Search

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.

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.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.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.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.

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).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.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.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.

Resume But de l’etude L’objectif de cette etude etait d’objectiver si les modifications des therapeutiques cardiovasculaires, realisees au cours de l’hospitalisation de la personne âgee atteinte d’HTA et/ou d’Insuffisance cardiaque (IC), etaient poursuivies en ambulatoire a 3 mois de l’hospitalisation. Methode Il s’agit d’une etude longitudinale menee au sein d’une unite de soins de court sejour geriatrique. Les patients de plus de 65 ans, atteints d’HTA et/ou d’IC, ayant eu au moins une modification du traitement cardiovasculaire au cours de l’hospitalisation, et ayant accepte le suivi a 3 mois ont ete inclus dans l’etude longitudinale. A l’admission, au cours de l’hospitalisation et a 3 mois de l’hospitalisation via les pharmacies d’officine, les donnees medicamenteuses concernant le traitement cardiovasculaire ont ete recueillies. Resultats Au cours de l’hospitalisation, 142 (73,6 %) patients ont eu au moins une modification concernant leur traitement de l’HTA et/ou l’IC, representant 249 modifications. Quarante et un patients ont beneficie du suivi a 3mois. A 3 mois, les modifications therapeutiques avaient ete poursuivies par 48,8 % des medecins traitants (n = 20 patients). Pour le reste, 41,5 % des patients avaient beneficie de nouvelles modifications therapeutiques (28 modifications pour 10 patients) et 9,7 % des medecins traitants (n = 4 patients) avaient repris la prescription medicamenteuse initiale avant hospitalisation. Conclusion La reevaluation geriatrique realisee au cours de l’hospitalisation a donne lieu a 249 modifications ayant pour objectif de limiter l’iatrogenie medicamenteuse, notamment en reduisant le sur-traitement et les prescriptions potentiellement inappropriees. Des difficultes de continuite de la prise en charge des patients entre l’hopital et la ville ont ete identifiees.

Resume Malgre la diffusion du concept, des methodes, puis, l’inscription dans les textes qui fondent notre exercice professionnel, le developpement de la pharmacie clinique dans les differentes structures de soins en France ne s’est pas fait de maniere synchrone, selon le meme deploiement, la meme priorisation des activites, les memes moyens et la meme vitesse. Une raison est, sans doute, le temps incompressible qu’il faut pour que les mentalites evoluent, les pratiques s’installent sur le terrain et les experimentations prennent corps. A un moment donne de ce processus, le role d’une societe savante est de proposer une reflexion sur un modele de pratique permettant d’homogeneiser sur le territoire, l’offre de services cliniques de l’equipe pharmaceutique. Cet article a cette ambition. C’est le fruit d’un travail collectif de la Societe francaise de pharmacie clinique. Le modele propose comporte 3 types de prestations, s’inscrivant dans un contexte organisationnel impose (modele statique) et/ou une notion de parcours (modele dynamique) : 1. dispensation ; 2. bilan de medication ; 3. plan pharmaceutique personnalise. Cette version de modele est amenee a evoluer au gre du niveau de competences des pharmaciens, des experiences des equipes pharmaceutiques et du niveau d’integration de l’activite au sein des parcours de soins, tout ceci sous contraintes organisationnelles, reglementaires et financieres.

Resume Le vieillissement de la population est associee a une augmentation d’actes chirurgicaux et donc du nombre d’anesthesie generales et locoregionales. A ce titre, la fracture du col femoral concerne plus de 75 000 patients par an et constitue donc un enjeu de sante publique du fait d’une morbi-mortalite non negligeable. Les experts issus de quatre societes savantes, la SFAR, la SOFCOT, la SFGG et la SFPC ont redige 26 recommandations concernant la prise en charge perioperatoire du patient âge en s’interessant plus particulierement a la fracture de l’extremite superieure du femur. Une premiere partie concernait l’evaluation en preoperatoire du risque cardiovasculaire, des fonctions cognitives et de la fonction renale. Les auteurs ont recommande une prise en charge pluridisciplinaire et une gestion preoperatoire rationnelle des traitements afin de reduire le risque de confusion. Le delai d’intervention des FESF a ete fixe a 48 h et les modalites de monitorage precisees (monitorage hemodynamique, de la pression arterielle de l’oxygenation et de la temperature). Une technique d’anesthesie n’a pas ete privilegiee pour la chirurgie de la FESF mais une titration des agents anesthesiques a ete recommandee. Les experts ont egalement recommande la mise en place d’un programme de prevention non medicamenteuse de la confusion postoperatoire ainsi qu’une strategie de gestion des episodes confusionnels postoperatoires tels que l’usage d’une benzodiazepine a demi-vie courte ou d’un neuroleptique de derniere generation. Le bloc femoral ou iliofascial ont ete probablement recommandes en postoperatoire a la difference des infiltrations, peu contributives dans ce type de chirurgie.

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

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.

Summary 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 ± 13.7 years) 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.

Resume Objectifs Analyser les representations et les croyances des pharmaciens et preparateurs en officine vis-a-vis de la prise en soin de la depression chez les personnes âgees. Methodes Une etude qualitative a ete menee aupres de pharmaciens et preparateurs en officine. La premiere etape de l’etude a consiste au developpement du guide d’entretien permettant la conduite des entretiens semi-diriges. A partir des retranscriptions des entretiens enregistres en audio, une analyse thematique des verbatims recueillis a ete realisee. Resultats Huit pharmaciens et 5 preparateurs en officine ont ete inclus. Les principales thematiques identifiees etaient les suivantes : 1/la depression : les representations sociales de la depression et ses facteurs de risque chez la personne âgee ; la facon de parler de la depression au comptoir avec le patient ; 2/la prise en charge de la depression : la facon de parler du traitement antidepresseur au comptoir avec le patient, notamment la duree du traitement, la posologie, l’efficacite et les effets indesirables du traitement, mais egalement les therapeutiques alternatives et les conseils de vie ; 3/les freins et les leviers a l’adhesion medicamenteuse au traitement antidepresseur chez la personne âgee. Conclusions Des freins a la realisation d’un suivi pharmaceutique des patients âges atteints de depression ont ete identifies : stigmatisation de la maladie, confidentialite au comptoir, manque de communication avec le prescripteur, mais egalement un manque de connaissance. Ainsi, un renforcement de la formation initiale et continue concernant la posture a adopter aupres de ces patients et la prise en charge des maladies mentales serait benefique.

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.

BACKGROUND Anxiety symptoms frequently experienced by patients with a major neurocognitive disorder (NCD) are often treated with long-term benzodiazepines despite known adverse effects. Pregabalin has shown efficacy in generalized anxiety disorders but has not been studied in patients with a major NCD. The objective of this study was to describe the use of pregabalin for anxiety in patient with a major NCD and the impact of its use on the pharmacological treatment change. METHODS A retrospective study was conducted using data of hospitalized patients in a cognitive-behavioral specialized unit between January 2015 and December 2017. Patients with a major NCD treated by pregabalin were included in this study. Data about the use of pregabalin (initiation and effective dosage, titration duration) and the use of other psychotropics were collected from the patients' medical records. RESULTS Thirty-three patients were included (mean age, 79.6 ± 11.7 years; 66.7% women). The mean duration of pregabalin titration was 18.6 ± 1.4 days, and the mean effective dosage was 200.0 ± 130.8 mg/d (range, 50-700 mg/d). At admission (before pregabalin use), 78.8% of patients were treated with a systematic prescription of benzodiazepine. At discharge (with pregabalin use), a significant decrease in patients with systematic prescription of benzodiazepine was observed (78.8% vs 33.3%, P = 0.001). During hospitalizations, no pregabalin treatment has been discontinued for lack of efficacy or for tolerance. CONCLUSIONS Larger controlled studies are needed to confirm the efficacy and the safety of pregabalin to treat anxiety symptoms associated with neurocognitive disorders.

Background There are several assessment scales to evaluate the risk of falls or the adverse drug reaction risk. Few are sufficiently specific to assess the impact of drug prescriptions on falls in geriatric populations. Objective To define the risk of anticholinergic and sedation-related ADRs in an elderly hospitalized patient population using the Drug Burden Index (DBI), Anticholinergic Drug Scale (ADS), and Sedative Load Model (SLM). Setting Five geriatric university hospital centers in France. Method Multicenter prospective cohort study from 2011 to 2013. Drug prescriptions were compiled to estimate anticholinergic and sedative exposure. Any associations between the drug scales and falls were assessed. Main outcome measure Drug exposure estimated with the DBI, ADS, and SLM scales. Results 315 patients, with a mean age of 87 years and 117 documented falls, were included from 5 geriatric hospitals. Sixty-one percent of these patients had a DBI > 0, 20.3% had an ADS ≥ 3, 56.2% a SLM > 0. No association was detected between the scores and the risk of a fall (p > 0.05). Factors significantly associated with a risk of a fall were: a prior history of a fall in the previous 12 months (adjusted odds ratio [aOR] = 7.24, 4.06-12.89), orthostatic hypotension ([aOR] = 2.84; 1.39-5.79), or prescription of antidepressants ([aOR] = 2.12; 1.17-3.84). Conclusion A specific scale to identify high-risk prescriptions would help clinicians and pharmacists to optimize therapeutic treatments for the elderly. In light of the multifactorial characteristics of falls, predicting their risk should be based on a well-defined set of factors.

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

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

Resume Le bilan de medication est un entretien structure avec le patient, realise par le pharmacien en collaboration avec le medecin generaliste dans le but d’optimiser la prise en charge therapeutique. Plusieurs pays anglo-saxons l’ont inclus dans les missions du pharmacien d’officine. En France, les dernieres negociations conventionnelles avec l’Assurance maladie ont valide la remuneration de cet acte juge prioritaire pour les patients âges et polymediques.

Objective To investigate the association between the medication exposure, measured by the polypharmacy/excessive polypharmacy and the anticholinergic and/or sedative drug exposure, on frailty status among French older community-dwelling patients. Setting day-care unit in France (Lyon), with retrospective data from July, 2017 to March, 2018. Method This monocentric cross-sectional study included community-dwelling patients aged 65 years and over and admitted at the day-care unit for a geriatric evaluation. Frailty was assessed according to the frailty phenotype, described by Fried et al. Polypharmacy and excessive polypharmacy were defined as the concomitant use of 5–9 and 10 or more drugs, respectively. The cumulative anticholinergic and sedative exposure was measured using the drug burden index (DBI). The DBI score was presented in 4 differentiated scores: a null score (DBI = 0), a combined score (anticholinergic and sedative score), an anticholinergic score, and a sedative score. The association between medication and frailty was assessed by logistic regression models controlled for multiple potential confounders. Main outcome measure Association between medication exposure (polypharmacy, anticholinergic and sedative exposure) and frailty. Results In this study, 403 patients were included: 44.7% were frail and 40.7% were pre-frail. Polypharmacy and excessive polypharmacy affected 44.7% and 17.1% of the population respectively. The mean DBI was 0.33 ± 0.43, with 16.4% of patients with only sedative exposure, 9.7% with only anticholinergic exposure and 33.0% with both exposures. After adjustment, polypharmacy and excessive polypharmacy were associated with frailty with adjusted odds ratios (95% confidence interval) of 2.18 (1.03–4.22) and 2.72 (1.01–7.37) respectively. The cumulative exposure to anticholinergic and sedative drugs (combined score) was significantly associated to an increased risk for frailty with adjusted odds ratios (95% confidence interval) of 3.54 (1.47–8.57). Conclusion The study showed that polypharmacy and cumulative anticholinergic and sedative exposure are associated with frailty. Further research should address the potential benefit of collaborative medication review for preventing medication-associated frailty.

Many arguments support the development of pharmaceutical care in patients with neurocognitive disorders and their caregivers: polypharmacy, drug-related cognitive decline, poor drug adherence, increased use of psychotropic drugs and potentially inappropriate medications. The aim of this narrative review was to identify the pharmacist's roles in caring for patients with Alzheimer's disease and related disorders and their caregivers. Seventeen publications were selected after literature research. The various interventions conducted by pharmacists were as follows: achievement of a medication review that could be focused on the reduction of the anticholinergic burden or the number of psychotropic drugs, therapeutic education of the patient and his caregiver concerning the treatment management, personalized pharmaceutical follow-up, screening and orientation of patients with a cognitive impairment or caregivers with signs of fragility (burden, anxiety or depressive symptoms). The majority of studies targeted the patient care. Other interventional studies will be necessary to evaluate the impact of a pharmaceutical care for the dyad, including the caregiver, on the improvement of drug management but also on clinical outcomes, including the cognitive function, the autonomy, the use of the health care system, the quality of life and the self-efficacy.

Resume Objectifs Les complements nutritionnels oraux (CNO) occupent une place importante dans la prise en charge de la denutrition ou risque de denutrition chez la personne âgee. Nous avons effectue une evaluation des pratiques professionnelles concernant l’utilisation des CNO dans un hopital geriatrique. Methodes Pour chaque patient, plusieurs criteres etaient evalues : l’evaluation nutritionnelle avant prescription de CNO, la prescription et sa conformite par rapport a l’avis dieteticien, la delivrance du CNO ainsi que la surveillance et la reevaluation des CNO. Resultats Cinquante patients etaient inclus. L’evaluation nutritionnelle comprenait le poids actuel, l’indice de masse corporelle, la perte de poids, l’albuminemie, la prealbuminemie et l’evaluation des ingesta. Ces criteres etaient retrouves respectivement dans 100, 94, 78, 100, 96, 90 % des dossiers. La prescription etait conforme a l’avis dieteticien a 72 % tant sur le CNO prescrit que sur le nombre de prises. La tracabilite de l’observance et de la tolerance etait respectivement de 50 % et 38 %. La reevaluation, comprenant la mesure du poids et le dosage de la prealbumine hebdomadairement, etait realisee dans 12 et 0 % des cas. Conclusion L’evaluation nutritionnelle est optimale dans notre etablissement contrairement a la reevaluation des CNO. Cette etude met en exergue la necessite de promouvoir la tracabilite de l’observance et de la tolerance des CNO dans le dossier patient informatise mais aussi de favoriser l’evaluation de l’efficacite de la prise de CNO par la mesure du poids.

Informal caregivers of patients with a cognitive impairment may face exhaustion while taking care of their relatives, and are themselves at higher risk of disease. The objective was to assess the relationship between patients' comorbidities evaluated with the Charlson index, and the caregiver burden, independently of health disorders related to cognitive impairment.Cross-sectional observational study.Memory clinic at the University Hospital of Lyon.Outpatients with cognitive complaint and consulting a Clinical and Research Memory Centre of Lyon (n = 1300).Comorbidity was measured using the Charlson Comorbidity Index related to age (CCI). The caregiver burden was measured with the short version of the Zarit Burden Interview (ZBI). The relationship was assessed between the CCI and the mini-Zarit and other patients' characteristics: behavior, cognition, autonomy as assessed respectively by the Neuropsychiatric Inventory (NPI), Mini Mental State Examination (MMSE), Instrumental Activities of Daily Living (IADL), etiology, and stage of the cognitive impairment.The study included 1300 outpatients: mean age: 80.8 ± 7 years. The mean CCI was 4.8 ± 1.7. The mini-Zarit score: 3.1 ± 2.0. The caregiver burden increased by 0.22 per unit of CCI (95% confidence interval 0.15-0.28, P.001) in unadjusted analysis. The caregiver burden remained significantly associated with CCI, after adjustment for the MMSE, IADL, and NPI.The caregiver burden is higher when patients' comorbidities increase, independently of behavioral and psychological symptoms, level of functional autonomy, and the stage of the cognitive disease. However, dementia may be the comorbidity that contributes the most to caregiver burden.

International audience

Resume Introduction L’association d’un anticoagulant (ACO) et d’un antiagregant plaquettaire (AAP) est frequente chez la personne âgee (PA) polypathologique, notamment dans le cadre d’indications separees. Parallelement, l’âge, les comorbidites et la polymedication sont autant de facteurs de risque hemorragique. Des lors, quelle attitude adopter en pratique quotidienne ? L’objectif de cet article est de presenter et de discuter les resultats des etudes cliniques evaluant l’association ACO et APP chez la PA. Materiel et methode Une revue de la litterature, publiee entre 1990 et 2012, a ete effectuee. Resultat Aucune des etudes randomisees evaluant l’association chez la PA ne montre de diminution du risque thromboembolique comparee a une monotherapie par ACO ou AAP en cas de fibrillation auriculaire (FA). En prevention secondaire du syndrome coronarien aigu, le benefice reste a preciser. Seule l’etude s’interessant aux PA en FA ayant subi une intervention coronarienne percutanee a demontre une diminution de la mortalite et des evenements cardiaques graves. Conclusion Dans le cadre d’indications separees, aucune etude n’est actuellement disponible sur l’interet d’une telle association chez la PA. Pour autant, une evaluation individuelle et objective du rapport benefice–risque (sur la base d’outils specifiques) permettrait d’optimiser la prise en charge therapeutique de ces patients.

Resume En cas de difficultes pour avaler, l’ecrasement ou l’ouverture des medicaments est une pratique courante. Si l’administration necessite une modification de la forme galenique, il convient de (re)evaluer le traitement. La Societe francaise de pharmacie clinique a realise un guide informant sur la possibilite d’ecraser ou d’ouvrir un medicament a partir d’elements pharmacocinetiques et galeniques et/ou de proposer des alternatives.

Summary Background Recent literature reports of potential adverse effects (AEs) of proton pump inhibitors (PPIs), especially during long-term treatments. Purpose To present a literature review of major AEs: digestive infections, pneumonia, bone fracture, hypomagnesemia, interstitial nephritis, gastric cancer and neutropenia. Data sources The authors used Pubmed; articles in English or French, published between August 2006 and August 2011 were analyzed. Study selection Two reviewers analyzed the references of title and summary to retain mainly observational studies, controlled clinical trials, meta-analyzes, case reports. Results For digestive infections: observational studies have shown a link moderate to high (OR 1.4 to 8.3) with exposure to PPIs. For pneumonia: some case-control studies reported a modest significative risk (OR 1.2 to 1.6), some not. The risk appears dose dependent and greater in subjects at risk. For fractures: the majority of observational studies report a significative increase in low to moderate risk (OR 1.2 to 3.1), correlated with the dose and duration of treatment. For magnesium deficiency: rare but potentially severe, they are described in case reports. Interstitial nephritis are described in case reports and for different PPIs, suggesting a class effect. For the stomach neoplasm: if three observational studies show an increased cancer risk (OR 1.5 to 2, 3), confounding factors make the causal link uncertain. Neutropenia is reported in a clinical observation, a class effect is suggested. Limitations One can regret the absence of controlled clinical trials; indeed the observational studies have the interest to move closer to “real life”, but often have methodological bias. Conclusion Although AEs PPIs do not call into question the usefulness of this drug class, they show the need to limit their prescribing to indications for which efficacy has been proven. Moreover, PPIs treatment must be regularly reassessed to avoid exposing patients to unnecessary risks.

Introduction Alzheimer's Disease and Related Diseases (ADRD) are associated with a caregiver burden that increases with the progression of the disease. Psychosocial interventions reported a moderate improvement on caregivers' burden. Patients with ADRD and their older caregivers are also exposed to a higher risk of developing drug-related problems. The main objective of the PHARMAID study is to measure the impact of personalized pharmaceutical collaborative care integrated to a multidisciplinary psychosocial program on the burden of caregivers. Methods The PHARMAID study is a 18-month randomized controlled trial that started in September 2016. This paper describes the study protocol. PHARMAID plans to enroll 240 dyads, i.e. ADRD patients and caregivers, whose inclusion criteria are: outpatient with mild or major neurocognitive disorders due to ADRD, living at home, receiving support from a family caregiver. Three parallel groups will compare a control group with two experimental groups: psychosocial intervention and integrated pharmaceutical care at a psychosocial intervention. The main outcome is the caregiver's burden assessed by the Zarit Burden Index at 6, 12 and 18 months. Discussion This is the first trial designed to assess the specific impact of the integration of pharmaceutical care in a multidisciplinary psychosocial program on the caregiver's burden. The results will inform policymakers on strategies to implement in the near future. Trial Registration number: [ ClinicalTrials.gov : NCT02802371 ] Registered in June 2016.

Resume Introduction Le contenu de l’enseignement dispense au cours des etudes de pharmacie doit permettre l’utilisation pratique des connaissances acquises, dans un souci d’amelioration du soin medicamenteux. L’objectif de ce travail a ete de mettre en lumiere les lacunes que presentent les etudiants de la filiere officine debutant leur stage hospitalier de 5 e annee. Methode Quatorze etudiants en stage de 5 e annee accompli dans un CHU ont ete invites a mettre en lumiere ces lacunes au fur et a mesure de leur immersion dans le soin medicamenteux. Ils l’ont fait sous l’observation attentive des praticiens hospitaliers les encadrant. Ces praticiens se sont appuyes sur des referentiels metiers, des outils documentaires employes en routine clinique et des publications leur ayant servi a asseoir leurs pratiques de soins pharmaceutiques. Resultats Les insuffisances ou lacunes identifiees ont ete : la forme et le contenu de la communication avec d’autres professionnels de sante, la forme de la communication avec les patients, la faible appropriation des outils documentaires indispensables a une pratique clinique pertinente, la meconnaissance de la codification des interventions pharmaceutiques, les risques lies au conditionnement des medicaments et les avancees et dangers lies aux technologies de l’information. Discussion Ces lacunes constituent un handicap retardant le processus qui conduit a passer du stade d’etudiant au stade de professionnel de sante. Il revient aux praticiens hospitaliers la necessite de combler ces lacunes avant immersion totale en situation de soin. Conclusion Ces resultats invitent a reviser partiellement le contenu du programme d’enseignement dispense avant la 5 e annee.

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.

The identification of factors used to predict caregiver burden may help preventive care. This study aimed to assess the relationship between evolution of patients with subjective cognitive decline (SCD) or progressive neurocognitive disorder (NCD) and evolution of caregiver burden.Observational, longitudinal study.The study was conducted in the Clinical and Research Memory Center of the University Hospital of Lyon (France), between the November 1, 2011 and the June 30, 2014, with a maximum follow-up of 30 months.The study population included outpatients with SCD or NCD at all stages, and their informal caregiver.The caregiver burden was assessed during 2 visits of the patients and their caregiver, with the short version of the Zarit Burden Inventory (ZBI). Functional, cognitive performance, and behavioral and psychological symptoms were measured twice, concomitantly with the ZBI, using the Instrumental Activities of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE), and the Neuropsychiatric Inventory (NPI), respectively. Etiology and stage of the cognitive impairment were collected.The population study included 222 patients (mean age at inclusion: 80 years old, 62.9% females), with an average follow-up 12.6 ± 6 months. Proportion of patients with major NCD at the second visit (62.2%) increased compared with inclusion (50.0%). MMSE and IADL decreased between the 2 visits (P .001), whereas ZBI increased (mean ZBI: 3.2 ± 2 at baseline, mean ZBI: 3.8 ± 2 at follow-up, P .001). In unadjusted analyses, ZBI tended to be higher for patients whose MMSE decreased of at least 3 points between the visits. ZBI increased over time when IADL decreased (P value for within-patient effect.001), while it remained stable when the IADL increased. ZBI increased when NPI increased. After mutual adjustment for change of MMSE, IADL, NPI, and etiologies, increase of ZBI over time remained significant when MMSE decreased at least 3 points between baseline and follow-up, when IADL decreased, and when NPI increased of at least 4 points.In a study population of patients with SCD or NCD at all stages, concomitant decrease of cognitive performance, increase of functional impairment, and increase neuropsychiatric symptoms over time were independently associated with increased caregiver burden. The identification of risk factors associated with an increased caregiver burden over time may allow a better evaluation of the impact of specific interventions on cognitive, behavioral, and functional dimensions of NCD on caregivers.ClinicalTrials.govNCT02825732.

Resume Le syndrome confusionnel postoperatoire est une complication frequente, potentiellement grave, tout particulierement chez les personnes âgees. Sa survenue est associee a une augmentation de la mortalite, des complications postoperatoires et du risque de declin cognitif et/ou fonctionnel entrainant le placement en service de long sejour. Elle peut s’accompagner d’une hausse de la duree moyenne de sejour et des couts hospitaliers. Son diagnostic peut etre facilement realise au lit du malade grâce a la Confusion Assessment Method, outil diagnostique de reference. Il existe de nombreux facteurs favorisant et precipitant, surtout s’ils se combinent. A ce jour, il n’y a aucune preuve d’efficacite d’approches pharmacologiques dans la prevention du syndrome confusionnel. Cependant, differentes etudes ont montre un impact favorable d’interventions non pharmacologiques. Ces interventions incluent, entre autres, un programme d’education destine aux equipes medicales et soignantes et un protocole multidisciplinaire ciblant certains facteurs de risques. La prise en charge du syndrome confusionnel est une urgence comprenant la prise en charge etiologique et symptomatique. Le traitement vise avant tout les etiologies directes, les facteurs precipitant et secondairement les facteurs favorisant.

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.

BACKGROUND Caregivers play a major role in the care of patients with dementia and are themselves at higher risk of disease. OBJECTIVES We investigate which factors are associated with caregivers burden of outpatients visiting a memory clinic and how functional autonomy and behavioral and psychological symptoms can influence caregiver burden. METHODS The study population was chosen from outpatients with progressive cognitive complaint. The caregiver burden was measured with the short version of the Zarit Burden Interview (ZBI). The relationship was assessed between the ZBI and the patients characteristics, including Neuropsychiatric Inventory (NPI), Instrumental Activities of Daily Living scale (IADL), the Mini-Mental State Examination (MMSE), etiology, and stage of the cognitive impairment. RESULTS In a population of 548 patients, IADL, NPI, antidepressant drugs, and MMSE were found to be related to ZBI, while diagnosed etiology and disease stage were not significant: ZBI decreased by 0.34 point for every unit of IADL, and by 0.03 point for every unit of MMSE; ZBI increased by 0.03 point for every unit of NPI. From the IADL scale, the ability to handle finances, food preparation, responsibility to take medications, mode of transportation, and ability to use the telephone increased the ZBI. Five areas of the NPI increased the ZBI: apathy, agitation, aberrant motor behavior, appetite disorders (p < 0.001), and irritability (p = 0.03). CONCLUSION Caregivers experience a higher burden due to disease symptoms such as impairment of functional autonomy and behavioral and cognitive impairment, whatever the etiology of the cognitive decline.

This study aimed to assess whether exposure to anticholinergic and sedative medications and its evolution was associated with increased risk of in-hospital falls and all-cause mortality. Furthermore, results were compared with 2 definitions of drug burden index (DBI) against the outcomes.This observational, multicentric, and longitudinal study was conducted among patients aged 65 years or older, in 3 geriatric hospitals, in Francheville, Lyon, and Villeurbanne, France (duration of follow-up, 11.6 months). The exposure to anticholinergic and sedative medications was quantified using a DBI, at admission and at the end of observation for 337 patients. The evolution of exposure was the absolute difference between the index at admission and at the end of observation. The outcomes were in-hospital falls and all-cause mortality.Overall, 5.9% of patients experienced a fall. The risk of fall was nearly 3-fold in patients whose DBI increased during hospital stay compared to those with stable or decreased DBI (hazard ratio, 2.9 [1.14-7.12]; P = 0.03), after adjustment for comorbidities.The overall proportion of mortality was 6.5%. The evolution of DBI during hospital stay was not related to the risk of mortality (hazard ratio, 1.9 [0.8-4.4]; P = 0.14). Results were similar with the 2 definitions of DBI.Increased exposure to anticholinergic and sedative medications during hospital stay is associated with a higher risk of in-hospital falls but not with mortality. The DBI could be implemented in hospital, to guide prescription and reduce anticholinergic and sedative drug exposure.

Background and Purpose— Because acute ischemic strokes (ISs) are mainly hospitalized, hospital discharge data could be used to routinely follow their incidence management. We aimed to assess sensitivity and positive predictive value of the French hospital discharge database (HDD) to identify patients with acute IS using a prospective and exhaustive cohort (AVC69) of acute IS cases. Methods— A selection algorithm based on IS diagnosis coded with the International Classification of Diseases ( ICD-10 ) and cerebral imaging codes was used to identify all hospital stays with the primary diagnosis of IS in the HDD of the university hospitals of the Rhône area. Cases identified through HDD search were compared with IS cases identified through an exhaustive cohort study conducted in the Rhône district and confirmed on medical records review. Results— There were 465 confirmed cases of IS hospitalized in 1 of the 4 university hospitals during the study period. The HDD search identified 313 among those (true-positive cases) but missed 152 cases (false-negative cases). The sensitivity of the HDD search was 67.3% (95% confidence interval, 63.1–71.5), and the positive predictive value was 95.1% (95% confidence interval, 92.8–97.4). Additionally, HDD search retrieved 16 cases, which were not eventually IS (false positives). Sensitivity was better when patients were hospitalized in neurological departments. Conclusions— The lack of sensitivity to identify acute IS patients through HDD search does not seem to be accurate enough to validate the use of these data for incidence estimates. Efforts have to be made to improve the coding quality.

Recent literature reports of potential adverse effects (AEs) of proton pump inhibitors (PPIs), especially during long-term treatments.To present a literature review of major AEs: digestive infections, pneumonia, bone fracture, hypomagnesemia, interstitial nephritis, gastric cancer and neutropenia.The authors used Pubmed; articles in English or French, published between August 2006 and August 2011 were analyzed.Two reviewers analyzed the references of title and summary to retain mainly observational studies, controlled clinical trials, meta-analyzes, case reports.For digestive infections: observational studies have shown a link moderate to high (OR 1.4 to 8.3) with exposure to PPIs. For pneumonia: some case-control studies reported a modest significative risk (OR 1.2 to 1.6), some not. The risk appears dose dependent and greater in subjects at risk. For fractures: the majority of observational studies report a significative increase in low to moderate risk (OR 1.2 to 3.1), correlated with the dose and duration of treatment. For magnesium deficiency: rare but potentially severe, they are described in case reports. Interstitial nephritis are described in case reports and for different PPIs, suggesting a class effect. For the stomach neoplasm: if three observational studies show an increased cancer risk (OR 1.5 to 2, 3), confounding factors make the causal link uncertain. Neutropenia is reported in a clinical observation, a class effect is suggested.One can regret the absence of controlled clinical trials; indeed the observational studies have the interest to move closer to "real life", but often have methodological bias.Although AEs PPIs do not call into question the usefulness of this drug class, they show the need to limit their prescribing to indications for which efficacy has been proven. Moreover, PPIs treatment must be regularly reassessed to avoid exposing patients to unnecessary risks.