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Comment réduire la dépendance iatrogène chez les sujets âgés hospitalisés ?

Résumé

L’hospitalisation représente la première cause de déclin fonctionnel chez les personnes âgées; 30 à 60% d’entre elles perdent de l’autonomie sur les activités de base de la vie quotidienne (AVQ). Cette perte d’indépendance résulte de l’affection aigue qui a motivé l’hospitalisation mais est aussi liée aux modalités de prise en charge.

Objectif

cet article est la première étape d’un projet visant à prévenir la «dépendance iatrogène» à l’hôpital.

Methode

lors d’une réunion de deux jours à Monaco, un groupe de travail composé de 20 experts internationaux a analysé 106 articles relevants, défini les axes de travail et rédigé une synthèse.

Résultats

1- La “Dépendance Iatrogène” (Iatrogenic Disability) a été définie par le groupe d’experts comme la dépendance le plus souvent évitable en relation avec les soins. Elle fait intervenir trois composantes intriquées et cumulatives: 1) la fragilityé préexistante du patient, 2) la sévérité de la pathologie qui a conduit le malade à l’hôpital 3) enfin la structure hospitalière et les soins qu’elle dispense. 2- La prévention de la «dépendance Iatrogène » implique des étapes successives. La première consiste à prendre conscience que l’hospitalisation peut créer de la dépendance. Les études épidémiologiques ont permis d’identifier les populations à risques grâce à des scores composites (HARP, ISAR, SHERPA, COMPRI, ...).

La deuxième étape consiste à considérer que le déclin fonctionnel n’est pas une fatalité. Des référentiels qualité ont déjà été rédigés. Des interventions pour prévenir la dépendance sur des populations ciblées ont été mises en place: simple consultation gériatrique, interventions monofactorielles (mobilité, confusion, iatrogénie ...) ou interventions multidomaines (GEM Units et ACE Units, HELP, Fast Track, NICHE ...). Ces actions, essentiellement centrées sur la fragilité du patient, ont des résultats limités car elles prennent peu en compte le fonctionnement de l’institution, non orientée vers la prévention du déclin fonctionnel. La dispensation des soins affiche aussi des dysfonctionnements: manque de connaissances en gériatrie, défaut d’évaluation et de prise en charge du statut fonctionnel. Les nouvelles interventions devront non seulement repérer les patients à risques pour qu’ils bénéficient d’une prise en charge spécialisée mais aussi avoir pour cible la structure hospitalière et les soins. Ceci implique de réaliser une « démarche qualityé » graduée et de repenser l’organisation de l’hôpital autour de la personne âgée.

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Membres du I.A.G.G. / A.M.P.A Task Force les 21 et 22 janvier 2011:Pr. S. Andrieu, C. Balandier, Dr. P. Bonhomme, P. Decourt, Dr. S. Connee-Bertrand, F. Couriol, Pr. J. Fitten, Pr. F. Forette, Pr.A. Franco, D. Gabeloux, Dr. C. Lafont, Dr. S. Louchart de Lachapelle, P. Migliasso, Pr. M. Pahor, Dr. A. Pesce, Dr. P. Porasso, Pr. P. Robert, G. Ruault, Dr. A. Salva, Pr. B. Vellas, RM Van Lerberghe

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Lafont, C., Gérard, S., Voisin, T. et al. Comment réduire la dépendance iatrogène chez les sujets âgés hospitalisés ?. cah. année gerontol. 3, 6 (2011). https://doi.org/10.1007/s12612-011-0199-9

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  • DOI: https://doi.org/10.1007/s12612-011-0199-9

Mots clés

  • Vieillissement
  • Personne âgée
  • Hospitalisation
  • Dépendance iatrogène
  • Déclin fonctionnel
  • Risque mesuré
  • Evaluation gériatrique