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.

[Acute renal failure in geriatrics]. / Insuffisance rénale aiguë en gériatrie.

Acute renal failure (ARF) is a frequent medical problem, affecting 20% of hospitalized patients. Aging leads to functional changes in the kidney, disruptions to hydrosodium homeostasis, and is associated with a higher prevalence of chronic kidney disease due to the impact of numerous chronic illnesses (diabetes, arterial hypertension, benign prostatic hypertrophy, etc.). All these age-related impairments hamper the kidney's ability to adapt to acute events. While elderly subjects can develop all types of AKI, they are particularly at risk of iatrogenic AKI due to polymedication, functional AKI due to a change in their ability to maintain hydrosodium homeostasis, and obstructive AKI linked to urological pathologies.

[Healthcare professionals' perception of advanced nursing practice in Ehpad with regard to the risk of drug iatrogenicity in heart failure patients]. / Perception des professionnels de santé sur la pratique avancée infirmière en Ehpad au regard du risque d'iatrogénie médicamenteuse chez l'insuffisant cardiaque.

Medication iatrogenia is a real public health problem. Elderly people are particularly at risk, due to their multiple pathologies, including heart failure; residents of residential care facilities for the dependent elderly (Ehpad) are no exception. Studies show that this risk is avoidable in 60% of cases, and that advanced practice nurses (APNs) can play a pivotal role in preventive measures. How would the role of the APN be perceived by other healthcare professionals working with these heart failure patients institutionalized in Ehpad?

[Pregabalin under the prison lens. Reflections on an emerging issue]. / Prégabaline sous la loupe carcérale. Réflexions sur une problématique émergente.

The practice of medicine in prison confronts the prescriber with emerging trends in psychotropic drug misuse. We examine the increasing demand for pregabaliun, as we observe it in patients in detention, and offer a reflection on the health issues. We explain our approach to abstaining from prescribing.

[Targeting anticoagulated patients for medication reconciliation at discharge in orthopaedic surgery]. / Conciliation médicamenteuse de sortie ciblée en chirurgie orthopédique : focus sur les anticoagulants.

In orthopedic surgery, the well-known iatrogenic risk of oral anticoagulants is particularly increased due to surgical management (suspension and resumption of treatment). In order to prevent avoidable iatrogenic events linked to incomplete discharge documents, targeted medical reconciliation (MR) has been deployed. This is a single-center prospective study conducted in orthopaedic surgery for six months including any patient treated upon admission with an oral anticoagulant. The analysis of the compliance of discharge documents (hospitalization report and prescriptions) was carried out before and after pharmaceutical interventions. The criteria analysed included the mention of the oral treatment, its dosage as well as the supervision of the switch from heparin therapy to the usual oral treatment. The documents were compliant if the mention of oral anticoagulant treatment and the date of the shift were correctly documented. Thirty-seven patients were included. The compliance rate of discharge documents was significantly improved by MR, going from 13.5 % to 78.4 % (P <0.05). The non-compliances before the intervention concerned the absence of mention of: the usual treatment (64.9 %), its dosage (81.1 %) or the switch's securing (75.7 %). Discharge from surgery of the patient on anticoagulants is a stage presenting a real risk which can be managed by the intervention of pharmacists. Improving the compliance of discharge documents is a first step towards better securing drug management.

[Medication reconciliation and hospital-community transition securisation: Survey of community pharmacists]. / Conciliation médicamenteuse et sécurisation de la transition hôpital­ville : enquête auprès des pharmaciens d'officine.

OBJECTIVE: To collect the community pharmacists' perception on their role in the medication reconciliation's process. METHODS: We did an observational transverse study thanks to a survey of community pharmacists working in France, conducted in 2020. A digital questionnaire was submitted to Parisian community pharmacists before being shared on two Facebook groups. The responses were analysed with Microsoft Excel® software. We calculated percentages, used Chi2 or Fisher's exact tests and did qualitative analyses. RESULTS: We collected the perception of 135 community pharmacists, the majority was women (80%), relatively young (69.6% of 40 years old or less). They were 63.7% to claim knowing the medication reconciliation, but they could not define it properly. The subject's knowledge was statistically related to age (P-value<0.001) and previous contacts of the health care facilities (P-value<0.001). The majority of interviewed pharmacist considered the transmission of information to those health facilities as relevant and feasible and they expressed their willingness to get involved. However, they were limited by some obstacles such as the non-exhaustiveness of the medicinal record, the unsecured mail and the lack of feedbacks. CONCLUSIONS: Although the community pharmacists expressed interest for the medication reconciliation process and willingness to get involved, their role remained limited. Therefore, this process needs an improvement of its organisation and a generalisation of its practice to really benefit the hospital-community transition's safety.

[Rules of good practice for the elderly]. / Les règles de bonne pratique chez le sujet âgé.

The treatment of infectious diseases in geriatric medicine is a complex subject. Diagnosis is often difficult, as is the correct indication for antibiotic therapy. To combat antibiotic resistance, we need to limit unnecessary antibiotic prescriptions and prevent the onset of bacterial infections, notably through vaccination.

[Pharmaceutical cares as means of prevention against drug iatrogenic: Case of oral anticoagulant]. / Les soins pharmaceutiques comme moyen de prévention contre les risques iatrogènes des médicaments : cas des anticoagulants oraux.

Oral anticoagulant can have a significant risk of adverse events, particularly when it is initiated, modified or interrupted. Pharmaceutical care through medication reconciliation could improve the benefit-to-risk ratio of these drugs. A prospective and interventional single center study was conducted from March through August 2018 in medicine and surgical units. Patients with an oral anticoagulant prescribed and coming from outpatient sector were included. These patients received a medication reconciliation at admission and discharge. Frequency and type of discrepancies were studied. Their gravity rating was assessed using the Cornish et al. scale. This study included 162 patients. The medication reconciliation at the admission allowed the detection of 133 unintentional discrepancies which 16 of them represented a high risk for the patient included nine errors about oral anticoagulant prescribing. Concerning the reconciliation at discharge, 51 unintentional discrepancies had been detected: 12 of them represented a high risk for the patient included eight errors about oral anticoagulant prescription. The acceptance rate of the discrepancies was 86% and reflected discrepancies severity. This result reached 96.4% if we took into account discrepancies with a severe clinical impact. This study highlighted oral anticoagulant represented relevant prioritization criteria to the long-lasting implementation of pharmaceutical care. This secures the management of the patient since the admission until the hospital discharge. The last step of our approach would be to study the needs about data transmission to the community caregivers.

[From medication reconciliation to shared medication review: Pilot study integrating support for community pharmacists within a pharmaceutical care pathway]. / De la conciliation médicamenteuse au bilan partagé de médication : étude pilote intégrant un accompagnement des pharmaciens d'officine au sein d'un parcours de soins pharmaceutiques.

INTRODUCTION: Medication reconciliation at hospital and the shared medication review are two complementary activities for securing the medication management of the elderly patient. We are experimenting with a pharmaceutical care pathway including a support approach to promote continuity between these two activities and the initiation of shared medication review. MATERIALS AND METHODS: An admission and discharge medication reconciliation has been set up in a geriatric follow-up care and rehabilitation service. A drug assessment was also carried out during the hospital stay. Support for community pharmacists following conciliation was provided by phone calls. Medication discrepancies at admission and discharge, pharmaceutical interventions (PI) as well as satisfaction and difficulties encountered by community pharmacists were collected. RESULTS: Thirty-three patients were included in the study. On admission, 33% of patients had an unintentional discrepancy and 15% on discharge. On average 1.15 PI per patient were notified. The support was propounded to 13 pharmacists. Eight pharmacists (62%) accepted it. Among them, 5 (62.5%) had never performed a medication review. Lack of time was the main difficulty encountered by pharmacists. DISCUSSION AND CONCLUSION: Our pathway enables to integrate hospital and primary care activities and specifically support the delicate transition between them. This enables to facilitate the implementation of these activities and to maintain a relevant and secure continuity of pharmaceutical care.

[Surgical complications in adult urology: Surgery of the external genitalia]. / Les complications chirurgicales en urologie adulte : chirurgie des organes génitaux externes.

AIM: Define and present the complications of surgery of the external genitalia (EG), as well as their management. METHOD: Bibliographic search using the Medline (NLM Pubmed tool) and Embase bibliographic databases using the following keywords: scrotal surgery, orchidopexy, hydrocele, varicocele, testicular biopsy, vasectomy, cryptorchidism, orchiectomy, testicular implant, subcapsular orchiectomy, spermatic cord cyst, posthectomy, penis curvature surgery, penile implant, urethral strictures. RESULTS: EG surgery is common in urology, it includes scrotal surgeries and penile surgeries, which are performed openly. They expose to complications such as bleeding, infection, scar disunity requiring early reassessment especially in case of ambulatory procedure. Rare complications must be known, some of which must lead to expert management. CONCLUSION: Complications of surgical treatment of EG should be identified and managed. This report should allow a better understanding and management of these complications.

[Lipid pneumonitis, a serious iatrogenic event with lubricating laxatives]. / La pneumopathie lipidique, un accident iatrogène grave aux laxatifs lubrifiants.

The prescription of lubricating laxatives (paraffin oil) is widespread in geriatrics because of the frequency of constipation. These molecules can cause serious adverse effects such as lipoid pneumonia, especially in subjects with swallowing disorders.

Drug-related problems among older patients: Analysis of 8 years of pharmacist's interventions.

OBJECTIVES: To analyse the most frequent DRP over time and pharmacists' interventions made among older patients aged over 75 years old. DRP between older patients and younger patients aged 18 to 74 years and between older patients treated in geriatric wards or not were also compared. METHODS: A cross-sectional observational study conducted on DRP detected by pharmacists at the university hospital centre of Lyon and prospectively recorded in the Act-IP© database from January 2008 to December 2015. RESULTS: A total of 56,223 DRP were investigated - 19,056 in older patients and 37,167 in younger patients. A supratherapeutic dosage was mainly reported (22.4% in older patients vs. 19.0% in younger patient) and pharmacists made interventions mostly to adjust dosage (27.3% vs. 24.2%). Physicians' acceptance was significantly lower in older patients (57.1% vs. 64.3%). DRP associated to a drug included a supratherapeutic use of acetaminophen (5.2% vs. 3.8%) and hypnotics (4.0% vs. 1.4%), medication in cardiology used without indication (1.4% vs. 0.2%) and underuse of vitamin D (1.2% vs. 0.1%). Supratherapeutic dosages were more significantly detected with a lower overall physicians' acceptance in older patients treated in general wards. CONCLUSIONS: This study highlights the specificity of DRP among older patients and encourages health care professionals to remain especially alert regarding older patients treated in general wards. These findings can contribute to define or adjust training needs and quality indicators to improve the daily practices of health care professionals.

[Clinical medication review in French community pharmacy: Interest of a new pharmaceutical service for detection of drug related problems]. / Le bilan partagé de médication: intérêt de la mise en place d'un nouveau service pharmaceutique dans la detection de problemes lies aux therapeutiques.

OBJECTIVE: Using clinical medication reviews, analyze the most pharmaceuticals intervention generating treatments and the problems associated. METHODS: Analysis of activity reports made by 6th year pharmaceutical students from the University of Bordeaux, class of 2017-2018. RESULTS: 76 % of clinical medication review have detected at least one drug related problem in the population of this study. Drug classes that most frequently lead to pharmaceutical interventions are nervous system drugs, alimentary tract and metabolisma drugs and cardiovascular system drugs. The most frequent drug related problems are an unjustified prescription, a contraindication or a non-compliance with the standards of care and posology issues. CONCLUSIONS: The most at risk and pharmaceutical intervention generating drugs in this study are the same as described in the international literature. This shows that more precautions must be taken for their use in the elderly. Furthermore, this new pharmaceutical service is an efficient way to detect them.

[A pragmatic approach to iatrogenic risk in the emergency room]. / Approche pragmatique du risque iatrogène aux urgences.

The links between the emergency department (ED) and drug-related harm are close. In practice, it is necessary to ask systematically if an iatrogenic accident is possible and to evaluate a new prescription carefully so as not to create iatrogenia during the visit to the emergency department. Any situation in which a nurse takes charge of an emergency room must be subject to precautions. Simple measures should be put in place during any hospitalisation of an elderly person.

[Is the medication reconciliation achievable and relevant in Psychiatry?: Feedback on the implementation of medication reconciliation on hospital admission]. / La conciliation médicamenteuse est-elle réalisable et pertinente en Psychiatrie ? : Retour d'expérience sur la mise en place de la conciliation à l'admission.

OBJECTIVE: The health care pathway of patients suffering from mental disorders is complex and includes a risk of interruption of treatment. We implemented medication reconciliation at patients' admission to mental health care service in February 2017. The aim of this study was to achieve a feedback experience answering our questions about the feasibility and relevance of this process. METHOD: A prospective analysis of medication reconciliations over the first 7 months of implementation was carried out according to 3 activity indicators and 6 performance indicators. RESULTS: A total of 39 patients were reconciled and 56.4 % of them were in enforced hospitalization unit. All patients were interviewed by the pharmacist. Collected information during this interview was concordant with at least one of the other sources in 70.4 % of the cases. Thirteen patients were not reconciled within 72h after their admission because of their psychiatric pathology. The average number of unintentional medication discrepancy (UMD) detected was 0.97 per reconciled patient. The rate of major gravity UMD was 23.7 %. The number of UMDs per patient was significantly higher in enforced hospitalization unit (P<0.05). UMDs were essentially related to somatic drugs (81.6 %). Nearly 95 % of the detected UMDs resulted in a modification of prescription. CONCLUSION: These results show that medication reconciliation at patients' admission is feasible and relevant in psychiatry. To limit constraints related to psychiatric pathology, we propose to perform medication reconciliation of patients more than 72 hours after patient admission provided that their clinical condition allows it.

[Cutaneous drug reactions]. / Toxidermies.

Cutaneous drug reactions are a common reason for calls and visits. This term chiefly refers to hypersensitivity reactions ranging from benign rash without contraindication of treatment to severe life-threatening clinical pictures, such as anaphylactic shock and epidermal necrolysis. They should be carefully managed from the outset. Indeed, history taking and precise semiological description of the lesions are crucial to the formulation of recommendations for the patient. Allergological investigation of such reactions has developed greatly in recent decades and must now be carried out much more extensively. The arrival of new drug families such as biotherapies and the development of drug habituation protocols constitute the challenges of tomorrow for cutaneous drug reactions.

[A new support given to patients in retail pharmacies: The "shared checkup of medication"]. / Un nouveau dispositif d'accompagnement du patient en officine : le « bilan partagé de médication ¼.

In accordance with the recommendations of the HPST law of 21st July 2009, the retail pharmacists heavily put a lot into new missions, concerning as well prevention and screening as therapeutic education of patient. In that context, two types of pharmaceutical conversations relative to patient's therapeutic training were primarily planned : the first one concerns patients with thrombosis' risk treated by oral anticoagulants (antivitamin K or direct oral anticoagulant), whereas the second one is intended to asthmatics cured by corticoids' inhalation. Then the publication in 2017 and 2018 respectively of amendments no 11 et 12 to the National convention of 4th April 2012 organizing relationships between titular pharmacists and health insurance planned a third type of support called « shared checkup of medication ¼. It is a matter of program of personalized pharmaceutical monitoring intended to patients at least 65 years old and suffering from one or several long-lasting affection(s), and also to patients at least 75 years old and chronically treated by at least five different active substances. Those new pharmaceutical conversations aim on the one hand to improve observance of chronic medications - current by elderly patients - and on the other hand to prevent drug iatrogenesis - favored by polymedication - while reasserting the major role of the retail pharmacist as health professional.

[Telemedicine and drug iatrogenesis in nursing homes]. / Télémédecine et iatrogénie médicamenteuse en Ehpad.

Inappropriate drug prescribing is an avoidable cause of adverse drug events, sources of an increase in morbimortality, excess spending and a decrease in quality of life. Many actions exist to improve prescribing quality and to secure the medication circuit in nursing homes. As part of the deployment of telemedicine, the benefit of a medico-pharmaceutical tele-expertise system for medication is evident.

[Crushing or opening medication: what practices, what risks?] / Écrasement ou ouverture des médicaments : quelles pratiques, quels risques ?

The practice of crushing tablets or opening up capsules to be taken orally, when it is not prescribed, can affect the efficacy of a treatment, or even cause an adverse event. A survey carried out in 2016 revealed that this is a common practice, especially among elderly people. However, alternative forms exist and can be prescribed.

[Medicines and elderly patients: abuse, dependency or attraction?] / Médicaments et sujets âgés : abus, dépendance ou attirance ?

Psychotropic medicines represent, after alcohol, the second class of substances most susceptible to abuse by elderly people. It can be particularly difficult for caregivers to understand such behaviour as these are prescription-only medicines. This misuse is partly a result of older people tending to trivialise and overrate pharmaceutical drugs, ignoring the potential of non-medicinal methods and psychotherapeutic treatments. The boundaries between prescribed use, overuse, self-medication, excessive use, dependency or addiction to prescription drugs are blurred in older people. Alongside withdrawal methods, prevention must be prioritised by respecting the recommendations of medicine prescriptions in geriatrics and deprescription.