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.

Integrated clinical pharmacy activities into the pediatric kidney graft pathway

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.

[The use of melatonin in older patients hospitalized in geriatric units in France: survey of hospital pharmacists]

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.

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.

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.

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.

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.

How a Patient Personalised Clinical Pharmacy Programme Can Secure Therapeutic Care in an Orthogeriatric Care Pathway (5P Project)?

Background

A new model was developed for integrating a personalised clinical pharmacy programme (5P project) into the orthogeriatric care pathway.

Objective

To secure the therapeutic care of orthogeriatric patients.

Design and Setting

Prospective descriptive study in a multisite teaching hospital from June 2019 to January 2020.

Subjects

Patients aged ≥75 years admitted for hip fracture.

Methods

A prescription review was performed for all patients at inclusion. Other clinical pharmacy activities (additional prescription review, pharmaceutical interviews, medication reconciliation) were dedicated to “high-risk” patients. Potential medication errors (ME), either pharmaceutical interventions (PI) or unintentional discrepancies (UID), were recorded. The potential clinical impact of PI was evaluated by a pluriprofessional expert panel using a validated tool.

Results

In the 455 patients included, 955 potential ME were detected, that is ≥1 potential ME for 324/455 (71%) patients. In acute care, 561 PI were formulated during prescription review for 440/455 (97%) patients and 348/561 (62%) were accepted by physicians. Medication reconciliation was performed for 213 patients, 316 UID were identified. In rehabilitation units, a second prescription review was performed for 112/122 (92%) “high-risk” patients, leading to 61 PI. The clinical impact was evaluated for 519/622 (83%) PI. A consensus was obtained for 310/519 (60%) PI: 147/310 (47%) were rated as having minor clinical impact, 138/310 (45%) moderate, 22/310 (7%) major, 2/310 (0.6%) vital, and 1/310 (0.3%) null.

Conclusion

The 5P project secured the orthogeriatric care pathway by detecting a great number of potential ME, including PI mostly considered as having a significant clinical impact.

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.

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.

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, 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.

[Medication management of hypertension and heart failure in older patients: What happens to therapeutic changes after hospitalization?]

PURPOSE

The objective of this study was to objectivize if the cardiovascular therapeutic changes performed during hospitalization of older patients with hypertension and/or heart failure (HF), were maintained in ambulatory 3 month after hospitalization.

METHODS

This is a longitudinal study conducted in a geriatric unit. Patients over 65 years with hypertension and/or HF, who had at least one change in cardiovascular medicaton during hospitalization, and who accepted the 3-month follow-up were included in the longitudinal study. At admission, during hospitalization and 3 months after hospitalization data concerning cardiovascular medication were collected.

RESULTS

During hospitalization, 142 (73.6%) patients had at least one change in hypertension and/or HF medication. Overall, 249 changes were performed. Forty-one patients received follow-up at 3 months. At 3 months, therapeutic changes were maintained by 48.8% of the general practitioners (n=20 patients). For the rest, 41.5% of the patients had benefited from new therapeutic changes (28 changes for 10 patients) and 9.7% of the general practitioners (n=4 patients) had restored the initial prescription before hospitalization.

CONCLUSIONS

Medication review performed by geriatricians and pharmacists during hospitalization resulted in 249 changes. These changes aimed at limiting iatrogenic disease, by reducing overtreatment and potentially inappropriate prescriptions. Difficulties in the patient care continuity between the hospital and ambulatory setting have been identified.

Caregiver in Alzheimer's disease, pharmacist, and pharmacy technician attitudes and knowledge about caregiver burden screening in community pharmacies

OBJECTIVES

To explore caregiver, pharmacist and pharmacy technician attitudes toward burden screening in community pharmacies and assess caregiver burden in community pharmacies.

METHODS

Descriptive cross-sectional study conducted in 10 community pharmacies in France. Pharmacists, pharmacy technicians and caregivers of patients with Alzheimer's disease were included in this study. Two self-reported questionnaires were used to explore attitudes of participants toward the burden screening in community pharmacy and to assess the caregiver burden in community pharmacy. The short version of the Zarit Burden Interview (range 0-7) was used for the burden screening.

RESULTS

Fifty-two pharmacists and pharmacy technicians, and 20 caregivers (61.8±13.7years) participated in this study. Seventy percent of caregivers and 96% of pharmacists/pharmacy technicians stated that caregiver burden screening should be conducted in community pharmacies. 65% of caregivers reported their caregiver status to their community pharmacist. Eighty-two percent of pharmacist/pharmacy technicians thought they had to inform the caregiver's general practitioners (GP) about the detected burden level. Of the 20 included caregivers, 18 had a perception of burden. The mean caregiver burden score detected in this exploratory study was 4.0±1.7, corresponding to a moderate to severe burden.

CONCLUSIONS

According to caregivers' opinion, community pharmacists and pharmacy technicians represent accessible health care professionals in primary care to quantify caregiver burden. The burden screening can be easily incorporated into clinical service offerings in community pharmacy practice. It provides a valuable opportunity to identify high-risk caregivers with the aim of referring them to their GP to prevent the caregiver's frailty.

[Community pharmacists' and pharmacy technicians' attitudes and beliefs about depression in elderly]

OBJECTIVES

To analyze attitudes and beliefs of community pharmacists and pharmacy technicians about depression and treatment in older patients.

METHODS

A qualitative study was conducted with community pharmacists and pharmacy technicians. The first step of the study was to develop an interview guide to conduct semi-directive interviews. A thematic analysis was conducted based on the transcripts of the recording of audio interviews.

RESULTS

Eight pharmacists and 5 pharmacy technicians were included. The mean duration of semi-directive interviews was 14.8±4.6minutes. The main identified themes were as follows: 1/the depression: beliefs about depression and its risk factors in older patients; how to talk about depression with older patients at the counter; 2/the management of depression: how to talk about antidepressant with older patients at the counter, including treatment duration, dosage, efficacy and adverse effects of treatment, but also alternative therapies and advices; 3/barriers and facilitators of antidepressant adherence in older patients.

CONCLUSIONS

Barriers to conduct pharmaceutical care focusing on depression among older patients in community pharmacy have been identified: disease stigmatization, lack of privacy at the counter and lack of communication with the prescribing physician; but also a lack of knowledge concerning the specific therapeutic strategy for depression in the elderly. Thus, strengthening the pharmacy student teaching and the community pharmacist and pharmacy technician training regarding the posture to adopt and the therapeutic management of older patients with mental illness would be beneficial.

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.

One-Year Evolution of Behavioral and Psychological Symptoms of Dementia in Patients Initially Hospitalized in Cognitive Behavioral Units: The EVITAL Prospective Cohort

BACKGROUND

The 2008-2012 French Alzheimer's Plan has provided hospital Cognitive and Behavioral Units (CBU) to improve the management of patients with productive behavioral and psychological symptoms of dementia (BPSD). Little is known concerning the behavioral outcome of these patients after discharge.

OBJECTIVE

The present study investigated the long-term evolution of BPSD over one year after CBU discharge.

METHODS

The EVITAL cohort included 221 participants admitted to the CBUs of 3 French hospitals. BPSD were collected using the Neuropsychiatric Inventory (NPI) at admission and 3, 6, and 12 months after hospitalization. The global NPI score evolution was assessed using a linear mixed-effect model. A four-factor model of the NPI including behavioral dyscontrol, psychosis, mood, and agitation subscores was also analyzed.

RESULTS

Our analysis focused on 148 patients followed up during 12 months and evaluated at each visit. The global NPI score was 48.5 (SD 21.7) at baseline, 28.8 (SD 18.7) at 3-month, 23.2 (SD 16.4) at 6-month and 20.9 (SD 15.9) at 12-month follow-up. The score significantly decreased from baseline to follow-up (F = 109.3 p < 0.0001). Moreover, the decrease was observed for each NPI subscores. The Clinical Dementia Rating (CDR) scale score was significantly linked to the baseline NPI score (t = 2.76, p = 0.009). Conversely, the NPI decline was observed whatever the CDR level.

CONCLUSION

The present study showed a decrease in the global NPI score and all its subscores during the year following the CBU hospitalization, regardless of the initial CDR score.

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.

Anticholinergic drugs and functional, cognitive impairment and behavioral disturbances in patients from a memory clinic with subjective cognitive decline or neurocognitive disorders

Background

Drugs with anticholinergic properties may be associated with various adverse clinical effects. The relationship between the anticholinergic (AC) burden and functional, global cognitive performance and behavior disturbances was assessed among elderly patients.

Methods

A cross-sectional study was conducted between January 2012 and June 2014 in a memory clinic among outpatients living at home and with subjective cognitive decline (SCD) or neurocognitive disorders (NCD). The AC burden was measured using the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden (ACB), Chew’s score, Han’s score, and the number of drugs with AC activity. Functional, cognitive performance and behavior disturbances were assessed using the Instrumental Activities of Daily Living (IADL) scale (IADL), the Mini Mental State Examination (MMSE), and the Neuropsychiatric Inventory (NPI).

Results

Among 473 included patients, 46.3% were at major NCD. Patients took on average 5.3 ± 2.6 drugs. MMSE was lower when Han’s score (p = 0.04) and number of AC drugs were higher (p < 0.001). IADL was lower when AC burden was higher, whatever the AC measurement. NPI was higher when ACB, Han’s score, and number of AC drugs were higher. After adjustment, all AC scores remained associated with IADL, while Han’s score and number of drugs with AC remained associated with the MMSE.

Conclusions

In patients with SCD or NCD, AC burden is associated with lower functional score, whereas the cross-sectional association between AC burden and cognitive performance or behavioral disturbance varies according to AC scores. Particular attention should be paid when prescribing drugs with AC properties, especially among patients with memory complaints.

How to explore the needs of informal caregivers of individuals with cognitive impairment in Alzheimer's disease or related diseases? A systematic review of quantitative and qualitative studies

BACKGROUND

This study aims to review the methodologies used to identify the needs, the existing needs assessment instruments and the main topics of needs explored among caregivers of patients with mild cognitive impairment to dementia.

METHODS

MEDLINE, PsycINFO, The Cochrane Library and Web of science were searched from January 1980 to January 2017. Research studies in English or French were eligible for inclusion if they fulfilled the following criteria: quantitative, qualitative and mixed method studies that used instrument, focus group or semi-structured interviews to assess the informal caregiver's needs in terms of information, coping skills, support and service.

RESULTS

Seventy studies (n = 39 quantitative studies, n = 25 qualitative studies and n = 6 mixed method studies) met the inclusion criteria and were included. Thirty-six quantitative instruments were identified but only one has been validated for the needs assessment of dementia caregivers: the Carer's Needs Assessment for Dementia (CNA-D). The main areas of needs explored in these instruments were: information, psychosocial, social, psychoeducational and other needs.

CONCLUSIONS

No instrument has been developed and validated to assess the needs of informal caregivers of patients with cognitive impairment, whatever the stage and the etiology of the disease. As the perceived needs of caregivers may evolve with the progression of the disease and the dementia transition, their needs should be regularly assessed.

Factors associated with changes in exposure to anticholinergic and sedative medications in elderly hospitalized patients: multicentre longitudinal study

BACKGROUND AND PURPOSE

Elderly patients exposed to drugs with anticholinergic or sedative properties may have an increased risk of adverse events. This study aimed to assess the relationship between patient characteristics and changes of exposure to anticholinergic and sedative medications during their hospital stay.

METHODS

A multicentre longitudinal study was set up on hospitalized patients (aged ≥65 years) using at least one drug at admission. The primary outcome was change of exposure to anticholinergic and sedative drugs between admission and discharge. Sociodemographic characteristics of the patients, comorbidities, life habits and information about the hospital stay (origin of admission, reasons for hospitalization) were collected.

RESULTS

The study included 337 patients (mean age, 85.4 years) with an average hospital stay of 30.1 ± 37.5 days. The drug burden index increased during the hospital stay among males (P = 0.03), patients for whom the reason for hospitalization was either a stroke (P = 0.001) or inability to stay in their own home (P = 0.001), and patients with diabetes mellitus (P = 0.009). In the adjusted model, drug burden index increased among patients hospitalized for stroke, inability to stay in their own home or post-surgery, and for patients with diabetes mellitus or hypertension.

CONCLUSIONS

The drug management of elderly patients during hospital stays may increase exposure to anticholinergic and sedative drugs. Although the anticholinergic and sedative properties may be in relation to the therapeutic purpose, they also represent an unexpected risk. Physicians and clinical pharmacists should consider performing optimization of the drug prescriptions for patients at risk.

[Identification of knowledge deficits of pharmacy students at the beginning of the fifth year of pharmacy practice experience: Proposals to change the content of academic programs]

INTRODUCTION

In France, community pharmacy students performed a hospital pharmacy practice experience during the 5th year of the university curriculum. The purpose of a part of the content of the academic teaching program delivered before this practice experience is to prepare the students for their future hospital activities. It should enable them for the practical use of knowledge in order to improve pharmacotherapy, laboratory diagnosis and monitoring of patients' care. The aim of this study was to show if there are gaps in this program.

METHODS

Fourteen students performing their clerkship in a teaching hospital were invited to highlight these gaps when they were gradually immersed in the pharmaceutical care. They did so under the careful observation of hospital pharmacist preceptors. These practitioners referred to professional guidelines, documentary tools used in daily clinical practice and publications supporting their pharmaceutical care practices.

RESULTS

Shortcomings and gaps identified were: how to communicate with other healthcare professionals and the content of verbal exchanges, how to conduct a patient-centered consultation, documentation tools required for relevant pharmacist' interventions, codification of pharmacist's interventions, risks related to drug packaging and benefit risk assessment of health information technologies.

DISCUSSION

These gaps represent a handicap by delaying the process that led to move from student to healthcare professional. Hospital pharmacist preceptors have to fill in these gaps before engaging students in pharmaceutical care.

CONCLUSION

These results invite to revise partly the content of the academic teaching program delivered before the 5th year hospital pharmacy practice experience.

Logistic, ethical, and political dimensions of stepped wedge trials: critical review and case studies

Background

Three arguments are usually invoked in favour of stepped wedge cluster randomised controlled trials: the logistic convenience of implementing an intervention in phases, the ethical benefit of providing the intervention to all clusters, and the potential to enhance the social acceptability of cluster randomised controlled trials. Are these alleged benefits real? We explored the logistic, ethical, and political dimensions of stepped wedge trials using case studies of six recent evaluations.

Methods

We identified completed or ongoing stepped wedge evaluations using two systematic reviews. We then purposively selected six with a focus on public health in high, middle, and low-income settings. We interviewed their authors about the logistic, ethical, and social issues faced by their teams. Two authors reviewed interview transcripts, identified emerging issues through qualitative thematic analysis, reflected upon them in the context of the literature, and invited all participants to co-author the manuscript.

Results

Our analysis raises three main points. First, the phased implementation of interventions can alleviate problems linked to simultaneous roll-out, but also brings new challenges. Issues to consider include the feasibility of organising intervention activities according to a randomised sequence, estimating time lags in implementation and effects, and accommodating policy changes during the trial period. Second, stepped wedge trials, like parallel cluster trials, require equipoise: without it, randomising participants to a control condition, even for a short time, remains problematic. In stepped wedge trials, equipoise is likely to lie in the degree of effect, effectiveness in a specific operational milieu, and the balance of benefit and harm, including the social value of better evaluation. Third, the strongest arguments for a stepped wedge design are logistic and political rather than ethical. The design is advantageous when simultaneous roll-out is impractical and when it increases the acceptability of using counterfactuals.

Conclusions

The logistic convenience of phased implementation is context-dependent, and may be vitiated by the additional requirements of phasing. The potential for stepped wedge trials to enhance the social acceptability of cluster randomised trials is real, but their ethical legitimacy still rests on demonstrating equipoise and its configuration for each research question and setting.

[Pharmacist's interventions on proton pump inhibitor prescriptions in a University Hospital]

PURPOSE

In France, efforts to optimize prescribing of proton-pump inhibitors (PPIs) are rare. Various studies have shown that the prescription of these drugs is excessive. This has consequences regarding costs and iatrogenesis. The objective of this study was to describe the type of drug related problems (DRP) and pharmaceutical interventions reported by pharmacists practicing in a university hospital.

METHODS

Drug related problems and pharmaceutical interventions (PI) made, were recorded on a database. They were classified according to the grid code of the French Society of Clinical Pharmacy.

RESULTS AND DISCUSSION

Over a 3 years period, 132.890 prescriptions were analysed. 15.347 generated PI. Among them 701 (4.6%) concerned PPIs. Most frequently reported problems were: lack of indication or patients without a documented indication (24.4%), drug-drug interactions (22.4%) and inappropriate route or mode of administration (19.8%). Discontinuation has been proposed in 40.5% of cases, followed by substitution (22.0%) and dosage titration (17.3%). Physicians modified the prescription according to 51.3% of PI. The main PI, discontinuation therapy, is associated with over-prescription of this drug class. Nevertheless, the rate of DRP recorded (0.5%) is low compared to the high exposure of patients on PPIs and misuse (or overuse?) reported in the literature.

CONCLUSION

PI made during the analysis of prescription contributes to rationalizing the use of PPIs. The action of the pharmacist must be strengthened through training of health professionals, and communication strategies to improve practices.

[Role of clinical pharmacist in the therapeutical optimization in geriatric outpatient hospital]

SETTING

Cares in outpatient hospital for elderly patients is a period of interest for multidisciplinary reassessment and pharmaceutical care of the prescription. The objective is to present the implementation of the pharmaceutical care activity at the outpatient hospital.

METHODS

Between August and October 2011, elderly patients hospitalized in the outpatient hospital for a brief appraisal had a pharmaceutical care. The clinician introduced pharmaceutical reviews in the synthesis letter for general practitioner. An analysis of the activity was carried out over 3 months.

RESULTS

A pharmaceutical care had been realized for 67 patients, mean age of 81.7 years. Among medical related problems identified, 39.6% were for potentially unnecessary medication. A stop was proposed for 44% of pharmaceutical interventions. A total of 91 pharmaceutical interventions and 13 recommendations were made and 34% of patients had potentially inappropriate medication.

CONCLUSION

According to the objective to reduce the therapeutics contributing to the iatrogenesis, this approach allowed us to undertake a multidisciplinary collaboration oriented toward the relay between hospital and city cares.

[Post-surgery cognitive disorders: prevention, diagnosis and treatment strategies]

Hip fracture is an important step in the autonomy evolution in elderly. As gait is particularly jeopardised after such a traumatism, cognition may also be acutely impaired. Elderly post-surgery delirium is frequent, but chronic progression of cognitive impairment and dementia may occur. The concept of cognitive reserve is crucial for understanding risk factors of post-surgery delirium in elderly. The more the cognitive reserve is decreased before such a traumatism, the higher the delirium and dementia progression risk is. A neurodegenerative disease such as Alzheimer's disease may be clinically silent prior the traumatic event, and may decompensate soon after as the cognitive reserve is not sufficient anymore. Dementia may then lead to progressive autonomy loss. A systematic interdisciplinary approach is needed to prevent frail patients from delirium, and to early cure it to decrease the risk of long-term autonomy loss.

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, β = 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