Monitoring of Potentially Inappropriate Prescriptions in Older Inpatients: A French Multicenter Study.

OBJECTIVES: To determine whether potentially inappropriate medications (PIMs) or potentially inappropriate associations (PIAs) prescribed knowingly are associated with patient monitoring. DESIGN: Prospective observational study. SETTING: Geriatric units (n = 56) in 28 hospitals. PARTICIPANTS: Inpatients aged 75 and older (N = 1,327). MEASUREMENTS: Potentially inappropriate prescriptions (PIP) were defined as a PIM or a PIA selected by an expert board from lists of explicit criteria (Beers, Priscus, Laroche, French Health Agency) using a Delphi process. They were considered to be prescribed knowingly if they were maintained after reassessment by the geriatrician and the clinical pharmacist. Primary outcome was the rate of PIPs maintained (prescribed knowingly) and for which a geriatrician declared that specific monitoring was performed. Secondary outcomes were the parameters monitored and the rate of participants receiving knowingly a PIP. RESULTS: One thousand sixty-three PIPs were detected in 607 participants (46%). After reassessment, 826 (78%) PIPs were maintained in 490 participants (37%), the main reasons being participant's regular treatment and lack of alternative. Psychotropic (36%), cardiovascular (including antithrombotics) (29%), and laxative or antiemetic drugs (16%) were the most-frequent classes prescribed knowingly. The geriatricians declared to perform clinical or biological monitoring for 69% (n = 570) of PIMs or PIAs prescribed knowingly. Three types of specific monitoring were identified: clinical, biological, and follow-up with a specialist. CONCLUSION: Approximately three-quarters of PIMs or PIAs were prescribed knowingly, of which 69% were monitored, with wide variations in occurrence and in quality according to drug classes. This underlines the need for accurate guidelines on PIP monitoring.

Apathy and depression in mild Alzheimer's disease: a cross-sectional study using diagnostic criteria.

Apathy and depression are the most frequent neuropsychiatric symptoms in Alzheimer's disease (AD). In a cross-sectional observational study of 734 subjects with probable mild AD, we evaluated the prevalence of apathy and depression. After the use of specific diagnostic criteria, we tested the interaction between the two syndromes and their relation with specific comorbidities, and different functional outcomes. Depression was diagnosed using the diagnostic criteria for depression in AD, and apathy with the diagnostic criteria for apathy in neuropsychiatric disorders. According to the specific diagnostic criteria, depression had a 47.9% prevalence, while apathy prevalence was 41.6%. Apathy and depression were associated in 32.4% of patients (n = 225). 9.4% (n = 65) had only apathy, 15.4% (n = 107) had only depression, and 42.9% had no apathy and no depression (n = 298). The three most frequent depressive symptoms were fatigue or loss of energy (59.4%), decreased positive affect or pleasure in response to social contacts and activities (46.2%), and psychomotor agitation or retardation (36.9%). Concerning apathy, loss of goal-directed cognition was the most frequently altered (63.6%), followed by loss of goal-directed action (60.6%) and loss of goal-directed emotion (43.8%). Patients with both apathy and depression more frequently required a resource allowance for dependency. Neurological comorbidities were more frequent in the "apathy and depression" and "depression alone" groups (p < 0.001). Apathy and depression overlap considerably, and this might be explained by the presence of some non-specific symptoms in both diagnostic criteria. The need for social support is higher when a patient fulfills the two diagnostic criteria.

Health management of older persons with chronically medicated psychotic disorders: the results of a survey in France.

BACKGROUND: The medical care of elderly patients with psychotic disorders is a matter of major concern. The aim of the study was to investigate health conditions and treatment of elderly patients with psychotic disorders in France. METHODS: The SAGE (Schizophrenia AGEd) study (observational, cross-sectional) was a survey conducted among 123 physicians in France, regarding prescriptions of antipsychotic drugs in elderly patients (≥60 years) suffering from psychotic disorders. The survey was based on a questionnaire addressing the mental and somatic health management of the patients. RESULTS: Data from 930 patients (mean age: 70.4 years) were collected. Most patients (58.5%) suffered from schizophrenia, 20.8% had delusional disorder and 20.6% hallucinatory chronic psychosis (very-late-onset schizophrenia-like psychosis). 70.8% of them were outpatients, while 29.2% were inpatients. The severity of psychotic symptoms was assessed in 97.8% of patients, but cognitive function was only evaluated in 41.6%. Some 46.5% of patients were treated with atypical antipsychotics alone, 36.2% with classical antipsychotics alone and 17.3% received a combination of both, atypical and classical antipsychotics; 36.3% patients were given antiparkinsonian medication, of whom only 17.8% as preventive treatment; 51.1% of patients had somatic comorbidities, particularly cardiovascular disorders (34.0%). Evaluation of renal and/or liver function to adjust the dose of treatment was done in only 32.1% of patients. Over the previous 12 months, almost half of the patients had had no ECG, glycemia or creatininemia investigated and HDL-cholesterol and triglycerides were available for less than one-third of them. CONCLUSIONS: Antipsychotic and antiparkinsonian drug prescriptions in French aged psychotic patients follow only partially the clinical guidelines and recommendations of consensus conferences. Moreover, cognitive, cardiac and metabolic aspects are not fully managed as expected.

[Depression: an underrated consequence of stroke in elderly]. / La dépression: une complication méconnue de l'accident vasculaire cérébral chez les sujets âgés.

Stroke is a major cause of morbidity, disability and hospitalization in the elderly. Depression frequently occurs after stroke and influences functional recovery, a crucial factor for the prognosis. The physiopathology of post-stroke depression is not entirely elucidated and might involve several mechanisms: direct consequences of brain lesions, especially in certain localizations, neuroendocrine mechanism or psychological reaction to a life event responsible for stress and handicap. Antidepressant drugs improve depressive symptoms and functional recovery. Therefore, search for depression should be systematic early at the stroke reeducation phase to instaure appropriate treatment.

[Clinical aspects of the depression in the elderly]. / Aspects cliniques de la dépression du sujet âgé.

Depression is the most frequent psychiatric disorder in the aged and a major cause of dependence. Its prognosis is poor on account of its consequences on physical health, the risk of suicide and of chronic evolution. It severely impairs the quality of life of the patients and makes a major contribution to the cost of public health since depressed subjects are hospitalized and use medical care more frequently than non depressed patients. However, they do not receive proper treatment for their depression. There is a large agreement on the necessity to improve the diagnosis of depression in the aged and to provide its adequate management. The difficulty of its diagnosis is not related to some specificity of depression but to the attitude of physicians toward aging. The recent guidelines for the diagnosis of depression insist on the indepency of the criteria regarding to age. The specificity of depression in the aged is only related to some clinical aspects and factors related to aging which interfere with its recognition, especially significant somatic complaints, cognitive disturbances and anxiety. Depression is no part of normal aging, but many risk factors are associated with aging, especially bereavement. A close clinical approach is required to distinguish depression from bereavement.