Nicole Barbara Vogt-ferrier

Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities

OBJECTIVE the study aimed to determine the prevalence of and risk factors for inappropriate prescribing (IP) and prescribing omission (PO) in elderly with mental co-morbidities. PARTICIPANTS One hundred fifty consecutive inpatients with mental co-morbidities hospitalised for acute medical illness (mean age 80 +/- 9, 70% of women) were considered for the study. MEASUREMENTS IP and PO were prospectively identified according to STOPP/START criteria at hospital admission. RESULTS over 95% were taking >or=1 medication (median = 7) which amounted to 1,137 prescriptions. The prevalence of IP was 77% and PO was 65%. The most frequent encountered IP concerned drugs adversely affecting fallers (25%) and antiaggregants therapy without atherosclerosis (14%). PO concerned antidepressants with moderate/severe depression (20%) and calcium-vitamin D supplementation (18%). Independent predictors for IP were increased number of concomitant drugs (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.13-1.89), being cognitively impaired (OR 1.83, 95% CI 1.55-2.24), and having fallen in the preceding 3 months (OR 2.03, 95% CI 1.52-2.61) or hospitalised in the preceding year (OR 1.09, 95% CI 1.02-1.23). Concerning PO, psychiatric disorder (OR 1.64, 95% CI 1.42-2.01) and increase level of co-morbidities (OR 1.79, 95% CI 1.48-1.99) were identified. Living in an institutional setting was a predictive maker for both IP (OR 1.45, 95% CI 1.27-1.74) and PO (OR 1.67, 95% CI 1.32-1.91). CONCLUSION IP and PO were highly prevalent raising the need of a greater health literacy concerning geriatric conditions in non-geriatrician practitioners who care elderly as well as in the community, in hospital and institutional settings for improving quality and safety in prescribing medication.

Use of Transdermal Drug Formulations in the Elderly

Transdermal drug delivery systems are pharmaceutical forms designed to administer a drug through the skin to obtain a systemic effect. They ensure a constant rate of drug administration and a prolonged action. Several different types of transdermal delivery devices are available on the market. They are either matrix or reservoir systems and their main current uses are to treat neurological disorders, pain and coronary artery disease, and as hormone replacement therapy.Transdermal drug administration has a number of advantages compared with the oral route: it avoids gastrointestinal absorption and hepatic first-pass metabolism, minimizes adverse effects arising from peak plasma drug concentrations and improves patient compliance. Compared with the parenteral route, transdermal administration entails no risk of infection. For elderly people, who are often polymedicated, transdermal drug delivery can be a good alternative route of administration.Transdermal absorption depends on passive diffusion through the different layers of the skin. As skin undergoes many structural and functional changes with increasing age, it would be useful to know whether these alterations affect the transdermal diffusion of drugs. Studies have shown that age-related changes in hydration and lipidic structure result in an increased barrier function of the stratum corneum only for relatively hydrophilic compounds. In practice, no significant differences in absorption of drugs from transdermal delivery systems have been demonstrated between young and old individuals. The need for dose adaptation in elderly patients using transdermal drug delivery systems is therefore not related to differences in skin absorption but rather to age-related cardiovascular, cerebral, hepatic and/or renal compromise, and to ensuing geriatric pharmacokinetic and pharmacodynamic changes.

Interdisciplinary Geriatric and Psychiatric Care Reduces Potentially Inappropriate Prescribing in the Hospital: Interventional Study in 150 Acutely Ill Elderly Patients with Mental and Somatic Comorbid Conditions

BACKGROUND Potentially inappropriate medications and prescription omissions (PO) are highly prevalent in older patients with mental comorbidities. OBJECTIVE To evaluate the effect of interdisciplinary geriatric and psychiatric care on the appropriateness of prescribing. DESIGN Prospective and interventional study. SETTING Medical-psychiatric unit in an academic geriatric department. PARTICIPANTS Participants were 150 consecutive acutely ill patients aged on average 80.0 ± 8.1 years suffering from mental comorbidities and hospitalized for any acute somatic condition. INTERVENTION From admission to discharge, daily collaboration provided by senior geriatrician and psychiatrist working in a usual geriatric interdisciplinary care team. MEASUREMENTS Potentially inappropriate medications and PO were detected and recorded by a trained independent investigator using STOPP/START criteria at admission and discharge. RESULTS Compared with admission, the intervention reduced the total number of medications prescribed at discharge from 1347 to 790 (P < .0001) and incidence rates for potentially inappropriate medications and PO reduced from 77% to 19% (P < .0001) and from 65% to 11% (P < .0001), respectively. Independent predictive factors for PIP at discharge were being a faller (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.43-2.09) and for PO, the increased number of medications (OR 1.54; 95% CI 1.13-1.89) and a Charlson comorbidity index greater than 2 (OR 1.85; 95% CI 1.38 - 2.13). Dementia and/or presence of psychiatric comorbidities were predictive factors for both potentially inappropriate medications and PO at discharge. CONCLUSION These findings hold substantial promise for the prevention of IP and OP in such a comorbid and polymedicated population. Further evaluations are, however, still needed to determine if such an intervention reduces potentially inappropriate prescribing medication-related outcomes, such as incidence of adverse drug events, rehospitalization, or mortality.

Syndrome sérotoninergique consécutif à l'association d'escitalopram et de cyclosporine chez une patiente de 84 ans

Due to the stimulation of central and peripheral 5-hydroxytryptamine receptors, the serotonin syndrome is a potentially lethal situation. The large variety of its clinical manifestations leads to a difficult diagnosis. We describe the case of a serotonin syndrome induced by the combined escitalopram and cyclosporine administration. An 84-year-old woman was hospitalized with a history of delirium associated with hyperthermia. The diagnosis of serotonin syndrome was suspected with the combination of the clinical features: the absence of infection, the selective serotonin reuptake inhibitor administration, and the absence of other metabolic and cerebral aetiology. After the discontinuation of escitalopram, the patients condition improved rapidly. This report is a reminder of the clinical and pharmacological features of the serotonin syndrome from a recent literature review.

Breakthrough Pain in Elderly Patients with Cancer: Treatment Options

The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda.