Philippe Cestac

Antihypertensive drugs, prevention of cognitive decline and dementia: A systematic review of observational studies, randomized controlled trials and meta-analyses with discussion of potential mechanisms

BackgroundChronic hypertension, particularly midlife high blood pressure, has been associated with an increased risk for cognitive decline and dementia. In this context, antihypertensive drugs might have a preventive effect, but the association remains poorly understood.ObjectivesThe aim of this systematic review was to examine all published findings that investigated this relationship and discuss the mechanisms underlying the potential benefits of antihypertensive medication use.MethodsA literature search was conducted using MEDLINE, Embase, and the Cochrane Library for publications from 1990 onwards mentioning hypertension, antihypertensive drugs, cognitive decline, and dementia.ResultsA total of 38 relevant publications, corresponding to 18 longitudinal studies, 11 randomized controlled trials, and nine meta-analyses were identified from the 10,251 articles retrieved in the literature search. In total, 1,346,176 subjects were included in these studies; the average age was 74xa0years. In the seven longitudinal studies assessing the effect of antihypertensive medication on cognitive impairment or cognitive decline, antihypertensive drugs appeared to be beneficial. Of the 11 longitudinal studies that assessed the effect of antihypertensive medication on incidence of dementia, only three did not find a significant protective effect. Antihypertensive medication could decrease the risk of not only vascular dementia but also Alzheimer’s disease. Four randomized controlled trials showed a potentially preventive effect of antihypertensive drugs on the incidence of dementia or cognitive decline: SYST-EUR (Systolic Hypertension in Europe Study) I and II, with a 55xa0% reduction in dementia risk (3.3 vs. 7.4 cases per 1,000 patient years; pxa0<xa00.001); HOPE (Heart Outcomes Prevention Evaluation), with a 41xa0% reduction in cognitive decline associated with stroke (95xa0% confidence interval [CI] 6–63); and PROGRESS (Perindopril Protection against Recurrent Stroke Study), with a 19xa0% reduction in cognitive decline (95xa0% CI 4–32; pxa0=xa00.01). Meta-analyses have sometimes produced conflicting results, but this may be due to methodological considerations. The lack of homogeneity across study designs, patient populations, exposition, outcomes, and duration of follow-up are the most important methodological limitations that might explain the discrepancies between some of these studies.ConclusionAntihypertensive drugs, particularly calcium channel blockers and renin–angiotensin system blockers, may be beneficial in preventing cognitive decline and dementia. However, further randomized controlled trials with longer periods of follow-up and cognition as the primary outcome are needed to confirm these findings.

Potentially inappropriate drug prescribing and associated factors in nursing homes.

IMPORTANCEnPolymedication is frequent in nursing home (NH) residents. This increases the risk of potentially inappropriate drug prescribing (PIDP), which can lead to adverse drug events, such as falls and hospitalization.nnnOBJECTIVEnTo identify PIDP in NH residents and to investigate subject-related and NH structural and organizational factors associated with PIDP.nnnDESIGNnCross-sectional study.nnnSETTINGnA total of 175 NHs in Midi-Pyrénées region, South-Western France.nnnPARTICIPANTSnA total of 974 subjects randomly selected from the 6275 NH residents participating in the IQUARE study.nnnEXPOSUREnPatients with PIDP.nnnMAIN OUTCOMES AND MEASURESnPIDP was the main outcome measure. It was defined using a specific indicator, based on the Summary of Product Characteristics, on the Laroche list, and on residents clinical data. PIDP was defined as the presence of at least 1 of the following criteria: (1) drug with an unfavorable benefit-to-risk ratio; (2) drug with questionable efficacy according to the Laroche list; (3) absolute contraindication; (4) significant drug-drug interaction. Associated factors were identified by using multivariable logistic regression models.nnnRESULTSnAmong the 974 residents included, 71% had PIDP. PIDP was more frequent in patients without dementia, with several comorbidities and taking multiple medications. In the multivariable analysis, age (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.01-1.03) and Charlson Comorbidity Index (CCI; P = .003, CCI = 1 versus 0: OR1/0 1.22; 95% CI 0.85-1.74, CCI ≥ 2 versus 0: OR2/0 1.72; 95% CI 1.23-2.41) were associated with an increased likelihood of PIDP. By contrast, dementia was associated with a lower likelihood of PIDP (OR 0.70; 95% CI 0.53-0.94). Among NH structural and organizational characteristics, the access to psychiatric advice and/or to hospitalization in a psychiatric unit (OR 1.36; 95% CI 1.02-1.82) and the presence of a reevaluation of drug prescriptions (OR 1.45; 95% CI 1.07-1.96) were associated with an increased likelihood of PIDP.nnnCONCLUSIONS AND RELEVANCEnOur work suggests that some NH characteristics are associated with an increased likelihood of PIDP. Gaining a better understanding of the factors influencing PIDP, especially structural and organizational NH factors, can help to determine the interventions that should be implemented.

Detecting Frailty in Primary Care: A Major Challenge for Primary Care Physicians

Many previously considered chronic diseases (eg, impaired vision,hip or knee arthritis) can today be efficiently treated and solved. Atthe same time, because of the aging population, the prevalence ofchronic conditions (eg, Alzheimer disease or cardiovascular diseases)is also increasing.Older people are the most clinically heterogeneous subpopulationcompared with any other age group. Although many elders are stillrobust even at advanced age, others experience multimorbidity,frailty, and disability, with consequent reduction of life expectancyand quality of life.Although the definition of frailty is largely debated,

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.

Effects of a geriatric intervention aiming to improve quality care in nursing homes on benzodiazepine use and discontinuation

BACKGROUNDnBenzodiazepines and Z drugs are often prescribed in residents of nursing homes (NH) despite their well-known deleterious effects. We aimed to investigate if a general intervention on quality of care led to discontinuation of benzodiazepine, and to examine which NH-related factors were associated in change of benzodiazepines use.nnnMETHODSnIQUARE is a quasi-experimental study, investigating the impact of an intervention based on a geriatric education with NH staff on several quality indicators of care (including appropriate prescriptions). All participating NH received an initial and 18-month audit regarding drug prescriptions and other quality of care variables. The analysis included 3973 residents, 2151 subjects (mean age: 84.6u2009±u20098.5u2009years; 74.3% women) in the control group and 1822 (mean age: 85.5u2009±u20098.1u2009years; 77.4% women) in the intervention group. Outcomes at 18u2009months were benzodiazepines use, long-acting benzodiazepines use, new-use of benzodiazepines, and discontinuation. The effect of the intervention was investigated using mixed-effect logistic regression models, including NH variables and residents health status as confounders.nnnRESULTSnHigher reductions in benzodiazepine use (-2.8% vs. -1.5%) and long-acting benzodiazepine (-3.7% vs. -3.5%) were observed in intervention group, but not statistically significant. None of the structural and organisational NH-related variables predicted either discontinuation or new-use of benzodiazepines; hospitalisations and initial use of meprobamate increased the likelihood of becoming a new-user of benzodiazepines. Multivariate analysis suggested that living in a particular NH could affect benzodiazepines discontinuation.nnnCONCLUSIONSnA general intervention designed to improve overall NH quality indicators did not succeed in reducing benzodiazepines use. External factors interfered with the intervention. Further studies are needed to examine which NH-related aspects could impact benzodiazepines discontinuation.

Hospitalization Drug Regimen Changes in Geriatric Patients and Adherence to Modifications by General Practitioners in Primary Care

ObjectivesTo evaluate the overall rate of adherence by general practitioners (GPs) to treatment modifications suggested at discharge from hospital and to assess the way communication between secondary and primary care could be improved.DesignObservational prospective cohort study.SettingPatients hospitalized from the emergency department to the acute geriatric care unit of a university hospital.Participants206 subjects with a mean age of 85 years.MeasurementsChanges in drug regimen undertaken during hospitalization were collected with the associated justifications. Adherence at one month by GPs to treatment modifications was assessed as well as modifications implemented in primary care with their rationale in case of non-adherence. Community pharmacists’ and GPs’ opinions about quality of communication and information transfer at hospital-general practice interface were investigated.Results5.5 ± 2.8 drug regimen changes were done per patient during hospitalization. The rate of adherence by GPs to treatment modifications suggested at discharge from hospital was 83%. In most cases, non-adherence by GPs to treatment modifications done during hospitalization was due to dosage adjustments, symptoms resolution but also worsening of symptoms. The last of which was particularly true for psychotropic drugs. All GPs received their patients’ discharge letters but the timely dissemination still needs to be improved. Only 6.6% of community pharmacists were informed of treatment modifications done during their patients’ hospitalization.ConclusionOur findings showed a successful rate of adherence by GPs to treatment modifications suggested at discharge from hospital, due to the fact that optimization was done in a collaborative way between geriatricians and hospital pharmacists and that justifications for drug regimen changes were systematically provided in discharge letters. Communication processes at the interface between secondary and primary care, particularly with community pharmacists, must be strengthened to improve seamless care.

The Effect of Exercise and Social Activity Interventions on Nutritional Status in Older Adults with Dementia Living in Nursing Homes: A Randomised Controlled Trial

ObjectivesExamine the effects of a 24-week exercise intervention against a social intervention on body weight, body mass index (BMI) and nutritional status in PWD living in nursing homes.DesignRandomized controlled trial.ParticipantsNinety-one older people with dementia living in nursing homes. Interventions: Exercise (n=44) or social-based activities (n=47), taking place twice per week, for 60 minutes/session, during 24 weeks.MeasurementsNutritional status was measured with the mini-nutritional assessment (MNA), weight and BMI.ResultsAfter the 24-week intervention, none of MNA (B-coeff. 1.28; 95% CI -2.55 to 0.02), weight (-0.06; -1.58 to 1.45) and BMI (-0.05; -0.85 to 0.74) differed significantly between groups after adjustment for multiplicity. In the social group, MNA significantly improved while it remained stable in the exercise group. The percentage of at-risk and malnourished patients reduced in both groups by more than 6%.ConclusionThe results suggest that social activities have as good effects as exercise activities on nutritional status in PWD nursing home residents.

Reducing potentially inappropriate drug prescribing in nursing home residents: effectiveness of a geriatric intervention

Potentially inappropriate drug prescribing (PIDP) is frequent in nursing home (NH) residents. We aimed to investigate whether a geriatric intervention on quality of care reduced PIDP.

Effect of Exercise on Behavioral Symptoms and Pain in Patients With Dementia Living in Nursing Homes

Objectives: Examine the effects of a 6-month exercise intervention on neuropsychiatric symptoms, pain, and medication consumption in older people with dementia (PWD) living in nursing homes (NH). Methods: Ninety-one older PWD living in NH performed a 6-month structured exercise intervention (n = 44) or a social activity intervention (n = 47). Neuropsychiatric symptoms were measured by the neuropsychiatric inventory (NPI), pain was assessed using the Algoplus scale, and dementia-related drug prescriptions were obtained for all participants. Results: Between-group analysis found a nonsignificant difference that could be of clinical relevance: a 4-point difference in the NPI and 1.3-point difference in the reduction of the number of medications favoring exercisers. No significant differences were found for pain, and a trend was found for an increase in medication consumption in the social group. Conclusion: Exercise effects did not differ from social intervention effects on neuropsychiatric symptoms, pain, and medication consumption in older PWD living in NH.

CP-219 Assessment of the appropriateness of prescriptions of clotting factors complex (OCTAPLEX) and fibrinogen (CLOTTAFACT) in a university hospital

Background In 2015, Octaplex and Clottafact were identified among the most prescribed medications with a high financial impact in the university hospital. Expenses for those drugs increased respectively by 10% (+€23 900) and 14% (+€239 300) in 2015. Purpose The aim of the study was to evaluate the appropriateness of Octaplex and Clottafact prescriptions to see if this increase was justified. Material and methods We audited the prescriptions made in the first quarter of 2016 with a set of criteria based on these medications’ indications. Those criteria were divided in 3 groups: conformity of the prescription with regulatory demands (group 1), for example (IE) was there a computerised traceability of the medication’s prescription? Relevance of the prescription regarding patient biological (group 2) and clinical (group 3) data. We assigned a score for each criterion, weighted to reflect its importance. The sum of scores then gave each prescription a letter, characterising their appropriateness. The letters were: A=appropriate, B=intermediately appropriate and C=inappropriate. This method was approved by physicians and pharmacists, and members of the commission for medicines of the hospital. Results 16% (44/272) of prescriptions were audited: 28% (14/111) were for Octaplex and 19% (30/161) for Clottafact. Group 1: 50% of prescriptions were classified as A (22/44), 36% (16/44) were B and 14% (6/44) were C. only 34% (15/44) were computerised. Group 2: 54% were classified as A (24/44), 41% (18/44) were B and 5% (2/44) were C. For 37% (11/30) of fibrinogen prescriptions, there was no hypofibrinogenaemia. Group 3: 75% (33/44) were classified as A, 20% (9/44) were B and 5% (2/44) were C (for those 2 prescriptions, there was no mention of bleeding or blood transfusion in the patients’ records). Conclusion 25% (11/44) of the prescriptions were appropriate, 72% (32/44) were intermediately appropriate and 3% (1/44) seemed inappropriate. This is acceptable considering that these medications are usually administered in emergencies, when staff have to think and act fast. These results have been presented to the prescribers with a reminder of those medicines with indications of a ‘last resort’ character. This type of audit will be renewed periodically, the set of criteria being adaptable to any medication. No conflict of interest