Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities

Objective: the study aimed to determine the prevalence of and risk factors for inappropriate prescribing (IP) and prescribing omission (PO) in elderly with mental co-morbidities. Participants: one hundred fifty consecutive inpatients with mental co-morbidities hospitalised for acute medical illness (mean age 80 ± 9, 70% of women) were considered for the study. Measurements: IP and PO were prospectively indentified according to STOPP/START criteria at hospital admission. Results: over 95% were taking ≥1 medication (median = 7) which amounted to 1,137 prescriptions. The prevalence of IP was 77% and PO was 65%. The most frequent encountered IP concerned drugs adversely affecting fallers (25%) and antiaggregants therapy without atherosclerosis (14%). PO concerned antidepressants with moderate/severe depression (20%) and calcium-vitamin D supplementation (18%). Independent predictors for IP were increased number of concomitant drugs (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.13-1.89), being cognitively impaired (OR 1.83, 95% CI 1.55-2.24), and having fallen in the preceding 3 months (OR 2.03, 95% CI 1.52-2.61) or hospitalised in the preceding year (OR 1.09, 95% CI 1.02-1.23). Concerning PO, psychiatric disorder (OR 1.64, 95% CI 1.42-2.01) and increase level of co-morbidities (OR 1.79, 95% CI 1.48-1.99) were identified. Living in an institutional setting was a predictive maker for both IP (OR 1.45, 95% CI 1.27-1.74) and PO (OR 1.67, 95% CI 1.32-1.91). Conclusion: IP and PO were highly prevalent raising the need of a greater health literacy concerning geriatric conditions in non-geriatrician practitioners who care elderly as well as in the community, in hospital and institutional settings for improving quality and safety in prescribing medicatio

Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist

Polypharmacy in the elderly complicates therapy, increases cost, and is a challenge for healthcare agencies. In the context of the evolving role of the pharmacist, this systematic review examines the effectiveness of interventions led by pharmacists in reducing polypharmacy. A computerised search was conducted using Medline, Embase geriatrics and gerontology (2001 edition), the Cochrane Library and International Pharmaceutical Abstracts (IPA) databases. A manual search of articles on polypharmacy and the role of pharmacists in the therapy of the elderly and of the reference sections of all retrieved articles was also carried out. Search terms used were 'polypharmacy', 'elderly', 'aged', 'intervention' and 'pharmacist(s)'. Articles that fulfilled the following criteria were included: only elderly people were included in the study, or all ages were included but the study gave separate results for the elderly; the outcome was expressed as a reduction in the number of medications; a pharmacist participated in the study; and the study was a controlled or a randomised controlled study. We initially identified 106 articles, but only 14 studies met our four inclusion criteria. Reduction in the number of medications was not the major purpose of most selected studies but often a secondary outcome. Objectives differed, the general aim being to enhance the quality of prescribing in elderly patients. These controlled studies argued in favour of the effectiveness of pharmacists' interventions, even though the number of medications eliminated was small. Most studies were not designed to demonstrate the impact of reducing the number of drugs on the clinical consequences of polypharmacy (nonadherence, adverse drug reactions, drug-drug interactions, increased risk of hospitalisation, and medication errors). The most frequently reported outcome related to cost savings. It was therefore difficult to assess whether the interventions benefited the patient. The methodological quality of many identified studies was poor. In particular, the study objectives were often very broad and ill-defined. Polypharmacy itself has been defined in different ways and the appropriate definition may differ according to the patient population and the study setting. Further studies are needed to find the most effective way to reduce polypharmacy, especially in the frail elderly population, and to quantify the real advantages of simplifying their drug regimens in terms of improved quality of life

Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women

Urinary tract infections (UTI) are common in elderly patients. Authors of non systematic literature reviews often recommend longer treatment durations (7 to 14 days) for older women, but the evidence for such recommendations is unclear

Hypertension artérielle induite par les médicaments

In a few clinical cases, controlling arterial hypertension is really very difficult even when using the appropriate treatment(s) at the optimal dosage. In such cases, it is crafty to research any possible drug interferences with the antihypertensive treatment. Two clinical cases will illustrate that arterial hypertension can be either induced or very difficult to control due to opposite physiopathological mechanisms of drugs or to pharmacokinetic interactions. A review of the main interacting drug regimens will complete this paper, attesting that drugs as various as NSAID, corticosteroids, erythropoietin, cyclosporine, antidepressants, beta blockers, carbamazepine, sympathomimetics, antihistamines, tramadol and (...) can induce arterial hypertension

Prise en charge de la douleur chronique chez la personne âgée

Chronic pain is common in older adults and its consequences are often severe. Several studies have demonstrated that pain in older adults is poorly controlled because they underreport pain and caregivers often underestimate patient's pain. Analgesics can be used safely and effectively in this population. Start with the lowest effective dose, monitor frequently on the basis of expected absorption and pharmacokinetics of the drugs and then titrate on the basis of clinically demonstrated effects and the side effects. Other aspects of the management of pain in older persons will be described in the article

Allongement de l'espace QT et inhibition de la glycoprotéine P : à propos de deux observations gériatriques

Two cases with QT prolongation associated with the administration of standard drug doses are reported. Drug effects are determined by pharmacological and biological parameters. Drugs may be metabolized or transported by two systems: the cytochrome enzymes or the less well-known but nevertheless relevant P-glycoprotein system. P-glycoprotein is a pump that limits intracellular reabsorption and favors the elimination of exogenous substances. These two systems interact with each other to influence drug effects. A better knowledge of their mechanisms of action and their genetic determinants should help provide more individualized pharmacologic treatment to patients, in particular older patients

Breakthrough pain in elderly patients with cancer: treatment options

The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda

Effet analgesique des opiaces en usage cutane: quelle est leur efficacite?

Recent research has revealed the presence of opioid receptors in inflamed peripheral tissues. This gives rise to the possibility of treating the pain caused by wounds with the advantage of reducing the secondary effects related to the use of opioids and at the same time rendering their use more efficacious. The theory of a peripheral analgesic action of opioids has been tested in a variety of situations, in particular in brachial plexus blocks and intra-articular injections. In addition, the analgesic effect of opioids has been tested by cutaneous application for various conditions but on only a limited number of patients. On the basis of these case reports, we cannot conclude that the peripheral use of opioids is efficacious and the topical use of opioids cannot be recommended unless done within the framework of a controlled clinical trial

Syndrome sérotoninergique consécutif à l'association d'escitalopram et de cyclosporine chez une patiente de 84 ans

Due to the stimulation of central and peripheral 5-hydroxytryptamine receptors, the serotonin syndrome is a potentially lethal situation. The large variety of its clinical manifestations leads to a difficult diagnosis. We describe the case of a serotonin syndrome induced by the combined escitalopram and cyclosporine administration. An 84-year-old woman was hospitalized with a history of delirium associated with hyperthermia. The diagnosis of serotonin syndrome was suspected with the combination of the clinical features: the absence of infection, the selective serotonin reuptake inhibitor administration, and the absence of other metabolic and cerebral aetiology. After the discontinuation of escitalopram, the patient's condition improved rapidly. This report is a reminder of the clinical and pharmacological features of the serotonin syndrome from a recent literature review

Ostéonécrose des maxillaires et bisphosphonates

Widely prescribed, bisphosphonates inhibit bone resorption. They are not metabolised and have long half-lives. Two cases of osteonecrosis of the jaws have recently been attributed to bisphosphonates at the University Hospital of Geneva. The recent literature reveals more than a hundred similar cases throughout the world. Bone exposure appears spontaneously or after dental care. Treatment of the osteonecrosis is controversial and cure very difficult. This pathology is usually seen in patients on chemotherapy, steroids and i.v. bisphosphonates, but is sometimes seen with low-dose p.o. bisphosphonates. In view of the strong association between bisphosphonate therapy and osteonecrosis of the jaw, specialists have recommended dental and oral evaluation during bisphosphonate therapy as well as for several years after drug discontinuation