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What Is the Medication Iatrogenic Risk in Elderly Outpatients for Chronic Pain?

PURPOSE

Medication iatrogeny is a major public health problem that increases as the population ages. Therapeutic escalation to control pain and associated disorders could increase polypharmacy and iatrogeny. This study aimed to characterize the medication iatrogenic risk of elderly outpatients with chronic pain.

METHODS

This was a prospective cohort study recruiting patients 65 years or older with chronic pain. A medication iatrogenic assessment was performed based on the best possible medication history to record risk of adverse drug events (Trivalle score), STOPP (Screening Tool of Older Person's Prescriptions)/START (Screening Tool to Alert doctors to Right Treatment) criteria, and potentially inappropriate medications.

RESULTS

We recruited 100 patients with an average age of 71 years. The median number of medications before pain consultation was 8 (interquartile range = [7;11]). Trivalle score showed that 43% of patients were at moderate or high medication iatrogenic risk. Before consultation, 79% and 75% of patients had at least 1 STOPP or START criterion on their orders, respectively. One-third of orders mentioned benzodiazepine prescribed for more than 4 weeks. At least 1 potentially inappropriate medication was prescribed for 54% of the patients, with a median of 1 per patient (interquartile range = [0;1]). A combination of several anticholinergics was prescribed in 23% of patients.

CONCLUSION

Elderly patients with chronic pain are at risk of medication iatrogeny. Preventive measures as multidisciplinary medication review could reduce the iatrogenic risk in these outpatients.This study is registered at clinicaltrials.gov as NCT04006444 on July 3, 2019.

Post-traumatic stress disorder mistaken for behavioural and psychological symptoms of dementia: case series and recommendations of care

In late life, traumas may act cumulatively to exacerbate vulnerability to post-traumatic stress disorder (PTSD). PTSD is also a risk factor for cognitive decline. Major neurocognitive disorder (MND) can be associated with worsening of already controlled PTSD symptoms, late-life resurgence or de novo emergence. Misidentifying PTSD symptoms in MND can have negative consequences for the patient and families. We review the literature pertaining to PTSD and dementia and describe five cases referred for consultation in geriatric psychiatry initially for behavioural and psychological symptoms of dementia (BPSD), which were eventually diagnosed and treated as PTSD in MND subjects. We propose that certain PTSD symptoms in patients with MND are misinterpreted as BPSD and therefore, not properly addressed. For example, flashbacks could be interpreted as hallucinations, hypervigilance as paranoia, nightmares as sleep disturbances, and hyperreactivity as agitation/aggression. We suggest that better identification of PTSD symptoms in MND is needed. We propose specific recommendations for care, namely: clarifying diagnosis by distinguishing PTSD symptoms coexisting with different types of dementia from a specific dementia symptom (BPSD), gathering a detailed history of the trauma in order to personalise non-pharmacological interventions, adapting psychotherapeutic strategies to patients with dementia, using selective serotonin reuptake inhibitors as first-line treatment and avoiding antipsychotics and benzodiazepines. Proper identification of PTSD symptoms in patients with MND is essential and allows a more tailored and efficient treatment, with decrease in inappropriate use of physical and chemical restraints.

Pharmacist-led medication for pain in France: What population are we talking about? Results of the Optymed study

OBJECTIVES

Self-medication for alleviating pain is very prevalent in most countries. While safe self-medication is supposed to be dependent on both patient's behaviour and pharmacist's counselling, little is known about the context of the delivery of analgesics available without prescription. The primary objective of the study was to define sociodemographic profiles and behaviours of patients seeking non-prescribed analgesics in French community pharmacies. Secondary objectives included the assessment of pharmacist management and identification of risk-associated patients.

METHODS

This is a cross-sectional, national and multicentre study, including adults who asked for a prescription-free medication for acute or chronic physical pain. Information was collected through separate patient and healthcare professional (HCP) questionnaires.

RESULTS

The analysis was based on 1215 and 1271 patient and HCP questionnaires, respectively, collected from 164 pharmacies. The patient population consisted in women and men (ratio 6:4), mainly (71%) under 60 years old. Headaches, rheumatologic and musculoskeletal pains were the most frequent reasons for getting analgesics, with a median pain intensity of 6 on a scale graded from 0 (no pain) to 10 (intolerable pain). The main reasons guiding self-medication were time saving, a well-known pain and a well-known product. The mean time allocated to delivery was 4.7minutes. Indications, dose and posology were almost systematically addressed by the pharmacy staff, while contra-indications, drug-drug interaction or safety were mentioned in around two-third of cases. The proportion of patients identified at risks due to an inappropriate context of self-medication was 15.5%.

DISCUSSION AND CONCLUSIONS

This study shows a great heterogeneity of the population asking for non-prescribed analgesics in French community pharmacies. While pharmacists were able to identify patients at risks, a significant part may have 'slipped through the net'. The results support further studies to better define patient care pathway and optimize pharmacist-led medication.

Renal function and venous thromboembolic diseases

Anticoagulant agents have been approved by international regulatory agencies to prevent and treat venous thromboembolism (VTE). However, chronic kidney disease (CKD) is: (1) highly frequent in VTE patients; (2) strongly linked to VTE; and (3) a risk factor for cardiovascular morbidity/mortality and fatal pulmonary embolism. Therefore, an increasing number of patients are presented with CKD and VTE and more and more physicians must face the questions of the management of these patients and that of the handling of anticoagulant agents in CKD patients because of the pharmacokinetic modifications of these drugs in this population. These modifications may lead to overdosage and dose-related side effects, such as bleeding. It is therefore necessary to screen VTE patients for CKD and to modify the doses of anticoagulants, if necessary.

[Statin and cardiovascular diseases after 75 years]

Statin prescription in persons older than 75 years or with frailty signs raises questions on the role of cholesterol in the genesis of atherosclerosis in this population, on the benefit of this treatment in primary or secondary prevention, and on their side effects in a context of multiple pathology and multiple medications. These questions are approached with the available literature data for this population. In secondary prevention, statin prescription is recommended whatever the age although intensive treatment should be avoided. In primary prevention, in the absence of consensus, their prescription depends on both geriatric and cardiovascular risk assessment.