Médicaments chez les patients atteints de MCI (Mild Cognitive Impairment) (étude descriptive et liens entre profil neuropsychologique et)

PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Abstracts of the 18th Congress of the European Geriatric Medicine Society : Live from London and Online, 28–30 September 2022

Introduction: Overtreatment by glucose-lowering treatment (GLT) is frequent and harmful in older people with type 2 diabetes (T2D), making de-intensification of GLT essential. This systematic review aimed at comparing recommendations defining profiles of older patients to be targeted by de-intensification of GLT. Methods: Using a comprehensive search of the literature, we included all clinical practice guidelines (CPGs) providing recommendations for de-intensification of GLT in older patients (C 65 years), published in English, after 2015 and supported by European or North American scientific societies or expert groups were included. Of these, we extracted all recommendations defining profiles of patients to be targeted by de-intensification of GLT. Results: Five CPGs of good methodological quality were included, most of which were supported by North American scientific societies. They all recommend a list of different profiles of patients for whom de-intensification of GLT should be proposed, either because those patients have an important risk of hypoglycaemia (e.g. advanced age, severe glycaemic control, multiple co-morbidities, frequent hypoglycaemia), or because the benefit of GLT is uncertain (cognitive impairment, frailty, or patients at the end of life). There are important differences between CPGs, but they all recommend to de-intensify GLT in patients with cognitive impairment or frailty. The extracted recommendations were mainly expert opinion-based, explaining partly these differences between CPGs. Conclusion: Given the challenge of avoiding overtreatment in older patients with T2D, it is crucial to improve the quality of recommendations for de-intensification of GLT, and in particular the definition of patients to be targeted by de-intensification

Impact on Professional Relationships of the Presence of an Itinerant Night Nurse: A Qualitative Study of Care Homes for Older People

International audienceBackground: A trial scheme to improving night-time nursing in residential care homes for dependent older people in the Ile de France region of France involved appointing degree-qualified nursing staff to circulate between three or four care homes. In most old age care homes, the absence of a qualified nurse to carry out health procedures during the night leads to night-duty care teams having to deal with urgent medical complications. This study aims to identify the factors which may impede the building of cooperative relationships between night staff and mobile nurses working in a number of medical settings.Design: An inductive approach was used, based on analysis of in-depth interviews, observations and informal conversations to elicit the key themes. The field study was carried out over a four-month period from February to May 2015 in a number of selected residential care homes.Methods: 35 semi-structured interviews were conducted with health professionals representing a range of paramedical categories, and 7 night-time participant observation sessions, in which the researcher accompanied mobile nurses during their night-duty work. 22 care homes were visited in total. The participant observation sessions included informal conversations to complete the data collection process.Results: The findings demonstrate the importance of shared understandings of the organization of work among health professionals of different categories. Representations concerning mobile nurses by health care teams and their managers may have counter-productive effects and give rise to status tensions in relationships between care home staff. For their part, nurses who are not permanently present within care establishments have to employ strategies to maintain the cohesion with colleagues that their professional actions require, especially for managing emergency situations

Deprescribing Glucose-Lowering Therapy in Older Adults with Diabetes: A Systematic Review of Recommendations

Overtreatment by glucose-lowering treatment (GLT) is frequent, and may induce harmful hypoglycemic events in older people with type 2 diabetes (T2D), significantly increasing morbidity and mortality.1 Avoiding overtreatment by GLT, either by prescribing appropriate GLT according to their individual risks-benefits balance or by deprescribing GLT, is therefore a key issue in the management of older patients, as recommended by various scientific societies these last years.2 Nevertheless, there is currently no consensus on the definition of GLT overtreatment in older people,3 which prevents a clear statement on which patients should undergo deprescribing of GLT. It is therefore worthwhile to define the profiles of patients for whom GLT should be deprescribed. This systematic review of clinical practice guidelines (CPGs) aimed to compare the recommendations defining profiles of older patients in whom deprescribing GLT is recommended

Health status and drug use 1 year before and 1 year after skilled nursing home admission during the first quarter of 2013 in France: a study based on the French National Health Insurance Information System

International audienc

A prescription support-tool for chronic management of oral antithrombotic combinations in adults based on a systematic review of international guidelines

International audienceBACKGROUND: Oral antithrombotic (AT) drugs, which include antiplatelet and anticoagulant therapies, are widely implicated in serious preventable bleeding events. Avoiding inappropriate oral AT combinations is a major concern. Numerous practical guidelines have been released; a document to enhance prescriptions of oral AT combinations for adults would be of great help.OBJECTIVE: To synthesize guidelines on the prescription of oral AT combinations in adults and to create a prescription support-tool for clinicians about chronic management (≥ one month) of oral AT combinations.METHODS: A systematic review of guidelines published between January 2012 and April 2017, in English or in French, from Trip database, Guideline International Network and PubMed, dealing with the prescription of oral ATs in adults was conducted. In-hospital management of ATs, bridging therapy and switches of ATs were not considered. Some specific topics requiring specialized follow-up (cancer, auto-immune disease, haemophilia, HIV, paediatrics and pregnancy) were excluded. Last update was made in November 2018.RESULTS: A total of 885 guidelines were identified and 70 met the eligibility criteria. A prescription support-tool summarizing medical conditions requiring chronic management of oral AT combinations in adults with drug types, dosage and duration, on a double-sided page, was provided and tested by an external committee of physicians. The lack of specific guidelines for old people (age 75 years and older) is questioned considering the specific vulnerability of this age group to serious bleedings.CONCLUSIONS:Recommendations on prescriptions about chronic management of oral AT combinations in adults were mainly consensual but dispersed in numerous guidelines according to the medical indication. We provide a prescription support-tool for clinicians. Further studies are needed to assess the impact of this tool on appropriate prescribing and the prevention of serious adverse drug events

Inappropriate Use of Oral Antithrombotic Combinations in an Outpatient Setting and Associated Risks: A French Nationwide Cohort Study

International audienceWith the increase in prevalence of cardiovascular diseases, multimorbidity, and medical progress, oral antithrombotic (AT) combinations are increasingly prescribed. The aims of this study were to estimate the incidence of oral AT combinations, their appropriateness (defined as indications compliant with guidelines), and the related risk of major bleeding (i.e., leading to hospitalization) or death, among new users. We conducted a 5-year historical cohort study, using the French national healthcare database, including all individuals ≥ 45 years old with a first delivery of oral ATs between 1 January 2013 and 31 December 2017. The cumulative incidence of oral AT combinations was estimated with the Fine and Gray method, taking into account the competitive risk of death. We compared the cumulative incidence of major bleeding according to the type of oral AT treatment initiated at study entry (monotherapy or oral AT combinations). During the study period, 22,220 individuals were included (mean (SD) age 68 (12) years). The cumulative incidence of oral AT combinations at 5 years was 27.8% (95% confidence interval (CI) 26.8–28.9). Overall, 64% of any oral AT combinations did not comply with guidelines. The cumulative incidence of major bleeding and death in the whole cohort at 5 years was 4.1% (95% CI 3.7–4.6) and 10.8% (95% CI 10.1–11.6), respectively. Risk of major bleeding increased among individuals with oral AT combinations versus oral AT monotherapy at study entry (subdistribution hazard ratio sHR: 2.16 (1.01–4.63)); with no difference in terms of death. The use of oral AT combinations among oral AT users is frequent, often inappropriately prescribed, and associated with an increased risk of major bleeding

Prescriptions médicamenteuses chez les personnes âgées en EHPAD : une étude transversale multicentrique

Objectif. Évaluer de façon rétrospective la qualité des prescriptions des résidents des établissements d’hébergement pour personnes âgées dépendantes (EHPAD) avant la diffusion d’un livret thérapeutique. Méthodes. L’étude a porté sur les prescriptions de 495 résidents de 8 EHPAD, un jour donné. Un score de conformité de prescription a été calculé par rapport au livret à partir de 6 items. Résultats. Le nombre médian de médicaments par ordonnance était de 8,5. Sur 4 311 médicaments prescrits, le score moyen de conformité de la prescription au livret thérapeutique était de 4,96 ± 0,45, (3,4 ± 1,02 pour la prescription manuscrite et 4,54 ± 0,70 pour la prescription informatisée). Parmi ces 4 311 médicaments, 939 (21,8 %) appartenaient à des classes à risque, et devraient être accompagnés d’une surveillance prescrite ; seuls 154 (16,4 %) étaient associés à une prescription de surveillance. Conclusion. Il existe un défaut dans la surveillance des médicaments appartenant aux classes à risque. L’informatisation de la prescription permet d’améliorer la conformité des prescriptions comme le montre le score de conformité

Sedative-hypnotic initiation and renewal at discharge in hospitalized older patients: an observational study

Abstract Background Sedative-hypnotics (SHs) are widely used in France but there are no available data addressing their prescription specifically in hospitalized older patients. The objective is thus to determine the cumulative incidence of sedative-hypnotic (SH) medications initialized during a hospital stay of older patients, the proportion of SH renewal at discharge among these patients and to study associated risk factors. Methods We conducted a retrospective observational study in six internal medicine units and six acute geriatric units in eight hospitals (France). We included 1194 inpatients aged 65 and older without SH medications prior to hospitalization. Data were obtained from patients’ electronic pharmaceutical records. Primary outcome was the cumulative incidence of SH initiation in the study units. Secondary outcomes were the proportion of SH renewal at discharge and risk factors for SH initiation and renewal at discharge (patient characteristics, hospital organization). A Cox regression model was used to study risk factors for SH initiation. A mixed effects logistic regression was used to study risk factors for SH renewal at discharge. Results SH initiation occurred in 21.5% of participants 20 days after admission. SH renewal at discharge occurred in 38.7% of patients who had initiated it during their stay and were discharged home and in 56.0% of patients discharged to rehabilitation facilities. Neither patients’ characteristics nor hospital organization patterns was associated with SH initiation. SH initiation after the first six days after admission was associated with a lower risk of SH renewal in patients discharged to rehabilitation facilities (OR = 0.19, 95% CI: [0.04–0.80]). Conclusions Hospitalization is a period at risk for SH initiation. The implementation of interventions promoting good use of SHs is thus of first importance in hospitals. Specific attention should be paid to patients discharged to rehabilitation facilities

Association Between Psychotropic and Cardiovascular Iatrogenic Alerts and Risk of Hospitalizations in Elderly People Treated for Dementia: A Self-Controlled Case Series Study Based on the Matching of 2 French Health Insurance Databases

International audienceBackground: Elderly people are at risk of repeated hospitalizations, some of which may be drug related and preventable. In 2011, a group of French healthcare experts selected 5 iatrogenic alerts (IAs), based on criteria identified in a literature search and from their professional experience, to assess the appropriateness of medication in elderly patients. Objectives: Our objective was to examine the association between hospitalizations and IAs in elderly patients treated for Alzheimer disease who are particularly sensitive to adverse drug events. Design: A 2-year (January 1, 2011, to December 31, 2012) longitudinal national database study, with a study design similar to self-controlled case series, was performed to analyze data on drug prescriptions and hospitalization. IAs were defined as (1) long half-life benzodiazepine; (2) antipsychotic drugs in patients with Alzheimer disease; (3) co-prescription of 3 or more psychotropic drugs; (4) co-prescription of 2 or more diuretics; and (5) co-prescription of 4 or more antihypertensive drugs. Data were obtained by matching of 2 French National Health Insurance Databases. Setting: France. Participants: All affiliates, aged >= 75 years, receiving treatment for Alzheimer disease, alive on January 1, 2011 were included. Measurements: We calculated the relative increase in the number of hospitalizations in patients with IAs. The analysis was performed over four 6-month periods. Results: A total of 10,754 patients were included. During the periods with IAs, hospitalization rates increased by 0.36/year compared with 0.23/year in the periods without for the same patient, and the number of hospitalizations doubled [proportional fold change = 1.9, 95% confidence interval (1.8, 2.1)]. We estimated that 22% [95% confidence interval (20%, 23%)] of all hospitalizations were associated with IAs, 80% of which were due to psychotropic IAs. Conclusions: The IAs could be used as a simple and clinically relevant tool by prescribing physicians to assess the appropriateness of the prescription in elderly patients treated for Alzheimer disease