Potentially inappropriate medications and anticholinergic and sedative burden in older patients with haemophilia or von Willebrand disease: The M'HEMORRH-AGE study.

WHAT IS KNOWN AND OBJECTIVE: In older patients, multiple chronic conditions lead to the intake of multiple medications and a higher risk of adverse drug events. The exposure to inappropriate medications in older patients with bleeding disorders is poorly explored. The aim of this study was to describe the exposure to potentially inappropriate medications (PIMs) and medications with anticholinergic and sedative properties in older community-dwelling patients with haemophilia or von Willebrand Disease (VWD). METHODS: The M'HEMORRH-AGE study (Medication in AGEd patients with HAEMORRHagic disease) is a multicentre prospective observational study. Community-dwelling patients over 65 years with haemophilia or VWD were included in the study. PIMs were identified using the EU(7)-PIM list, and the anticholinergic and sedative drug exposure was measured using the Drug Burden Index. RESULTS AND DISCUSSION: 142 older community-dwelling patients with haemophilia (n = 89) or VWD (n = 53) were included (mean age: 72.8 ± 5.8 years). PIMs were used by 45.8% of older patients and were mainly represented by cardiovascular (34.9%), nervous systems (26.7%) and alimentary tract and metabolism PIMs (25.6%). Regarding anticholinergic and/or sedative medications, 37.3% of older patients were exposed mainly due to nervous system medications (68.3%), for example analgesics. WHAT IS NEW AND CONCLUSION: The M'HEMORRH-AGE study showed the exposure to PIMs and anticholinergic/sedative medications was high in older community-dwelling patients with haemophilia or VWD. Interventions focusing on deprescription of these inappropriate medications should be conducted in this specific population.

Implementation assessment of a patient personalized clinical pharmacy programme (5P project) into orthogeriatric care pathway.

WHAT IS KNOWN AND OBJECTIVE: The orthogeriatric path (hip-fractured elderly patients) is composed of several transition points (emergency surgery, orthopaedic, geriatric and rehabilitation units). The intervention of clinical pharmacists can ensure the continuity of patients' drug management during their hospital stay. The aim of the study was to assess the implementation of clinical pharmacy activities in an orthogeriatric pathway, regarding its impact on medication error prevention, the healthcare professionals' and patients' satisfaction, and the estimated associated pharmaceutical workload. METHODS: Participants were aged 75 or older and managed for proximal femoral fracture. Their admission prescription was reviewed. If they were evaluated at high risk of adverse event (AE), medication reconciliation (MedRec) and pharmaceutical interviews (admission, discharge, and targeted on oral anticoagulant) were added at different steps of their care pathway. The achievement and duration of each clinical pharmacy activity were recorded. The number of pharmaceutical interventions (PI) made during prescription review, and unintentional discrepancies (UID) identified during MedRec were collected. A satisfaction questionnaire was sent to patients and healthcare professionals. RESULTS AND DISCUSSION: Among 455 included patients, 284 patients were considered at high risk of AE. Clinical pharmacy activity achievement rates varied between 12% and 98%. A total of 622 PI and 333 UID were identified. The overall patients' and healthcare professionals' satisfaction was rated from 63% to 100%. The total workload was estimated at 376 h: on average 16 min per prescription review, 43 min per admission MedRec, 26 min per discharge MedRec and 17 to 25 minutes per interview. CONCLUSION: The implementation of the programme showed a high potential of drug management securing. To sustain it, additional pharmaceutical human resources and high-performance computing tools are needed.

Description of the Treatment Course by Pregabalin for Anxiety in Patients With a Major Neurocognitive Disorder.

BACKGROUND: Anxiety symptoms frequently experienced by patients with a major neurocognitive disorder (NCD) are often treated with long-term benzodiazepines despite known adverse effects. Pregabalin has shown efficacy in generalized anxiety disorders but has not been studied in patients with a major NCD. The objective of this study was to describe the use of pregabalin for anxiety in patient with a major NCD and the impact of its use on the pharmacological treatment change. METHODS: A retrospective study was conducted using data of hospitalized patients in a cognitive-behavioral specialized unit between January 2015 and December 2017. Patients with a major NCD treated by pregabalin were included in this study. Data about the use of pregabalin (initiation and effective dosage, titration duration) and the use of other psychotropics were collected from the patients' medical records. RESULTS: Thirty-three patients were included (mean age, 79.6 ± 11.7 years; 66.7% women). The mean duration of pregabalin titration was 18.6 ± 1.4 days, and the mean effective dosage was 200.0 ± 130.8 mg/d (range, 50-700 mg/d). At admission (before pregabalin use), 78.8% of patients were treated with a systematic prescription of benzodiazepine. At discharge (with pregabalin use), a significant decrease in patients with systematic prescription of benzodiazepine was observed (78.8% vs 33.3%, P = 0.001). During hospitalizations, no pregabalin treatment has been discontinued for lack of efficacy or for tolerance. CONCLUSIONS: Larger controlled studies are needed to confirm the efficacy and the safety of pregabalin to treat anxiety symptoms associated with neurocognitive disorders.

A multicenter cohort study to investigate the factors associated with functional autonomy change in patients with cognitive complaint or neurocognitive disorders: the MEMORA study protocol.

BACKGROUND: The identification of factors associated with functional impairment, in particular those which are potentially modifiable, may help to delay the advanced stages of functional dependence in patients with neurocognitive disorders such as Alzheimer's disease and related disorders. The objectives of the MEMORA cohort are to investigate the factors associated, first with functional autonomy change over time, and secondarily with the cognitive performance and behavioral disorders changes over time. METHODS: The MEMORA study is a multicenter prospective cohort study carried out throughout the patient's care pathway, in Memory centers of Lyon (France). The study will include 6780 patients at all stages of memory disorders in 6 years. The follow-up for each patient is planned for 3 years. The main outcome is the functional autonomy level change as assessed by the instrumental abilities of daily living (IADL) score. Patient characteristics include sociodemographic and clinical features, neuropsychological performance, pharmaceutical and non-pharmaceutical therapy. DISCUSSION: This study conducted in a context of routine care may help to identify the factors associated with functional impairment related to progressive neurocognitive disorders. Subsequently, interventions on potentially modifiable factors could be proposed to the patients to improve their management and delay functional dependence. TRIAL REGISTRATION: NCT02302482 , registered 27 November 2014.

Neurocognitive disorders: what are the prioritized caregiver needs? A consensus obtained by the Delphi method.

BACKGROUND: The symptoms related to neurocognitive disorders (NCD) may lead to caregiver burden increase. Involving caregivers in research may be an effective way of improving the practicalities and relevance of interventions. The aim of this study was to gather opinion and gain consensus on the caregivers 'priorities, using a Delphi method and including aspects of needs in pharmaceutical dimension. METHODS: Observational study using a modified Delphi method. This study was conducted in the Clinical and Research Memory Center of the University Hospital of Lyon (France), between September 2015 and January 2016. The expert panel was composed of 68 informal caregivers of people with subjective cognitive decline or NCD living at home. RESULTS: Caregivers assigned a very high importance to the dimension "information needs about their relative's disease", i.e. information on the disease, the treatment and the research; and to "coping skills", i.e. skills related to emotional support, communication, relationship evolution with the relative and skills to cope with behavioural crisis, behavioural and cognitive disorders. The aspect "coping with behavioural disorders" received a high selection rate (83%). CONCLUSIONS: The main needs selected can be used to design relevant interventions and give guidance to policy to support caregivers. To meet caregiver's needs, interventions should focus on information about disease and treatment and psychoeducational interventions.

A multi-center, randomized, controlled trial to assess the efficacy of optimization of drug prescribing in an elderly population, at 18 months of follow-up, in the evolution of functional autonomy: the OPTIM study protocol.

BACKGROUND: Pharmacotherapy is necessary for the management of many diseases which number increased with aging. However, potentially inappropriate prescriptions and polymedication increases iatrogenic risks and can lead to adverse events. To limit the consequences of potentially harmful prescriptions, optimization of drug prescribing is a major stake of improving quality and safety of care in the elderly. The purpose of the OPTIM study is to study the impact of the optimization of drug prescribing on the evolution of functional autonomy at 18 months of follow-up. METHODS: A multicenter, open-label, Randomized Controlled Trial was designed to assess the impact of an optimization program of drug prescribing consisting in a clinical medication review by a pharmacist, in collaboration with specialist physician of the geriatric/memory center and the referent physician, on the evolution of functional autonomy level, measured during 18 months of follow-up. The study will include 302 elderly outpatients visiting geriatric and memory centers, randomly distributed in one of the two parallel groups. One group will benefit of the intervention, while the other will be considered as control group. The effect of the intervention on evolution of the level of autonomy function, defined with repeated measures, will be estimated in a generalized linear mixed model. The intervention will be considered significant if the interaction between time and the study group is significant. Secondary analysis will be conducted to assess the impact of the intervention on secondary clinical outcomes. DISCUSSION: The "OPTIM" program should enable optimization of drug prescribing in elderly patients and therefore slow or prevent progression to loss of functional autonomy. It should also help to strengthen collaboration between the hospital team of geriatric/neurologist, the pharmacist and the private practice who are all involved in caring for the patient's health. The benefits for the patient are thus optimizing its medical management by linking health professionals met during his care pathway. In addition, pharmaceutical recommendations sent to referent physicians should help raise awareness of the prescription of drugs in these patients. TRIAL REGISTRATION NUMBER CLINICALTRIALS: NCT02740764.

Exposure to anticholinergic and sedative drugs, risk of falls, and mortality: an elderly inpatient, multicenter cohort.

This study aimed to assess whether exposure to anticholinergic and sedative medications and its evolution was associated with increased risk of in-hospital falls and all-cause mortality. Furthermore, results were compared with 2 definitions of drug burden index (DBI) against the outcomes.This observational, multicentric, and longitudinal study was conducted among patients aged 65 years or older, in 3 geriatric hospitals, in Francheville, Lyon, and Villeurbanne, France (duration of follow-up, 11.6 months). The exposure to anticholinergic and sedative medications was quantified using a DBI, at admission and at the end of observation for 337 patients. The evolution of exposure was the absolute difference between the index at admission and at the end of observation. The outcomes were in-hospital falls and all-cause mortality.Overall, 5.9% of patients experienced a fall. The risk of fall was nearly 3-fold in patients whose DBI increased during hospital stay compared to those with stable or decreased DBI (hazard ratio, 2.9 [1.14-7.12]; P = 0.03), after adjustment for comorbidities.The overall proportion of mortality was 6.5%. The evolution of DBI during hospital stay was not related to the risk of mortality (hazard ratio, 1.9 [0.8-4.4]; P = 0.14). Results were similar with the 2 definitions of DBI.Increased exposure to anticholinergic and sedative medications during hospital stay is associated with a higher risk of in-hospital falls but not with mortality. The DBI could be implemented in hospital, to guide prescription and reduce anticholinergic and sedative drug exposure.

Impact of cumulative exposure to anticholinergic and sedative drugs on cognition in older adults: a memory clinic cohort study.

BACKGROUND: Long-term exposure to anticholinergic and sedative drugs could be a modifiable risk factor for cognitive decline. The objective of this study was to measure the association between previous cumulative anticholinergic and sedative drug exposure (Drug Burden Index) and cognitive decline. METHODS: A cohort study (MEMORA cohort) was conducted in a French memory clinic for patients attending a consultation between November 2014 and December 2020, with at least 2 Mini-Mental State Examination (MMSE) measurements (≥ 6 months apart) and available medication data from the local Primary Health Insurance Fund database (n = 1,970). Drug Burden Index was linearly cumulated until each MMSE measurement and was used to categorise patients according to their level of exposure (no exposure, moderate, or high). The longitudinal association between Drug Burden Index and MMSE was assessed using a multivariate linear mixed model, adjusted for age, education level, anxiety disorders, depressive disorders, functional autonomy, and behavioural disorders. RESULTS: Overall, 1,970 patients were included with a mean follow-up duration of 2.78 years (± 1.54) and 2.99 visits per patients (5,900 MMSE + Drug Burden Index measurements collected). At baseline, 68.0% of patients had moderate cumulative anticholinergic and sedative drug exposure and a mean MMSE of 21.1. MMSE decrease was steeper in patients with moderate and high Drug Burden Index ( -1.74 and -1.70/year, respectively) than in patients with no exposure (-1.26/year) after adjusting for age, education, anxiety and depressive disorders, functional autonomy, and behavioural disorders (p < 0.01). CONCLUSIONS: Long-term exposure to anticholinergic and sedative drugs is associated with steeper cognitive decline. Medication review focusing on de-prescribing these drugs could be implemented early to reduce cognitive impairment.

Clinical impact of an individualised clinical pharmacy programme into the memory care pathway of older people: an observational study.

BACKGROUND: In older patients, medication exposure [i.e. polypharmacy, potentially inappropriate medications (PIMs), medications with anticholinergic and/or sedative properties] is a modifiable risk factor associated with cognitive iatrogenic risk and dementia. AIM: To assess the potential clinical impact of the implementation of an individualised clinical pharmacy programme at the initiation of the Memory care pathway in older patients with a cognitive complaint. METHOD: This prospective observational study included older patients with high-risk of adverse drug event (HR) admitted in a French geriatric university hospital to explore the cognitive complaint or the cognitive disorder between January and November 2021. Drug-related problems (DRPs) were identified during a medication review performed in HR patients, and pharmaceutical interventions (PIs) notified in the patient's hospitalisation report were collected. The clinical impact of PIs was assessed by an expert panel (geriatricians and clinical pharmacists) using the Clinical, Economic, and Organisational (CLEO) tool. RESULTS: Overall, 326 patients were eligible and 207 (63.5%) were considered as HR patients. Among HR patients, 88.9% (n = 184) were treated using at least 5 medications (polypharmacy), and 36.7% (n = 76) received at least one PIM with cognitive iatrogenic risk. During the medication review, 490 PIs were provided and their clinical impact was rated as minor for 57.3% (n = 281), moderate for 26.7% (n = 131), and major for 2.5% (n = 12). CONCLUSION: The integration of clinical pharmacist secured the Memory care pathway of older patients with a cognitive complaint by identifying an important number of DRPs and PIMs with potential cognitive iatrogenic risk.

Medication exposure of the dyad patient-caregiver in Alzheimer's disease and related dementias: a cross-sectional study.

BACKGROUND: Patients with Alzheimer's disease and related dementias and their caregivers can be defined as people with higher risk of developing medication-related problems due to aging and polypharmacy. AIM: To assess the medication exposure of patient with Alzheimer's disease and related dementias and their caregivers. METHOD: Ancillary cross-sectional study based on baseline medication data of the PHARMAID RCT. The PHARMAID study was a multi-center RCT assessing an integrated pharmaceutical care at a psychosocial program. Older outpatients with Alzheimer's disease and related dementias and their older caregivers were eligible for inclusion. Baseline medication data were used to assess the medication exposure, illustrated by the number of medications, the prevalence of potentially inappropriate medications (PIMs) using the EU(7)-PIM list and the Medication Regimen Complexity Index (MRCI). RESULTS: Seventy-three dyads were included in this ancillary study. The mean numbers (SD) of medications used by patients was 6.8 (2.6) and by caregivers was 4.7 (3.7). Overall, 60.3% of patients used at least one PIM and 47.9% of caregivers. Regarding the medication regimen complexity, the mean MRCI was 16.3(8.1) for patients and 11.3(10.5) for caregivers. CONCLUSION: The results of this study confirm the relevance of carrying out medication review with patients, but also with their caregivers who can be considered as hidden patients.

Can hospital discharge databases be used to follow ischemic stroke incidence?

BACKGROUND AND PURPOSE: Because acute ischemic strokes (ISs) are mainly hospitalized, hospital discharge data could be used to routinely follow their incidence management. We aimed to assess sensitivity and positive predictive value of the French hospital discharge database (HDD) to identify patients with acute IS using a prospective and exhaustive cohort (AVC69) of acute IS cases. METHODS: A selection algorithm based on IS diagnosis coded with the International Classification of Diseases (ICD-10) and cerebral imaging codes was used to identify all hospital stays with the primary diagnosis of IS in the HDD of the university hospitals of the Rhône area. Cases identified through HDD search were compared with IS cases identified through an exhaustive cohort study conducted in the Rhône district and confirmed on medical records review. RESULTS: There were 465 confirmed cases of IS hospitalized in 1 of the 4 university hospitals during the study period. The HDD search identified 313 among those (true-positive cases) but missed 152 cases (false-negative cases). The sensitivity of the HDD search was 67.3% (95% confidence interval, 63.1-71.5), and the positive predictive value was 95.1% (95% confidence interval, 92.8-97.4). Additionally, HDD search retrieved 16 cases, which were not eventually IS (false positives). Sensitivity was better when patients were hospitalized in neurological departments. CONCLUSIONS: The lack of sensitivity to identify acute IS patients through HDD search does not seem to be accurate enough to validate the use of these data for incidence estimates. Efforts have to be made to improve the coding quality.

[The use of melatonin in older patients hospitalized in geriatric units in France: survey of hospital pharmacists]. / Utilisation de la mélatonine chez les patients âgés hospitalisés en gériatrie en France : enquête auprès des pharmaciens hospitaliers.

In recent years, melatonin has been increasingly used in hospital settings for the treatment of sleep disorders in older patients, despite many barriers: restriction by ANSM, non-approval to healthcare facility use, and non-reimbursement. In order to describe the use of melatonin in older hospitalized patients, a survey was conducted between February and May 2022, with hospital pharmacists working in geriatric care units in France. Overall, 35 interviews were conducted with hospital pharmacists: 30 dispensed melatonin, with marketed prolonged-release melatonin medications (n = 30), and/or with immediate-release magistral or hospital preparations (n = 11). The conducted survey highlighted the criteria for using the different forms of melatonin, but also the disparities in terms of supply and management within the different establishments. Given the increasing use of melatonin in hospital settings and in order to guarantee the same accessibility to hospital teams and to patients on discharge from the hospital, a reassessment by the authorities of the melatonin-based medication status seems necessary in the light of the new available data.

Potentially inappropriate medications and anticholinergic and sedative burden in older community-dwelling patients with advanced chronic kidney disease

Objective: Regarding older patients, multiple chronic conditions lead to the intake of multiple medications, involving a higher risk of adverse drug events. In older patients with advanced chronic kidney disease, the medication exposure was poorly explored. The aim of this study was to describe the use of potentially inappropriate medications and medications with anticholinergic and sedative properties in older community-dwelling patients with advanced chronic kidney disease. Methods: An observational study was conducted in a geriatric day-care unit. All patients aged over 65 years with advanced chronic kidney disease, defined by estimated glomerular filtration rate < 20 mL/min/1.73 m2 or estimated glomerular filtration rate > 20 mL/min/1.73 m2 with rapid progression, and referred by nephrologist for pretransplant comprehensive geriatric assessment, were included in the study. Potentially inappropriate medications were identified using the EU(7)-PIM list, and he anticholinergic and sedative drug exposure was measured using the Drug Burden Index. Results: Overall, 139 patients were included in the study (mean age 74.4 ± 3.3 years, 32.4% females, 61.9% on dialysis). Potentially inappropriate medications were used by 74.1% (103/139) of patients and were mainly represented by proton pump inhibitors, alpha-1-blockers and central antihypertensive drugs. Regarding anticholinergic and / or sedative medications, 79.9% (111/139) of older patients were exposed. Conclusion: In older community-dwelling patients with advanced chronic kidney disease, the prevalence of potentially inappropriate medication exposure and anticholinergic and sedative exposure was high. Interventions focusing on deprescription of these inappropriate medications should be conducted in this specific population.

Objectif: Chez le patient âgé, la polypathologie est souvent associée à la prise de plusieurs médicaments, impliquant un risque élevé d'iatrogénie médicamenteuse. L'exposition médicamenteuse a été peu explorée chez les patients âgés atteints d'insuffisance rénale chronique. L'objectif de cette étude est de décrire l'exposition aux médicaments potentiellement inappropriés et aux médicaments présentant des propriétés anticholinergiques et sédatives chez ces patients. Méthodes: Il s'agit d'une étude observationnelle conduite au sein d'un hôpital de jour gériatrique. Tous les patients âgés de plus de 65 ans avec une maladie rénale chronique avancée, définie par un débit de filtration glomérulaire estimé inférieur à 20 mL/min/1,73 m² ou supérieur à 20 mL/min/1,73 m² avec une progression rapide, et adressés par un néphrologue pour la réalisation d'une évaluation gériatrique standardisée pré-transplantation rénale, ont été inclus dans l'étude. Les médicaments potentiellement inappropriés ont été identifiés à partir de la liste EU(7)-PIM, et l'exposition aux médicaments anticholinergiques et sédatifs a été mesurée à partir du Drug Burden Index. Résultats: Un total de 139 patients a été inclus dans l'étude (74,4 ± 3,3 ans, 32,4 % de femmes, 61,9 % dialysés). Des médicaments potentiellement inappropriés ont été retrouvés chez 74,1 % (103/139) des patients. Ils étaient principalement représentés par les inhibiteurs de la pompe à protons, les alpha-1-bloquants et les antihypertenseurs centraux. Concernant les médicaments anticholinergiques et/ou sédatifs, 79,9 % (111/139) des patients âgés étaient exposés. Conclusion: L'étude montre que la prévalence de l'exposition aux médicaments potentiellement inappropriés et aux médicaments anticholinergiques et/ou sédatifs est élevée chez les patients âgés atteints de maladie rénale chronique avancée. Des interventions portant sur la déprescription de ces médicaments devraient être menées auprès de cette population spécifique.

Integrated clinical pharmacy activities into the pediatric kidney graft pathway / Activités de pharmacie clinique intégrées dans le parcours du patient de greffe rénale pédiatrique

The pediatric renal graft pathway is at risk of care discontinuation, even though therapeutic adherence is essential. The objective is to evaluate the integration of clinical pharmacy activities into this care pathway. This feasibility study is divided into three stages: structuring, implementing and evaluation. In pre-transplant, immediate and remote post-transplant, interviews were proposed as well as the pharmaceutical analysis of medication prescriptions. In 8 months duration, 32 patients were included. All patients included in pre-transplant and immediate post-transplant benefited from the activities. At M0, all the prescriptions analyzed resulted in at least one problem detected. Half of the transplanted patients benefited from M1 maintenance, one patient from M3 maintenance and no M6 follow-up could be carried out. This work concludes with the good feasibility and integration of clinical pharmacy activities within the care pathway.

Le parcours de greffe rénale pédiatrique est à risque de rupture de soins car les patients sont polymédiqués alors même que l'adhésion thérapeutique est essentielle. L'objectif est d'évaluer l'intégration d'activités de pharmacie clinique dans ce parcours de soins. Cette étude de faisabilité se décline en trois étapes : structuration, mise en œuvre et évaluation. En pré-greffe, post-greffe immédiate et post-greffe à distance, des entretiens ont été proposés ainsi que l'analyse pharmaceutique des prescriptions médicamenteuses. En huit mois, 32 patients ont été inclus. Tous les patients inclus en pré-greffe et en post-greffe immédiate ont bénéficié des activités. À M0, toutes les prescriptions analysées ont abouti à au moins un problème détecté. La moitié des patients greffés ont bénéficié de l'entretien à M1, un patient de l'entretien à M3 et aucun suivi à M6 n'a pu être réalisé. Ce travail conclut à la bonne faisabilité et intégration des activités de pharmacie clinique au sein du parcours de soins.

Impact of pharmaceutical care integrated at a psychosocial intervention to reduce caregiver's burden in Alzheimer's disease or related dementias: Negative results at 18 months and difficulties to conduct PHARMAID RCT.

Background: Psychosocial interventions for caregivers of patients with Alzheimer disease and relative dementias (ADRD) reported a caregiver burden improvement. Multicomponent intervention integrating pharmaceutical care has not yet been evaluated while ADRD patients and their caregivers are exposed to high risk of drug-related problems. The PHARMAID study aimed to assess the impact of personalized pharmaceutical care integrated to a psychosocial program on the burden of ADRD caregivers at 18 months. Methods: The PHARMAID RCT was conducted between September 2016 and June 2020 [ClinicalTrials.gov: NCT02802371]. PHARMAID study planned to enroll 240 dyads, i.e. ADRD patients and caregivers, whose inclusion criteria were: outpatient with mild or major neurocognitive disorders due to ADRD, living at home, receiving support from a family caregiver. Three parallel groups compared a control group with two interventional groups: psychosocial intervention and integrated pharmaceutical care at a psychosocial intervention. The main outcome was the caregiver burden assessed by the Zarit Burden Index (ZBI, score range 0-88) at 18 months. Results: Overall, 77 dyads were included (32% of the expected sample size). At 18 months, the mean ZBI scores were 36.7 ± 16.8 in the control group, 30.3 ± 16.3 for the group with psychosocial intervention, and 28.8 ± 14.1 in group with integrated pharmaceutical care at psychosocial intervention. No significant difference was demonstrated between the three groups (p = 0.326). Conclusions: The findings suggest that PHARMAID program had no significant impact on caregiver burden at 18 months. Several limitations have been highlighted and discussed by the authors in order to formulate recommendations for further research.

Drug-related problems in older patients with advanced chronic kidney disease identified during pretransplant comprehensive geriatric assessment.

BACKGROUND: Older patients with advanced chronic kidney disease may be exposed to a higher risk of adverse drug events due to chronic kidney disease and aging. The integration of clinical pharmacist into pretransplant comprehensive geriatric assessment is an opportunity to perform medication optimization. OBJECTIVE: The aim was to describe drug-related problems in older patients with advanced chronic kidney disease. METHODS: Observational study was conducted with retrospective data from July 2017 to April 2019. Patients≥65 years with advanced chronic kidney disease, referred by nephrologists for pretransplant comprehensive geriatric assessment were included. During medication optimization, the pharmacist evaluated the appropriateness of each medication prescribed and identified drug-related problems. Any drug-related problem identified lead to a pharmaceutical intervention. RESULTS: In total, 103 patients were included (74.5±2.9 years, 26.2% female, 47.6% on dialysis). Overall, 394 drug-related problems were identified in 93.2% of patients (3.8±2.4 drug-related problems per patient) during the medication optimization. Cardiovascular medications (25.1%), antithrombotics (13.5%) and drugs for peptic ulcer and reflux disease (10.2%) were the most involved drugs in drug-related problems. Drug-related problems mainly concerned drugs without indication (27.1%), inappropriate method of administration (24.4%) and non-conformity to guidelines (20.1%). CONCLUSION: A high prevalence of drug-related problems in older patients with advanced chronic kidney disease was identified during medication optimization. The systematic integration of a clinical pharmacist in the multidisciplinary team performing pretransplant comprehensive geriatric assessment may be relevant to detect inappropriate prescriptions and to prevent from adverse drug events.

Development of clinical pharmacy programs integrated into patient care pathways using adverse event risks.

BACKGROUND: In the strained actual economic context, all clinical pharmacy activities cannot be achieved for all patients of all care pathways. So finding a way to prioritize moments and patients needing those activities is essential. This is the challenge of the "5P project" (Patient personalized clinical pharmacy program integrated into care pathway). OBJECTIVE: To present adverse event (AE) risk management approach applied to develop clinical pharmacy programs integrated into care pathway, using two methods. METHOD: Used as a priori AE risk management approach, the Delphi method and inductive approach analysis of semi-directed interviews were realized from April 1st to October 3rd, 2019, respectively in orthogeriatric (OG) and pediatric kidney transplantation (PKT) care pathways. Complementarily to bibliographic research, participants were medical and paramedical healthcare providers involved in the concerned care pathway. They have been interrogated regarding AE risks to identify the clinical pharmacy activities required, the patients who need them, and the appropriate steps of the care pathway. RESULTS: The Delphi method for OG care pathway has revealed: 1/. Patients were prioritized by the presence of at least 2 among the following 4 criteria: age ≥90 years old, cardiovascular diseases, prescribed potentially inappropriate medication for elderly patients, obesity or diabetes; priority steps were the post-operative and rehabilitation care steps. 2/. Prescription reviews, medication reconciliation and targeted pharmaceutical informative interview about oral anticoagulants were required. Nine semi-directed interviews used for PKT care pathway has revealed: 1/. Clinical pharmacy activities were carried out for all patients. Priority steps were pre-transplantation, immediate post-operative, and post-transplantation. 2/. Prescription reviews and educative interviews were required. CONCLUSIONS: The two presented methods can be used to both develop patient prioritization and targeting steps for clinical pharmacy activities, and integrate it into care pathway. Today, those two developed programs have been executed in our teaching hospital.

Impact of a multifaceted program to prevent postoperative delirium in the elderly: the CONFUCIUS stepped wedge protocol.

BACKGROUND: Postoperative delirium is common in the elderly and is associated with a significant increase in mortality, complications, length of hospital stay and admission in long care facility. Although several interventions have proved their effectiveness to prevent it, the Cochrane advises an assessment of multifaceted intervention using rigorous methodology based on randomized study design. Our purpose is to present the methodology and expected results of the CONFUCIUS trial, which aims to measure the impact of a multifaceted program on the prevention of postoperative delirium in elderly. METHOD/DESIGN: Study design is a stepped wedge cluster randomized trial within 3 surgical wards of three French university hospitals. All patients aged 75 and older, and admitted for scheduled surgery will be included. The multifaceted program will be conducted by mobile geriatric team, including geriatric preoperative consultation, training of the surgical staff and implementation of the Hospital Elder Life Program, and morbidity and mortality conference related to delirium cases. The primary outcome is based on postoperative delirium rate within 7 days after surgery. This program is planned to be implemented along four successive time periods within all the surgical wards. Each one will be affected successively to the control arm and to the intervention arm of the trial and the order of program introduction within each surgical ward will be randomly assigned. Based on a 20% reduction of postoperative delirium rate (ICC = 0.25, α = 0.05, ß = 0.1), three hundred sixty patients will be included i.e. thirty patients per service and per time period. Endpoints comparison between intervention and control arms of the trial will be performed by considering the cluster and time effects. DISCUSSION: Better prevention of delirium is expected from the multifaceted program, including a decrease of postoperative delirium, and its consequences (mortality, morbidity, postoperative complications and length of hospital stay) among elderly patients. This study should allow better diagnosis of delirium and strengthen the collaboration between surgical and mobile geriatric teams. Should the program have a substantial impact on the prevention of postoperative delirium in elderly, it could be extended to other facilities. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01316965.

Clinical, economic, and organizational impact of pharmacists' interventions in a cognitive-behavioral unit in France.

Objective Evaluate the clinical, economic, and organizational impact of pharmaceutical interventions performed during medication review in a cognitive-behavioral unit. Setting Study conducted in a cognitive-behavioral unit with retrospective data from January 2011 to june 2017. Methods This study was conducted from retrospective data of medication review in a cognitive-behavioral unit. During medication review, pharmacists identified relevant drug related problems lead to a pharmaceutical intervention which is submitted to the physician. All pharmaceutical interventions carried out from January 2011 to june 2017 were retrospectively analyzed to evaluate their clinical, economic and organizational impact using a multidimensional tool. Main outcome measure CLinical, Economic and Organizational impact using the CLEO tool. Results During the study period, 543 drug related problems and pharmaceutical interventions were recorded for patients hospitalized in the cognitive-behavioral unit (79.0 ± 9.5 years, 59% female). The most common types of drug related problems identified were 'non conformity to guidelines / contra-indication' (28.7%), 'drug without indication' (21.7%), and 'improper administration' (15.1%). The majority of pharmaceutical interventions were considered to have at least a clinical significant impact from the pharmacist's perspective (74%). Regarding the economic and organizational dimensions, 55.2% of pharmaceutical interventions would decrease the costs of care and 35.9% of pharmaceutical interventions would be favorable on the quality of care process. Conclusions The present study shows that the pharmacist may detect a high number of drug related problems with significant clinical relevance during medication review in a cognitive-behavioral unit. Describing and identifying significant pharmaceutical interventions in cognitive-behavioral unit patients allow us to better understand and improve clinical practice in this population.

Exposure to Anticholinergic and Sedative Drugs and Healthcare Costs in Older Patients with Neurocognitive Disorders.

BACKGROUND: Literature supports an increasing number of older patients living with neurocognitive disorders alongside with their annual worldwide costs. Therapeutic management of behavioral and psychological symptoms includes the use of anticholinergic and sedative drugs for which significant exposure is negatively associated with clinical outcomes. OBJECTIVE: The aim of this study was to assess the healthcare costs differences related to an increase in the exposure to anticholinergic and sedative drugs in older patients with neurocognitive disorder. METHODS: A longitudinal study was conducted during 3 years on 1,604 participants of the MEMORA cohort linked with both regional public health insurance and hospital discharge databases between 2012 and 2017. Direct medical and non-medical costs were included. Exposure to anticholinergic and sedative drugs was measured by the drug burden index (DBI). RESULTS: Costs difference associated with a DBI≥0.5 were + 338€ (p < 0.001). After adjustment on comorbidities, NCD stage, cognitive impairment, functional limitation, polypharmacy, and sociodemographic characteristics, a DBI≥0.5 was found to be an independent predictor of an increase of total healthcare costs by 22%(p < 0.001). CONCLUSION: Anticholinergic and sedative drugs have a substantial economic burden among older patients with neurocognitive disorder. More studies are required to assess the clinical and economic impact of an efficient strategy based on the reduction of the exposure to anticholinergic and sedative drugs and the promotion of non-pharmacological interventions.