Efficacy and Safety of Risperidone in Patients With Delirium: The RIDDLE Pilot Study.

BACKGROUND: The cornerstone treatment of delirium is to assess and treat its underlying causes and prevent further complications. Drug therapy may be necessary to control agitation and behavioral symptoms associated with delirium. The aim of this pilot study was to evaluate the feasibility of a randomized placebo controlled trial to evaluate the efficacy and safety of risperidone in the treatment of delirium. METHODS: This was a randomized double-blinded placebo-controlled trial. Patients were enrolled in the study if they were hospitalized and 65 years or older and had a diagnosis of delirium. Delirium Rating Scale revised 98 was used to determine delirium and motor agitation. RESULTS: A total of 14 participants with 57% being men and having a mean age of 86 years were included. There were no statistically significant differences between the risperidone and placebo group for the Delirium Rating Scale revised 98 score. There were no severe adverse reactions reported in the study, and no patients discontinued the study for adverse reactions. CONCLUSIONS: Risperidone at low doses (1 mg daily or less) was well tolerated for the treatment of delirium. Future large-scale trials are needed to evaluate the safety and efficacy of risperidone in the treatment of delirium. This pilot study taught us that the phase 2 RIsperDone DELirium trial will need a multicenter design with more research personnel to increase the number of participants enrolled.

Effectiveness of prescribing codes in reducing inappropriate proton pump inhibitors in ambulatory care.

BACKGROUND: Health care deciders are aware of the inappropriate use of proton pump inhibitors (PPIs). To reduce inappropriate prescriptions, the Conseil du Médicament (CdM) issued a practice guideline and the Régie de l'Assurance Maladie du Quebec (RAMQ) asked prescribers to justify its use by writing a specific indication code for their patients to obtain drug coverage. OBJECTIVES: This study aimed to evaluate the effectiveness of the intervention by the RAMQ to reduce inappropriate PPI prescription. METHODS: A cross-sectional quasi-experimental prospective study was performed in an emergency department. Patients aged 18 years or older were included in 2016 to 2017 and 2019 to 2021 in the pre- and postintervention group, respectively. The proportion of patients on PPI without an appropriate indication were identified from patient interviews and chart review. RESULTS: A total of 871 and 1475 patients were recruited in the pre- and postintervention groups. According to the CdM guideline, the proportion of inappropriate PPI prescription was 30.7% (n = 267) in the preintervention group and 49.1% (n = 724) in the postintervention group (P < 0.001). According to the RAMQ criteria, the proportion of inappropriate PPI prescription was of 76.1% (n = 663) and 81.4% (n = 1200) in the pre- and postintervention group, respectively (P < 0.001). CONCLUSION: This study highlights the ineffectiveness of the codes for PPI prescriptions in reducing inappropriate prescriptions. It seems that the obligation to write a code does not lead to a reassessment of PPI indication.

Factors associated with late-life psychosis in primary care older adults without a diagnosis of dementia.

PURPOSE: The epidemiology of late-life psychosis (LLP) remains unclear comparatively to early-onset psychosis. The study aims to estimate the prevalence and incidence of LLP over a 3-year period and examine the correlates of LLP in community-living older adults aged ≥ 65 years recruited in primary care. METHODS: Study sample included N = 1481 primary care older adults participating in the Étude sur la Santé des Aînés (ESA)-Services study. Diagnoses were obtained from health administrative and self-reported data in the 3 years prior and following baseline interview. The prevalence and incidence of LLP (number of cases) were identified in the 3-year period following interview. Participants with dementia or psychosis related to dementia were excluded. Logistic regressions were used to ascertain the correlates of LLP as function of various individual and health system factors. RESULTS: The 3-year prevalence and incidence of LLP was 4.7% (95% CI = 3.64-5.81) and 2.8% (95% CI = 1.99-3.68), respectively. Factors associated with both prevalent and incident LLP included functional status, number of physical diseases, hospitalizations, continuity of care and physical activity. Older age and the presence of suicidal ideation were associated with incident LLP, while higher education, a depressive disorder and a history of sexual assault were associated with persistent cases. CONCLUSIONS: Results highlight the importance of LLP in primary care older adult patients without dementia. Health system factors were consistent determinants of prevalent and incident LLP, suggesting the need for better continuity of care in at-risk primary care older adults.

Medication appropriateness on an acute geriatric care unit: the impact of the removal of a clinical pharmacist.

BACKGROUND: evidence is largely available indicating benefits to adding a pharmacist on acute care wards. The benefits of maintaining pharmacotherapeutic consultant services on a geriatric ward remain unexplored. OBJECTIVES: to determine the impact of the removal of a clinical pharmacist from an acute geriatric ward on patients' Medication Appropriateness Index (MAI) scores, admission-related outcomes and drug burdens. METHODS: researchers consulted the archives for records of patients admitted to the geriatric care unit before and after the pharmacist's withdrawal. The primary outcome of differential MAI scores and secondary outcomes of rehospitalisations, emergency department visits, durations of hospitalisation and differential drug count were compared pre- and post-intervention. An interrupted time series analysis regression model was used for the primary outcome. RESULTS: a total of 305 patients admitted before (n = 208) and after (n = 97) the pharmacist's withdrawal were included in the study. The intervention had a significant impact on the primary outcome, increasing the relative differential MAI score (adjusted mean) by 9.3 points (95% confidence interval 3.9-14.6). As for the secondary outcomes, differences in admission-related outcomes were non-significant but the mean differential drug count significantly increased post-intervention from 0.02 to 1.36 (P < 0.001). CONCLUSION: the removal of the pharmacist led to an increase in inappropriate drug prescription. Careful consideration should be given to decisions regarding the removal of the pharmacist from acute geriatric care teams.

Impact of Pharmacist Interventions in an Ambulatory Geriatric Care Clinic: The IMPACC Study.

OBJECTIVE: To compare the impact of a pharmacist's presence for the detection of drug-related problems (DRP) in an interdisciplinary geriatric-ambulatory clinic with a control group without a pharmacist.
DESIGN: Retrospective quasi-experimental study.
SETTING: A geriatric ambulatory-care clinic of a 772-bed tertiary-care teaching hospital in Montreal, Canada.
PARTICIPANTS: A total of 227 ambulatory patients 65 years of age and older presenting to their appointment at the geriatric ambulatory clinic between May 1, 2018, and April 30, 2019.
MAIN OUTCOME MEASURE(S): DRP detected by the interdisciplinary team during the patient evaluation process. Data were collected from clinical notes written by the health care professionals in the electronic medical chart.
RESULTS: The mean age was 80.8 years, and 60.8% of the population were female. Patients were prescribed a mean of 11.3 medications at home. Overall, 636 DRP were detected in the study population. In the adjusted analysis, the difference between the two groups was 2.7 (95% confidence interval 2.0-3.3) DRP detected favoring the group with a pharmacist.
CONCLUSION: The inclusion of a pharmacist in an interdisciplinary team in an ambulatory geriatric-care clinic was associated to a positive impact on care by substantially increasing the number of DRP detected in older patients.

Inappropriate Prescription of Proton Pump Inhibitors in a Community Setting.

BACKGROUND: Proton pump inhibitors (PPIs) are widely prescribed for gastrointestinal conditions, such as gastroesophageal reflux disease and dyspepsia, and for prevention of gastric ulcer. Although previous reports have described inappropriate prescription of PPIs in the hospital setting, data from the community are lacking. OBJECTIVE: To assess PPI prescriptions in the ambulatory setting. METHODS: Patients presenting to the emergency department of a teaching hospital between June 2016 and March 2017 were prospectively assessed for use of a PPI at home. The appropriateness of PPI prescription was evaluated on the basis of an interview with the patient and review of the medical record. The indication for PPI therapy was verified against current guidelines for the province of Quebec. RESULTS: Over the 9-month study period, 2417 patients were screened, of whom 871 were included in the study. In relation to the Quebec guidelines, PPI prescription was inappropriate for 267 (30.7%) of the patients. When prescription of PPI for ulcer prevention in certain groups of patients (age ≥ 65 years and using acetylsalicylic acid or platelet aggregation inhibitors; age ≥ 75 years and using celecoxib) was re-classified as appropriate, the proportion of inappropriate PPI prescriptions declined to 20.3% (177/871). CONCLUSIONS: These findings suggest that inappropriate prescribing of PPIs remains problematic in the community setting in the province of Quebec.

CONTEXTE: Les inhibiteurs de la pompe à protons (IPP) sont largement prescrits pour traiter les troubles gastro-intestinaux, comme le reflux gastro-oesophagien et la dyspepsie, et pour prévenir l'ulcère gastrique. Bien que des rapports antérieurs aient parlé de la prescription inadéquate des IPP dans les établissements de santé, il n'y a pas de données provenant de la communauté. OBJECTIF: Évaluer la pertinence des prescriptions d'IPP dans un milieu ambulatoire. MÉTHODES: Les patients se présentant au service des urgences d'un hôpital universitaire entre juin 2016 et mars 2017 ont été évalués de façon prospective relativement à l'utilisation d'un IPP à la maison. La pertinence de la prescription d'un IPP a été jugée d'après une entrevue avec le patient et l'analyse du dossier médical. On a vérifié si l'indication pour un traitement par IPP respectait les lignes directrices actuelles du Québec. RÉSULTATS: Sur une période de neuf mois, 2 417 patients ont été évalués et 871 d'entre eux ont été admis à l'étude. Par rapport aux lignes directrices du Québec, la prescription d'IPP était inadéquate pour 267 (30,7 %) des patients. Or, si la prescription d'IPP pour prévenir l' ulcère gastrique chez certains groupes de patients (âgés de 65 ans ou plus et prenant de l'acide acétylsalicylique ou un antiagrégant plaquettaire; âgés de 75 ans ou plus et prenant du célécoxib) était reclassée comme adéquate, la proportion de prescriptions d'IPP inadéquates reculait à 20,3 % (177/871). CONCLUSIONS: Ces résultats laissent croire que les prescriptions inadéquates d'IPP demeurent un problème dans le contexte communautaire au Québec.

Ferric Gluconate Complex in Elderly Hospital Inpatients without Terminal Kidney Failure.

BACKGROUND: Anemia is a common health issue for elderly patients. For patients with iron deficiency who cannot tolerate iron supplementation by the oral route, the parenteral route may be used. Options for parenteral iron supplementation include ferric gluconate complex (FGC). OBJECTIVES: To evaluate the safety of FGC in elderly patients without terminal kidney failure and to assess its efficacy in treating iron-deficiency anemia. METHODS: An observational chart review was conducted at a tertiary care university health centre. Patients included in the study were 65 years of age or older, had received at least 1 dose of FGC between January 1, 2014, and December 31, 2015, and had a hemoglobin count of less than 130 g/L (men) or less than 120 g/L (women) at baseline. For each patient, the observation period began when the first dose of FGC was administered and ended 60 days after the last dose. The main safety outcome (occurrence of any adverse reaction) was evaluated for every patient, with the efficacy analysis being limited to patients with a diagnosis of iron-deficiency anemia. RESULTS: A total of 144 patients were included in the study, of whom 76 had iron-deficiency anemia. No serious, life-threatening adverse reactions were reported. The most commonly reported adverse reactions were nausea and vomiting. The mean increase in hemoglobin count was 13.5 g/L, a statistically significant change from baseline. CONCLUSIONS: These results show that FGC is safe for use in elderly patients, with very few mild adverse reactions. Use of FGC led to increased hemoglobin count within 60 days. Of the 3 options for parenteral iron supplementation available in Canada, iron sucrose has not been studied in elderly patients, and iron dextran has a higher incidence of anaphylaxis, whereas FGC appears to be a safe alternative for patients with intolerance to oral iron.

CONTEXTE: L'anémie est un problème de santé courant chez les patients âgés. Les patients qui présentent une carence en fer et une intolérance à la prise de suppléments de fer par la voie orale peuvent être traités par voie parentérale. Le complexe de gluconate ferrique de sodium (CGFS) représente l'une des options d'apport complémentaire en fer par voie parentérale. OBJECTIFS: Évaluer l'innocuité du CGFS chez le patient âgé qui n'est pas atteint d'insuffisance rénale terminale et évaluer son efficacité dans le traitement de l'anémie ferriprive. MÉTHODES: Une analyse observationnelle a été menée au moyen des dossiers médicaux dans un établissement de santé universitaire de soins tertiaires. Les patients dont le dossier médical a été retenu pour l'analyse étaient âgés de 65 ans ou plus, avaient reçu au moins une dose de CGFS entre le 1er janvier 2014 et le 31 décembre 2015 et présentaient initialement un taux d'hémoglobine de moins de 130 g/L (hommes) ou de moins de 120 g/L (femmes). Pour chaque patient, la période d'observation s'étendait du moment où la première dose de CGFS avait été administrée au soixantième jour suivant la dernière dose. Le principal paramètre d'évaluation de l'innocuité (survenue de toute réaction indésirable) faisait l'objet d'une évaluation pour chaque patient. L'analyse de l'efficacité se limitait aux patients ayant reçu un diagnostic d'anémie ferriprive. RÉSULTATS: Au total, 144 patients ont été admis à l'étude et, parmi eux, 76 présentaient une anémie ferriprive. Aucune réaction indésirable grave menaçant la vie du patient n'a été notée. Les réactions indésirables les plus souvent signalées étaient des nausées et des vomissements. L'augmentation moyenne des taux d'hémoglobine était de 13,5 g/L, un changement statistiquement significatif comparé à la valeur de départ. CONCLUSIONS: Les résultats montrent que le CGFS est sécuritaire pour le patient âgé et qu'il ne provoque que très peu de réactions indésirables légères. L'emploi du CGFS a produit une augmentation des taux d'hémoglobine en moins de 60 jours. Parmi les 3 options d'apport complémentaire en fer pris par voie parentérale disponibles au Canada, le fer-saccharose n'a pas été étudié auprès de patients âgés et le fer-dextran est associé à une plus grande incidence de cas d'anaphylaxie; or, le CGFS semble être une solution sécuritaire pour les patients qui présentent une intolérance au fer administré par voie orale.

The Delirium Drug Scale is associated to delirium incidence in the emergency department.

ABSTRACTBackground:The Delirium Drug Scale (DDS) is an evaluation scale developed to assess a patient's drug burden for delirium. The primary goal is to validate the association between the DDS score and the incidence of delirium. METHODS: This study was an observational retrospective cross-sectional chart review study in patients aged 75 years and older. It was carried out in three emergency departments of a tertiary care university health center. Patients were included if a medication list was available. Delirium present upon admission was assessed during the first five days of admission. RESULTS: A total of 1,205 subjects were included in the analysis. The mean age was of 83.4 years, and 62.4% were female. The prevalence of delirium was 19.1%. A total of 745 patients (62%) were exposed to DDS medication. The relative risk for the low (1-2) and high (>2) exposure group according to the DDS score was of 1.26 (CI: 0.95; 1.66) and 2.18 (CI: 1.61; 2.96) compared to a score of 0. In the multivariate analysis, dementia, anxiety, insomnia, history of delirium, infection, and acute kidney failure were significantly associated to delirium. When adjusted for confounding variables, the DDS score was associated with the incidence of delirium with an odd ratio (OR) of 1.29 (CI: 1.16; 1.44). CONCLUSIONS: This study found that DDS score was associated with delirium incidence. The association persisted in the multivariate analysis adjusted for 26 known risks and precipitating factors for delirium.

Delirium following fesoterodine treatment for urgency incontinence in an 89-year old man.

We describe the case of an 89-year-old man who developed delirium following the introduction of fesoterodine to treat his urgency incontinence. The patient started experiencing visual hallucinations approximately five days after starting fesoterodine 4 mg once daily. Delirium resolved after fesoterodine was stopped. Despite the apparent safe cognitive profile due to its pharmacodynamic properties, fesoterodine should be used with caution in the elderly, frail population.

Assessment of quality of glycemic control in intensive care patients treated with an insulin infusion at a teaching hospital.

OBJECTIVE: To describe the quality of glycemic control in patients in intensive care units (ICUs) treated with an intravenous (IV) insulin infusion at a teaching hospital. METHOD: This retrospective study included patients admitted to the ICU and treated with an IV insulin infusion for at least 12 h between August 1 and November 30, 2011. Medical charts were reviewed. The primary quality indicator for glycemic control was the mean percent of blood glucose values per patient in the 6.1 to 8 mmol/L target range. RESULTS: A total of 351 patients were included; 61.5% of subjects had no known diabetes. Admissions were mainly for surgery (61.3%). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 16.8±7.3. The mean percent of blood glucose values per patient in the 6.1 to 8 mmol/L range was 35% for all subjects and 26.2% for patients with diabetes. If a target of 6.1 to 10 mmol/L was considered, those values became 63% and 54.6%. At least 1 episode of hyperglycemia (>10 mmol/L), hypoglycemia (<4 mmol/L) or severe hypoglycemia (<2.2 mmol/L) was documented in 68%, 9% and 1% of subjects, respectively. Glycemic variability (SD) was 1.9 mmol/L, and the median hyperglycemic index was 0.77 (interquartile [IQ]: 0.24 to 1.63). CONCLUSION: The quality of glycemic control in patients in the ICU at our hospital needs to be improved. A new computerized IV insulin protocol is currently being tested.