Drug identification by the patient: Perception of patients, physicians and pharmacists.

INTRODUCTION: Faced with the increasing number of pharmaceutical products on the market, several pharmacovigilance notifications regarding confusion between look-alike and sound-alike drugs have been reported. This study of perception among patients, family physicians and pharmacists aims to evaluate drug identification factors and the risk of errors of confusion for patients. MATERIAL AND METHODS: Patients were systematically approached in randomly selected pharmacies within the Midi-Pyrénées region in France and invited to complete a questionnaire. Two other questionnaires were respectively sent to family physicians and pharmacists in the same region asking for their opinion on patients' perception of the identification of prescribed medicines. RESULTS: Of the 768 patients interviewed, most report identifying their medications by name (brand name: 50%; generic: 21%), while a smaller number cite physical appearance (box: 16%, tablet: 7% and blister packaging: 3%). In practice the factors considered most likely to cause confusion by patients relate to drug appearance (look-alike tablets: 28%, look-alike boxes: 20% and look-alike blister packaging: 13%). In contrast, look-alike and sound-alike names (generic and brand names combined) were cited in 31% of cases. Physicians (n=345) and pharmacists (n=198) understimate that patients identify their treatment by name (physicians: 46%; pharmacists: 26% vs. patients: 71%), reporting instead that problems arise mainly from the appearance of medicines (physicians: identification: 52% and risk factors for confusion: 74%; pharmacists: identification: 74% and risk factors for confusion: 83%; versus patients: identification: 26%; risk factors for confusion: 61%). DISCUSSION: Our study highlights the critical role of medication name in identifying drugs among patients. However, confusion of look-alike tablets or pills figures prominently among fears surrounding medication errors. Despite several notifications of pharmacovigilance, this issue appears to be underestimated within the body of medical literature. Proper identification of medicines by patients is essential to improving medication safety and therapeutic compliance. Concrete measures can be undertaken to reach this goal.

Study protocol: Randomised controlled trial to evaluate the impact of an educational programme on Alzheimer's disease patients' quality of life.

INTRODUCTION: Therapeutic education is expanding in the management of Alzheimer's disease (AD) patients. Several studies have revealed a positive impact of therapeutic educational programmes on the caregiver's burden and/or quality of life. However, to date, no study has evaluated its impact on the quality of life of the AD patient. METHODS: The THERAD study (THerapeutic Education in Alzheimer's Disease) is a 12-month randomised controlled trial that started in January 2013. This paper describes the study protocol. THERAD plans to enroll 170 dyads (AD patient and caregiver) on the basis of the following criteria: patient at a mild to moderately severe stage of AD, living at home, receiving support from a family caregiver. The main outcome is the patient's quality of life assessed by the Logsdon QoL-AD scale at 2 months, reported by the caregiver. The study is being led by geriatricians trained in therapeutic education at Toulouse University Hospital in France. To date, 107 caregiver/patient dyads have been recruited. CONCLUSION: This is the first trial designed to assess the specific impact of a therapeutic educational programme on the AD patient's quality of life. The final results will be available in 2015. TRIAL REGISTRATION: [ClinicalTrials.gov: NCT01796314] Registered 19 February 2013.

Impact of polypharmacy on occurrence of delirium in elderly emergency patients.

OBJECTIVE: To examine associations between polypharmacy and delirium diagnosed in elderly patients hospitalized in geriatric acute care unit after emergency hospital admission. METHODS: Study design was an observational cohort study in the acute geriatric care unit of a university hospital. We included 410 consecutive patients admitted to the acute geriatric ward during 9 months. Within 72 hours of each patient's hospitalization, a clinically trained geriatrician collected the following data: sociodemographic details (age, sex, type of residence), predisposing factors for delirium, main cause of hospitalization, and current medications. Polypharmacy was defined as 6 or more drugs a day. Delirium was assessed by a geriatrician using the Confusion Assessment Method and was diagnosed on the basis of clinical history with an acute change in usual functional status, behavioral observation, and clinical and cognitive assessment. RESULTS: Nearly 25% of hospitalized patients had delirium. The Confusion Assessment Method was positive in 69% of patients receiving polypharmacy and in 30% of those not receiving polypharmacy, a relative risk of 2.33. The proportion of elderly patients receiving polypharmacy was 58.53%. CONCLUSIONS: In our study, polypharmacy is an independent risk factor for delirium in a population of elderly patients after emergency admission. In the geriatric population, delirium is an underestimated scourge and because of its medicosocial and economic consequences and its impact on morbidity and mortality, we need to give increased attention to the prevention and control of polypharmacy, which is a predisposing factor for delirium.

[Definition and issue of medications underuse in frail elderly patients]. / Omission de traitement chez la personne âgée : quelle définition pour quels enjeux ?

Underuse is defined as the absence of initiation of an effective treatment in subjects with a condition for which one or several drug classes have demonstrated their efficacy. Indeed, "effective treatment" actually means favourable benefit/risk ratio. To propose a detailed and functional definition of underuse for frail elderly we should discuss, beforehand, the better way to assess benefit/risk ratio of drugs in this population. Our work is based on a literature review in the field of inappropriate prescription and therapeutic optimization. We can foresee the hard way to accurately define underuse for frail geriatric patients because of the difficulties encountered to demonstrate drug efficacy, drug effectiveness, or even more drug risk in this specific population. Potential benefit of underused medications in this population are poorly evaluated before and even after market authorization. Premarketing clinical trials and pharmacovigilance also yield only relatively restricted information on safety of use. Underuse is a non optimal prescription modality and presumes a judgment on prescription act. This can lead to recommendations or quality indicators. It should therefore be scientifically valid and closely fit with a loss of health or loss of quality of life with a satisfying proof level. But the literature generally adopts an unsophisticated point of view. Medication introduction on the basis of a debatable definition of underuse could lead to an accumulation of useless drugs with potential adverse effects which is overuse.

Psychotropic drug consumption at admission and discharge of nursing home residents.

OBJECTIVES: To quantify transitions of residents into or out of nursing homes (NHs) and to describe psychotropic drug prescription at admission and discharge and with regard to dementia diagnosis. DESIGN: A descriptive, cross-sectional, noninterventional study. SETTING: The setting included 300 NH in France. PARTICIPANTS: Participants included 2231 NH residents. MEASUREMENTS: Participants reported the number, origin, and destination of residents transiting into or out of the NH in the previous 3 months and provided information on NH characteristics. For eight residents admitted or discharged by the NH, information was collected on medical characteristics, including psychotropic and antidementia drug prescription, and dementia status. RESULTS: The mean number of beds in participating NHs was 85.9 ± 33.2 (mean occupation rate = 96.6%). The mean number of admissions and discharges in the previous 3 months was 13.7 ± 8.5 and 11.2 ± 4.3, respectively. Most admissions (direct admission 3.2 ± 3.3 or readmission 6.4 ± 6.0) and discharges (4.4 ± 6.7) were from and to the hospital. Of the 2231 residents included, 1005 (45.0%) were diagnosed with dementia. At least one psychotropic drug (antidepressant, hypnotic, antipsychotic, or anxiolytic) was prescribed to 70.7% of residents and in particular an antipsychotic to 19.1% of residents. Psychotropic drugs, and in particular antipsychotic drugs, were significantly more prescribed to demented residents than to nondemented residents (76.2% vs 64.3% and 28.0% vs 11.8%, respectively). The extent of prescription (at least one psychotropic drug) was similar in residents admitted to (70.2%) and discharged from (67.5%) the NHs. Antidementia drugs (acetylcholinesterase inhibitors or NMDA receptor antagonists) were prescribed to 53.7% of demented residents. CONCLUSION: Movement of residents into and out of NHs and especially from and to the hospital is extensive and the prescription rate for psychotropic drugs is very high in this population, especially in residents with dementia. Multiple groups of health care providers should be targeted by educational measures to improve the quality of care for NH residents.

[Specific care plan in different stages of Alzheimer's disease]. / Spécificités du plan d'aide et de soins aux différents stades des maladies d'Alzheimer.

The management and follow-up of patients with Alzheimers disease have stage-specific characteristics. In the mild stage, the key challenges are above all to improve the early diagnosis and the communication of the diagnosis. With the patient's agreement, a follow-up should be scheduled to assess, at each stage of the disease, cognitive and functional decline, and detect psycho-behavioral, nutritional or mobility complications. In the moderate or severe stages, prevention and treatment of caregiver burnout should be included in the follow-up. Finally, in the very severe stage, end of life and ethical issues should be considered. The followup and the intervention plan should be adapted to each patient, and require coordination between health care professionals and social workers. However, the practical aspects of the follow-up and the ways in which those can be improved are yet to be defined.

Alzheimer's disease progression in the oldest old compared to younger elderly patient: data from the REAL.FR study.

OBJECTIVE: Although population-based studies have revealed marked increases in the prevalence and incidence of dementia, particularly in older age groups, longitudinal studies of cognitive change have been less frequently conducted. The aim of this study is to describe the progression of Alzheimer's disease (AD) in the oldest old (>or=85 years) and to compare it with the younger elderly. METHODS: A cohort of 114 AD patients >or=85 years old and 572 AD patients <85 years living in the community at inclusion were monitored over 2 years in 16 centers of the French AD network (REAL.FR study). Each subject underwent extensive medical examination including functional (Activities of Daily Living or ADL) and neuropsychological evaluations (including Mini Mental Status Evaluation or MMSE) every 6 months. RESULTS: The observed decrease in MMSE performance in patients >or=85 was -4.18 +/- 0.63 points during the 2-year follow-up (vs -4.62 +/- 0.25 in the younger group) with no statistically significant differences between the two groups. After adjusting for confounding factors, ADL score declined faster in the oldest old than in individuals <85 years old during the 2-year follow-up: -1.73 +/- 0.19 vs -1.27 +/- 0.08 (p = 0.0309). CONCLUSIONS: Our study showed, that while the progression of cognitive impairment was identical in both groups, after adjustment for variables related both to age and dependency, the progression of dependency was more rapid in those over 85 years old.