drug name, dosage, frequency, and route - and comparing it with the prescription after a transition of care (on admission, after transfer to another medical unit, and/or at discharge).

Two groups of patients will be created, one for which medication reconciliation at discharge will be practiced and the other a similar process but not standardized. Four to eight weeks after the discharge, the member of the pharmacy team is calling the usual community pharmacy to get the first non-hospital prescription by fax and compare the number of PIM with the prescription before hospitalization.