Antoine Piau

Impact of Polypharmacy on Occurrence of Delirium in Elderly Emergency Patients

OBJECTIVE To examine associations between polypharmacy and delirium diagnosed in elderly patients hospitalized in geriatric acute care unit after emergency hospital admission. METHODS Study design was an observational cohort study in the acute geriatric care unit of a university hospital. We included 410 consecutive patients admitted to the acute geriatric ward during 9 months. Within 72 hours of each patients hospitalization, a clinically trained geriatrician collected the following data: sociodemographic details (age, sex, type of residence), predisposing factors for delirium, main cause of hospitalization, and current medications. Polypharmacy was defined as 6 or more drugs a day. Delirium was assessed by a geriatrician using the Confusion Assessment Method and was diagnosed on the basis of clinical history with an acute change in usual functional status, behavioral observation, and clinical and cognitive assessment. RESULTS Nearly 25% of hospitalized patients had delirium. The Confusion Assessment Method was positive in 69% of patients receiving polypharmacy and in 30% of those not receiving polypharmacy, a relative risk of 2.33. The proportion of elderly patients receiving polypharmacy was 58.53%. CONCLUSIONS In our study, polypharmacy is an independent risk factor for delirium in a population of elderly patients after emergency admission. In the geriatric population, delirium is an underestimated scourge and because of its medicosocial and economic consequences and its impact on morbidity and mortality, we need to give increased attention to the prevention and control of polypharmacy, which is a predisposing factor for delirium.

Managing Cognitive Dysfunction through the Continuum of Alzheimer's Disease Role of Pharmacotherapy

It has been shown that, during several years preceding the diagnosis of Alzheimer’s disease there is a gradual cognitive decline with a continuum between the pre-dementia stage (still known as the prodromal stage but now included within the general concept of mild cognitive impairment [MCI]) and the other stages of the disease. In MCI, the use of cholinesterase inhibitors (ChEIs) is not associated with any delay in the onset of Alzheimer’s disease or dementia.During the dementia stages, the three ChEIs (donepezil, galantamine and rivastigmine) are efficacious for mild to moderate Alzheimer’s disease; therefore, monotherapy with a ChEI can be envisaged as initial treatment. Confirmation of the efficacy of ChEIs in the mild dementia stage is essentially based on the results from a single, randomized study carried out specifically among patients at this stage of severity. Memantine can represent an alternative to ChEIs in the moderate stage of Alzheimer’s disease. At the severe stage of the disease, memantine and donepezil are currently indicated. Indeed, memantine has been approved by numerous drug regulatory agencies for use in severe stages of the disease, whereas donepezil has only been approved by the US FDA. There is currently insufficient evidence for recommending combination therapy in Alzheimer’s disease.

Potentially inappropriate prescribing in a population of frail elderly people

Background Frailty is a clinical syndrome highly predictive of functional decline after a stress or a medical event, such as adverse drug events. Objective To describe the prevalence of potentially inappropriate prescribing in a population of frail elderly patients. Setting Geriatric day hospital for assessment of frailty and prevention of disability, Toulouse, France. Method A cross-sectional study performed from January to April 2014. Two pharmacists retrospectively analyzed the prescriptions of elderly patients who were sent to the day hospital to assess their frailty and to be given a personalized plan of care and prevention. Potentially inappropriate prescribing was defined by combining explicit criteria: Laroche list, screening tool of older people’s prescriptions, and screening tool to alert to right treatment with an implicit method (drug utilization review for each medication). Prescriptions’ optimizations were then suggested to the geriatricians of the day hospital and classified according to criteria defined by the French Society of Clinical Pharmacy. Main outcome measure Prevalence of potentially inappropriate prescribing. Results Among the 229 patients included, 71.2% had potentially inappropriate prescribing. 76 patients (33.2%) had at least one drug without any valid indication. 51 (22.3%) had at least one drug with an unfavorable benefit-to-risk ratio according to their clinical and biological data, 42 (18.3%) according to the Laroche list and 38 (16.6%) had at least one drug with questionable efficacy. Conclusion Our work shows that the incidence of PIP is high in the frail elderly and that, in most cases, it could be avoided with an adequate and regular reassessment of the prescriptions. In future, prescription optimization will be integrated into the personalized medical care plan to further prevent drug-related disability.

Telemedicine for the management of neuropsychiatric symptoms in long-term care facilities: the DETECT study, methods of a cluster randomised controlled trial to assess feasibility

Introduction Neuropsychiatric symptoms (NPSs) in elderly patients with dementia are frequent in long-term care facilities (LTCFs) and are associated with adverse events. Telemedicine is an emerging way to provide consultation and care to dependent LTCF residents who may not have easy access to specialty services. Several studies have evaluated telemedicine for dementia care but to date, no study has evaluated its impact in the management of NPS in patients with dementia living in LTCF. Methods and analysis The Dementia in long-term care facilities: Telemedicine for the management of neuropsychiatric symptoms (DETECT) study is a 24-month multicentre prospective cluster randomised controlled study with two arms: a control arm (usual care) and an intervention arm (telemedicine consultation) for NPSs management. DETECT enrolled 20 LTCFs. The primary outcome is based on the acceptability of the telemedicine among the LTCF staff which will be assessed in the intervention group by quantitative and qualitative indicators. The rate of unscheduled hospitalisations and/or consultations due to disruptive NPSs, psychotropic drug use and health costs will be described in both groups. Approximately, 200 patients are expected to be recruited. Ethics and dissemination The study protocol was approved and sponsored by the French Ministry of Health. The study received ethical approval from the Toulouse University Hospital Institutional Review Board. We will communicate the final results to the public via conferences and results will also be submitted for publication in international peer-reviewed scientific journals. Trial registration number NCT02472015.

A Smart Insole to Promote Healthy Aging for Frail Elderly Individuals: Specifications, Design, and Preliminary Results

Background Older individuals frequently experience reversible “frailty syndrome,”, increasing incidence of disability. Although physical exercise interventions may delay functional decline, there are difficulties in implementing them and performing seamless follow-up at home. Very few technological solutions attempt to address this challenge and improve individual participation. Objective Our objectives are to (1) develop a technological solution designed to support active aging of frail older persons, (2) conduct a first laboratory evaluation of the device, and (3) design a multidimensional clinical trial to validate our solution. Methods We conducted a first phase of multidisciplinary meetings to identify real end users and health professional’s unmet needs, and to produce specifications for the architecture of the solution. In a second phase, we performed laboratory tests of the first proposed prototype (a smart insole) with 3 healthy volunteers. We then designed an ongoing clinical trial to finalize the multidimensional evaluation and improvement of the solution. Results To respond to the needs expressed by the stakeholders (frailty monitoring and adherence improvement), we developed a prototype of smart shoe insole to monitor key parameters of frailty during daily life and promote walking. It is a noninvasive wireless insole, which automatically measures gait parameters and transmits information to a remote terminal via a secure Internet connection. To ensure the solution’s autonomy and transparency, we developed an original energy harvesting system, which transforms mechanical energy produced by the user’s walking movement into electrical energy. The first laboratory tests of this technological solution showed good reliability measures and also a good acceptability for the users. We have planned an original iterative medical research protocol to validate our solution in real life. Conclusions Our smart insole could support preventive strategies against disability in primary care by empowering the older patients without increasing the busy health professional’s workload. Trial Registration Clinicaltrials.gov NCT02316600; https://clinicaltrials.gov/ct2/results?term=NCT02316600&Search=Search. Accessed: 2015-05-13 . (Archived by WebCite at http://www.webcitation.org/6YUTkObrQ).

Optimization of drug therapy in elderly individuals admitted to a geriatric unit

Background A substantial share of adverse drug events involves inappropriate prescribing (IP). Specialized geriatric units are supposed to pay particular attention to prescribing appropriateness and to promoting a higher prescribing quality. Objective The objective of this study was to evaluate the reality of such assessment and optimization in real life (usual care) in a population of elderly individuals admitted to a geriatric unit. Method This is an observational study including all older patients admitted to an acute geriatric unit over a 6-month period. As part of usual care, the geriatrician is supposed to detect potentially inappropriate medication and potential prescribing omission using validated tools. The primary outcome was the prevalence rate of therapeutic modifications motivated by treatment optimization (stop, switch, or introduction). Multivariate logistic regression analyses were performed to identify the factors associated with therapeutic discontinuation. Results A total of 216 patients were included. The mean age was 85.7 years. Included patients had an average of 7.2±3.3 drugs at admission and 5.8±2.7 at discharge. IP was highly prevalent in our study where about 63% of the patients had experienced at least one modification because of overuse. The most commonly discontinued medications were drugs used to treat gastroesophageal reflux disease and peptic ulcer disease and serotonin reuptake inhibitor antidepressants. The most commonly introduced medications were analgesics and warfarin. By using multivariate analysis, we found that patient age and number of drugs on admission were significantly associated with medication discontinuation during hospital stay. Conclusion In this real-life study of all patients admitted to a Geriatric Post Emergency Unit, 83% of the patients had a treatment modification during hospital stay. The most original result of our study is the clear reduction in polypharmacy during hospitalization.

Thérapeutiques en regard des anomalies physiopathologiques de la maladie d’Alzheimer

La maladie d’Alzheimer (MA) est une pathologie neurodéénérative dans laquelle il existe une aggravation progressive es capacités cognitives et fonctionnelles en l’absence de traiteent. Actuellement, deux types d’interventions médicamenteuses ont distinguées. Les premiers essais thérapeutiques dans la MA isaient à évaluer des traitements symptomatiques, ils n’avaient as pour but de modifier l’évolution de la maladie mais plutôt e compenser la déplétion en neurotransmetteurs observée dans ette maladie. Nous disposons donc pour le moment des théapies médicamenteuses symptomatiques. Cependant, plusieurs pproches pharmacologiques disease modifying, visant à ralentir ’évolution de la maladie, basées le plus souvent sur la modulation e la production du peptide amyloïde et de sa dégradation, sur sa olymérisation ainsi que sur l’immunothérapie (active et passive) ont aujourd’hui à l’étude.