What about the relevance of PIP of psychotropics in older psychiatric inpatients?

OBJECTIVE: In 2019, a regional survey of potentially inappropriate prescriptions (PIP) of psychotropic drugs in elderly psychiatric inpatients was carried out highlighting their inappropriate use in this population. The aim of this study was to assess the clinical relevance - defined as the provision of an appropriate and necessary treatment, chosen from other alternatives as being the most likely to produce the expected results for a given patient - of these prescriptions considered inappropriate according to current established criteria. MATERIAL AND METHOD: Patients aged over 75, or 64 to 75 and polypathological with at least one PIP of psychotropic drugs or drugs with a high anticholinergic burden, identified by an audit grid established on the basis of STOPP/STARTv2 criteria and the Laroche list on the prescription at 48h of hospitalization, were included. The weighing of the inappropriateness nature of the prescription (resistance to treatment, period of crisis, comorbidities…) was established by a pharmacist-psychiatrist pair on the entire computerized record of the current episode. The clinical relevance of the PIP and the overall prescription was rated as 0 (irrelevant), 1 (partially relevant) or 2 (relevant). RESULTS: Thirty-four patients were included. One hundred and twenty-five PIP of psychotropic drugs were noted: 50.4% concerned benzodiazepines and non-benzodiazepines anxiolytics (BZD/Z), 25.6% neuroleptics (NL), 12% antidepressants (ATD) and 12% drugs with a high anticholinergic burden. On one hand, 49.2% of PIP of BZD/Z, 50% of PIP of NL and 20% of PIP of ATD were considered irrelevant. On the other hand, 49.2% of PIP of BZD/Z, 31.3% of PIP of NL and 13.3% of PIP of ATD were considered partially relevant. Furthermore, 1.6% of PIP of BZD/Z, 18.8% of PIP of NL and 66.7% of PIP of ATD were considered relevant. For PIPs of drugs with a high anticholinergic burden, 80% were deemed irrelevant, 13.3% partially relevant and 6.7% relevant. In all, of the 34 drug prescriptions studied, three (8.8%) were considered irrelevant, 11 (32.4%) partially relevant and 20 (58.8%) clinically relevant. CONCLUSION: This study highlighted the clinical relevance of more than half the prescriptions considered inappropriate according to current PPI criteria in the elderly. It underlines the interest of a new PPI detection tool for elderly patients with psychiatric disorders.

[Dermatoses of elderly inpatients in Casablanca: epidemiology and factors associated with length of stay]. / Dermatoses du sujet âgé en hospitalisation à Casablanca : épidémiologie et facteurs associés à la durée de séjour.

Geriatric in-patient dermatoses are diverse. Few data in Morocco describe the epidemiological profile and factors associated with average length of stay (LOS). Our aim was to identify these dermatoses and determine the factors associated with LOS.

[Addictions in the elderly: the viewpoint of an IPA working in EMPSA]. / Les addictions chez le sujet âgé : regard d'une IPA exerçant en EMPSA.

Many elderly people live well and at home, but some require somatic and psychiatric care. Mobile psychiatric teams for the elderly are called upon to intervene with people aged 65-70 and over who are experiencing psychological distress. Among senior citizens, addictive disorders are very common, and are associated with psychiatric and geriatric co-morbidities. Alcohol, tobacco and benzodiazepine use disorders require holistic, individualized care, based on identification, prevention and referral, as well as training and coordination of professionals and caregivers.

[Republication of: Evaluation of the implementation of the 2021 guidelines of the European Society of Cardiology for heart failure with reduced ejection fraction in patients aged over 75]. / Republication de : Évaluation de la mise en application des recommandations 2021 de la Société Européenne de Cardiologie pour l'insuffisance cardiaque à fraction d'éjection réduite chez les patients âgés de plus de 75 ans.

INTRODUCTION: Heart failure is a frequent pathology with a poor prognosis which mainly concerns elderly patients. The recommandations concerning the pharmagical treatment in heart failure with LVEF are reduced on randomized trials carried out on a young population. The aim of this work is to evaluate their application on a population aged ≥ 75. MATERIALS AND METHODS: This is a retrospective, bicentric cohort, concerning patients hospitalized between September 1, 2021 and March 31, 2023, at the hospital centers of Troyes and Romilly sur Seine. The primary endpoint was a composite endpoint combining rehospitalisation rate or all-cause death rate at 6 months. RESULTS: A group of 81 patients was included in the study. The average number of treatments is associated with a significant reduction in the rate of hospitalisations ord deaths at 6 months (p = 0,005); as it concerns the level of titration, the analysing comparing the "therapeutic inertia" group and the "current titration/maximum tolerated dose" group did not reveal any significant difference (p = 0,169). CONCLUSION: Our study highlighted the potential positive impact of the application of the latest ESC recommendations concerning first-line drug treatment on the rate of rehospitalisation or death from all causes, in patients with heart failure reduced LVEF aged over 75.

[Evaluation of the implementation of the 2021 guidelines of the European Society of Cardiology for heart failure with reduced ejection fraction in patients aged over 75]. / Évaluation de la mise en application des recommandations 2021 de la Société Européenne de Cardiologie pour l'insuffisance cardiaque à fraction d'éjection réduite chez les patients âgés de plus de 75 ans.

INTRODUCTION: Heart failure is a frequent pathology with a poor prognosis which mainly concerns elderly patients. The recommandations concerning the pharmagical treatment in heart failure with LVEF are reduced on randomized trials carried out on a young population. The aim of this work is to evaluate their application on a population aged ≥ 75. MATERIALS AND METHODS: This is a retrospective, bicentric cohort, concerning patients hospitalized between September 1, 2021 and March 31, 2023, at the hospital centers of Troyes and Romilly sur Seine. The primary endpoint was a composite endpoint combining rehospitalisation rate or all-cause death rate at 6 months. RESULTS: A group of 81 patients was included in the study. The average number of treatments is associated with a significant reduction in the rate of hospitalisations ord deaths at 6 months (p = 0,005); as it concerns the level of titration, the analysing comparing the "therapeutic inertia" group and the "current titration/maximum tolerated dose" group did not reveal any significant difference (p = 0,169). CONCLUSION: Our study highlighted the potential positive impact of the application of the latest ESC recommendations concerning first-line drug treatment on the rate of rehospitalisation or death from all causes, in patients with heart failure reduced LVEF aged over 75.

[Heart failure treatments]. / Les traitements de l'insuffisance cardiaque.

Heart failure is a frequent pathology in the elderly. In particular, it is responsible for many hospitalizations. A distinction is made between chronic and acute forms of heart failure. The management of these forms of heart failure is well established, with treatment recommendations that are regularly updated on the basis of new studies.

[Study of the links between type 2 diabetes and geriatric criteria]. / Étude des liens entre diabète de type 2 et critères gériatriques.

Type 2 diabetes in the elderly remains a major concern for all healthcare professionals and is itself considered a "global pandemic". Its prevalence is high and will continue to increase in years to come, becoming more and more prevalent in the elderly and very elderly. We offer a general summary of the work focusing on the links between type 2 diabetes and geriatric criteria.

[Proper use of oral anticoagulants in the elderly patient]. / Le bon usage des anticoagulants oraux chez le patient âgé.

Direct oral anticoagulants (DOACs) are tending to supplant antivitamin K inhibitors (VKAs) in their common indications, dominated in elderly patients by atrial fibrillation and venous thromboembolism. Nevertheless, it remains necessary to know how best to use VKAs for which there are still indications. It is also important not to assume that AODs can be prescribed without risk, while ignoring certain particularities in their handling, particularly in the most fragile patients with co-morbidities and multiple medications.

[Antidiabetic treatments for the elderly]. / Les traitements antidiabétiques chez le sujet âgé.

Diabetes is very common in people over 75. A broad arsenal of treatments is now available. It is important, however, to choose the right treatment regimen to suit the patient's specific glycemic targets.

[IPA exercise at extreme ages of life, differences or similarities?] / Exercice IPA aux âges extrêmes de la vie, différences ou similitudes ?

Advanced practice nursing is intended for children, adolescents, adults and the elderly. In the field of mental health, this population-based approach allows advanced practice nurses to apply all of their skills for individualized and adapted care. Whether these professionals work in child and adolescent psychiatry or in psychiatry for the elderly, their practices have many similarities.

[Presbyphagia and swallowing disorders]. / Presbyphagie et troubles de la déglutition.

Swallowing disorders, which are frequent in geriatrics, are linked to multiple pathologies: cancer, stroke, neurocognitive disorders, acute confusion, vigilance disorders, etc. They can have serious consequences and therefore require special care. From the identification of the disorders by the doctor, the nurse, the caregiver, to the speech therapy assessment, through the adaptation of the diet by the dietician, the management of swallowing disorders concerns all the medical and paramedical staff. The aim of this article is to present the main existing recommendations to promote the patient's feeding despite the presence of these disorders.

[Depression in the elderly and the care pathway]. / Dépression du sujet âgé et parcours de soins.

The French population is aging and forecasts for 2040 indicate that seniors could represent a quarter of the population. Depressive illness affects elderly subjects just as much, if not more. There is a clinical specificity of depression in this age group which explains why it is currently under-diagnosed and therefore under-treated. Taking into consideration the care pathway of the depressed elderly subject is a lever to increase the efficiency of access to care and to professionalize the coordinated approach to treatment.

[The place of radiotherapy]. / La place de la radiothérapie.

Radiation therapy (RT) is a key component of the management of elderly breast cancer patients. However, level I evidence in elderly patients is limited. Patient selection should include comorbidities and geriatric assessment. Advances in radiation planning and delivery are improving target coverage, reducing toxicity, and expanding treatment eligibility. Some alternative techniques, such as treatment in the lateral or prone position, may reduce the risk of toxicity. Shorter cycles of hypofractionated whole breast RT are safe and effective. In some cases, partial breast irradiation may be an option.

[Medical oncology treatment]. / Le traitement oncologique médical.

Although patients over 65 years of age represent the majority of breast cancer patients, we have limited data on the safety and efficacy of medical oncology treatments in this population. Their indications are based primarily on expert agreement. This literature review discusses the known data on the safety and efficacy of the main medical treatments for breast cancer: chemotherapy, cytokine-dependent kinase inhibitors 4/6, agents targeting human epidermal growth factor receptor-2, novel antibody conjugates, and immunotherapy.

[Medical oncological treatment of colorectal cancer in the elderly]. / Traitement chirurgical du cancer colorectal chez la personne âgée.

Approximately a quarter of patients undergoing colorectal cancer surgery are over 75 years of age. Their care must therefore be adapted to minimise his functional consequences, which can be more significant in an elderly patient.

[Place of radiotherapy in the treatment of rectal cancer in the elderly]. / Place de la radiothérapie dans le traitement du cancer du rectum chez le sujet âgé.

Rectal cancer is a common disease of the elderly. Current treatment recommendations are established for young subjects in good general health condition, without taking into account the frailty, comorbidities and polymedications inherent in patients over 75 years old. For locally advanced lower and middle rectal cancers (T3, T4 or N+), these are based on variations of regimens including neoadjuvant chemoradiotherapy, surgery of the rectum with total removal of the mesorectum, and a possibility of adjuvant chemotherapy. This restrictive treatment presents a problem of compliance and is not without adverse effects. Treatment by short exclusive radiotherapy or chemoradiotherapy with close monitoring according to the Watch and Wait strategy can be proposed to fragile patients not eligible for surgery, even if there is a non-negligible risk of recurrence.

[Use of antidepressants in unipolar depression in the elderly]. / L'utilisation des antidépresseurs dans l'épisode dépressif caractérisé unipolaire du sujet âgé.

OBJECTIVE: To study the ageing-related pharmacological modifications about major depressive episodes in the elderly and their impact on the efficiency and tolerability of antidepressants. METHODS: Research through Pubmed and the Cochrane Database of Systematic Reviews, using the following keywords "antidepressant" ; "treatment"; "late life depression"; "elderly"; up until July 2021. RESULTS: Antidepressants were found to be more efficient than a placebo in the elderly's response to and remission from major depressive episodes. Some depressive episode subtypes seem to be less responsive to antidepressants, such as depressive episodes of vascular origin, for which treating cardiovascular risk factors by statins, angiotensin receptor blockers or calcium channel blockers seems relevant. Two other depressive episode subtypes were highlighted : post-stroke depressive episodes and those induced by major neurocognitive disorders. Antidepressants showed an efficient response in the first case but not in the second. Even though antidepressants are known to stimulate cognitive performances in animals, as yet there is not sufficient evidence to prove they indeed improve cognitive functions, or reduce the risk of developing a neurocognitive disorder, or decelerate the cognitive decline in major neurocognitive disorders in humans. Ageing creates pharmacodynamical changes that increase older people's vulnerability to the side effects of antidepressants. Moreover, age-related pharmacokinetic modifications can also change every step in a drug's transformation process in the body, which leads to a high probability of having adverse effects. Since most antidepressants are eliminated using the P450 cytochrome system, their dosage must be adapted to changes of the P450 system. Somatic comorbidities can, in themselves, influence the pharmacokinetics of antidepressants. Many antidepressants interact with the P450 cytochrome and the P-GP protein, which puts them at a high risk of drug interactions. There is no proven efficiency difference between antidepressant classes. Some antidepressant adverse effects can be of particular importance in the elderly, like the risk of bleeding, cardiovascular episodes, hyponatremia, falling and fractures, anticholinergic effects, extrapyramidal syndrome, epilepsy, liver disease and death. Selective serotonin reuptake inhibitors have an indication as the first line of treatment, avoiding paroxetine and fluoxetine. Serotonin and norepinephrine re-uptake inhibitors are relevant if the patient presents psychomotor retardation or pain, while keeping in mind to check blood pressure. Tricyclics and monoamine oxidase inhibitors should be avoided because of their anticholinergic effects. Bupropion can be prescribed if the patient has extreme fatigue. Mirtazapine is useful when the patient presents sleep or appetite disturbance. Several molecules can be used in the case of drug-resistant depression, such as associating aripiprazole with small-dosage antidepressants, or electroconvulsive therapy, or repetitive Transcranial Magnetic Stimulation (rTMS). Ketamine and psychostimulants seem to have antidepressant effects, but complementary studies are needed to conclude. CONCLUSIONS: Unipolar major depressive episodes in the elderly are frequent and their medicinal treatment has specific features. Knowing the specificities of antidepressant use in the elderly allows to optimize its efficiency and to limit the risk of inappropriate prescription leading to harmful adverse effects.

[Potentially inappropriate psychotropic drug prescription in elderly people in West Occitanie area]. / Prescription de psychotropes potentiellement inappropriés chez les sujets âgés en Occitanie Ouest.

AIM: Psychotropic drugs remain frequently prescribed in elderly people. Some of them are classified as « inappropriate ¼ because they could increase the risk of adverse drug reactions. The aim of this study is to evaluate the prevalence of exposure to potentialy inappropriate psychotropic drugs (PIPs) in the elderly living in nursing home residents (EHPAD) in West Occitanie area. METHODS: We carried out a retrospective study on the cohort of PAAPI program (Personne âgée et amélioration des prescriptions inappropriées) participating in PAAPI program set up in West Occitanie in 2016 including 3095 patients during 2 years. PIPs were identified by the list EU(7)PIM and completed with the guidelines mailed by the National Drug Safety Agency. We measured the prevalence of exposure to PIPs in this population. RESULTS: The majority of the residents (n=2301, 74.4%) were female of the average age was 87.1±8.1 years and. The prevalence of exposure to psychotropic drugs was about 77.5% with an average of 1.6 prescription lines per patient (±1,1). We found antidepressants (36.5% of PIP) with mainly paroxetine (37.3% of antidepressants PIP), followed by venlafaxine (32.8%), hypnotics and sedatives (26.6% of PIP) with zopiclone with inappropriate dose (59.4% of hypnotics PIP), anxiolytics (25.8% of PIP) with alprazolam (37.9% of anxiolytics PIP), followed by bromazepam (16%) and antipsychotics (11.2% of PIP) with cyamemazine (100% of inappropriate prescription) followed by aripiprazole and haloperidol (respectively 100% and 14.7% of inappropriate prescription). CONCLUSION: According to our data, third of elderly people in Nursing Homes were exposed to a PIP suggesting that guidelines about psychotropic drugs prescription are not well followed. Then, information campaign of healthcare professionnals could be useful to improve psychotropic drug prescription in the elderly population.

[What academic training for pharmacy students for clinical pharmacy? Example of shared medication report]. / Quelle formation académique pour les nouvelles missions de pharmacie clinique à l'officine ? Exemple du bilan partagé de médication du sujet âgé.

OBJECTIVES: In 2018, the implementation of shared medication reports in pharmacy encourages pharmacists to cooperate with other healthcare professionals. This job allows a decrease of medication errors in elderly. This requires a reorganization of the training offered by universities (initial and continuing training). The aim is to present the results of this pedagogical experimentation. METHODS: The experimentation (years 2017-2018 and 2018-2019) required the creation of a course to allow students to carry out a pharmaceutical analysis suitable to elderly people, to set up and carry out a shared medication report in pharmacy. Then, during their 6th year internship, students had to carry out at least one shared medication report per month. A monthly follow-up was organized with a database online. RESULTS: Sixty-four students and 35 internship supervisors participated in the experimentation. All the students improved their ease in using clinical pharmacy tools (pharmaceutical analysis, pharmaceutical interventions, assessment of adherence, etc.). They carried out 345 shared medication reports. In 24.3% of cases, an improvement in the prescription was proposed to the doctor (general practitioner or specialist). For 80% of the internship supervisors, the initial training of the students helped to set up this new pharmacy activity. CONCLUSIONS: This teaching is appreciated by students and internship supervisors. It enabled the adoption of the various tools essential for carrying out shared medication reports in pharmacy. Shared medication reports reinforce the multidisciplinary work of pharmacists, especially with general practitioners.