[Inappropriate admissions of Ehpad residents to emergency departments]. / Admissions inappropriées des résidents d'Ehpad aux urgences.

After a review of inappropriate admissions of residents of residential care facilities for the dependent elderly (Ehpad) to the emergency room, we propose ways to reduce them. They include giving the coordinating physician a clinical role, organizing continuity and permanence of care in all Ehpad, signing agreements between Ehpad and hospital for direct hospitalization and collaboration with mobile teams and geriatric hotlines, generalizing the level of medical intervention in Ehpad, and deepening the training of Ehpad caregivers in geriatrics.

Direct Oral Anticoagulants versus Vitamin K Antagonists in Individuals Aged 80 Years and Older: An Overview in 2021.

Two main types of oral anticoagulants are available in France: vitamin K antagonists (VKA) and, more recently, direct oral anticoagulants (DOAC). The benefit−risk profile appears to be favorable for DOAC, which is as effective as VKA but safer (fewer cases of severe and cerebral bleeding). In a study in 2017, we observed that older adults did not seem to receive the same modalities of oral anticoagulants as younger individuals for various reasons. To assess anticoagulation prescribing practices over time, we repeated this cross-sectional study by comparing very old individuals taking DOAC to those taking VKA. Ambulatory individuals aged 80 years and older were included. They were affiliated with the Mutualité Sociale Agricole of Burgundy and were refunded for a medical prescription of oral anticoagulation in March 2021. The demographic characteristics, registered chronic diseases (RCD), number and types of prescribed drugs, and mortality of the DOAC group and the VKA group were compared. A total of 4275 subjects were included in the study: 67.44% (2883) received DOAC and 32.56% (1392) received VKA. The two groups were similar in age. In the DOAC group, there were more women (54.98% vs. 46.98%) (p < 0.001), fewer RCD (91.47% vs. 93.68%) (p = 0.014), and lower rates of venous thromboembolism (2.53% vs. 6.75%) (p < 0.001), severe heart failure (56.50% vs. 68.03%) (p < 0.001), and severe kidney diseases (1.38% vs. 3.59%) (p < 0.001), but there were more subjects with Alzheimer's disease (7.49% vs. 4.31%) (p = 0.001). Individuals in the DOAC group had fewer prescriptions of furosemide (48.53% vs. 55.75%) (p < 0.001) and fibrates (2.32% vs. 3.88%) (p = 0.044). They also had more prescriptions of proton pump inhibitors (43.95% vs. 39.44%) (p = 0.006) and antirheumatics (1.60% vs. 0.65%) (p = 0.009) than those in the VKA group. There was no difference in mortality. This study revealed that prescribing practices for DOAC have changed over time.

Direct Oral Anticoagulants versus Vitamin K Antagonists in Patients Aged 80 Years and Older.

The effectiveness of direct oral anticoagulants (DOAC) is non-inferior to vitamin K antagonists (VKA) to treat atrial fibrillation and venous thromboembolism (VTE). In this cross-sectional study, we compared older persons taking DOACs to those taking VKAs. We included ambulatory individuals ≥80 years, affiliated to Mutualité Sociale Agricole of Burgundy, who were refunded for a medical prescription in September 2017. The demographic conditions, registered chronic diseases (RCD), and number and types of prescribed drugs were compared in the DOAC group and VKA group. Of the 3190 included individuals, 1279 (40%) were prescribed DOACs and 1911 (60%) VKAs. Individuals taking VKAs were older than those taking DOACs (87.11 vs. 86.35 years). In the DOAC group, there were more women (51.92% vs. 48.25%) (p = 0.043), less RCD (89.60% vs. 92.73%) (p = 0.002), less VTE (1.80% vs. 6.59%), less severe heart failure (58.09% vs. 67.87%), less severe hypertension (18.22% vs. 23.60%), less severe kidney diseases (1.49% vs. 3.82%), and fewer drugs per prescription (6.15 vs. 6.66) (p < 0.01 for all). The DOAC group were also less likely to be taking angiotensin receptor blockers (10.79% vs. 13.97%), furosemide (40.81% vs. 49.66%) or digoxin (10.32% vs. 13.66%) than the VKA group (p = 0.009, p < 0.001, and p = 0.005). DOACs were less prescribed than VKAs. Individuals taking VKAs were older and had more severe comorbidities and more drugs per prescription than those taking DOACs.

The Prescription of Vitamin K Antagonists in a Very Old Population: A Cross-Sectional Study of 8696 Ambulatory Subjects Aged Over 85 Years.

We compared very elderly people taking vitamin K antagonists (VKA) and those not taking VKA (noVKA). Individuals were included in the noVKA group if there was no VKA on their reimbursed prescriptions during the study period. We also compared three subgroups, constituted by VKA type (fluindione, warfarin, or acenocoumarol). We included individuals aged over 85 years, affiliated to Mutualité Sociale Agricole of Burgundy, who were refunded for prescribed VKA in September 2017. The VKA and noVKA groups were compared in terms of demographic conditions, registered chronic diseases (RCD), number of drugs per prescription and cardiovascular medications. The three VKA subgroups were compared for the same items plus laboratory monitoring, novel and refill VKA prescriptions, and prescriber specialty. Of the 8696 included individuals, 1157 (13.30%) were prescribed VKA. Mean age was 90 years. The noVKA group had fewer women (53.67 vs 66.08%), more RCD (93.43 vs. 71.96%) and more drugs per prescription (6.65 vs. 5.18) than the VKA group (all p < 0.01). Except for direct oral anticoagulants and platelet aggregation inhibitors, the VKA group took significantly more cardiovascular medications. The most commonly prescribed VKA was fluindione (59.46%). Mean age was higher in the warfarin (90.42) than in the acenocoumarol (89.83) or fluindione (89.71) subgroups (p < 0.01). No differences were observed for sex (women were predominant) or RCD. 13% of subjects in this population had a VKA prescription. Fluindione was the most commonly prescribed VKA.

Impact of Influenza Vaccination on Mortality in the Oldest Old: A Propensity Score-Matched Cohort Study.

Influenza remains a major cause of illness and death in geriatric populations. While the influenza vaccine has successfully reduced morbidity and mortality, its effectiveness is suspected to decrease with age. The aim of this study was to assess the impact of influenza vaccination on all-cause mortality in very old ambulatory subjects. We conducted a prospective cohort study from 1 July 2016 to 31 June 2017 in a large unselected ambulatory population aged over 80 years. We compared all-cause mortality in vaccinated versus unvaccinated subjects after propensity-score matching, to control for age, sex and comorbidities. Among the 9149 patients included, with mean age 86 years, 4380 (47.9%) were vaccinated against influenza. In total, 5253 (57.4%) had at least one chronic disease. The most commonly vaccinated patients were those with chronic respiratory failure (76.3%) and the least commonly vaccinated were those suffering from Parkinson's disease (28.5%). Overall, 2084 patients (22.8%) died during the study. After propensity score matching, the mortality was evaluated at 20.9% in the vaccinated group and 23.9% in the unvaccinated group (OR = 0.84 [0.75-0.93], p = 0.001). This decrease in mortality in the vaccinated group persisted whatever the age and Charlson Comorbidity index. In conclusion, nearly a half of this ambulatory elderly population received Influenza vaccine. After adjustment on comorbidities, influenza vaccination was associated with a significant decrease in all-cause mortality, even in the eldest multimorbid population. Improving immunization coverage in this frail older population is urgently needed.

The prescription of direct oral anticoagulants in the elderly: An observational study of 19 798 Ambulatory subjects.

OBJECTIVE: Direct oral anticoagulants (DOACs) are increasingly prescribed to elderly people, but the epidemiologic data for this population remains scarce. We compared the elderly population taking DOACs and those not taking DOACs (noDOAC). METHOD: We included individuals over 75 years old, affiliated to Mutualité Sociale Agricole of Burgundy (a French regional health insurance agency), who had been refunded for a prescribed DOAC between 1st and 30th September 2017. The DAOC group (DAOCG) and noDOAC group (noDOACG) were compared in terms of demographic conditions, registered chronic diseases (RCD), and number and types of prescribed drugs. In the DOACG, we compared the type of prescribing physician and laboratory monitoring for novel prescriptions (initial) and prescription refills (≥ 3 months). RESULTS: Of the 19 798 included patients, 1518 (7.7%) were prescribed DAOCs and 18 280 (92.3%) were not. Mean and median age was 85 years in the 2 groups (DOACG and noDOACG). In the DOACG, there were more men (50% vs 40.2%), more RCD (88.9% vs 68.7%) and more drugs per prescription (6 ± 2.8 vs 5 ± 2.9) (All P < .01). The DOACG also took more antihypertensive drugs. The most commonly prescribed DOACs were apixaban (42.9%) followed by rivaroxaban (38.4%) and dabigatran (18.6%). Complete blood count, serum creatinine and coagulation function tests were requested for 69.4%, 75% and 22.2%, respectively, of patients prescribed DAOCs. CONCLUSIONS: The DOACG had more RCD and drugs per prescription than the noDOACG; routine laboratory monitoring was insufficient. What's known Platelet aggregation inhibitors (low-dose) are recommended for secondary prevention of cardiovascular events in patients suffering from symptomatic atherosclerosis. The main risk of this treatment is bleeding. What's new A prescription for platelet aggregation inhibitors was found in 34% of geriatric inpatients in this prospective study. Compliance to guidelines was better for symptomatic peripheral artery disease than for primary prevention in accordance with recent publications. Geriatric comorbidities had no impact on the prescription of platelet aggregation inhibitors. Underuse of platelet aggregation inhibitors was observed in 11.3% of cases and overuse in 13.7% of cases.

The prescription of antiplatelet medication in a very elderly population: An observational study in 15 141 ambulatory subjects.

OBJECTIVE: Despite the frequent use of antiplatelet medication (AM) in the elderly patients, very few studies have investigated its prescription. We describe AM prescription through retrospective study in ambulatory elderly patients. METHOD: All subjects aged over 80 years with a medical prescription delivered in March 2015 and affiliated to the Mutualité Sociale Agricole de Bourgogne. Subjects with prescriptions for AM were compared with those without. RESULTS: A total of 15 141 ambulatory elderly patients (83-89 years, 61.3% of women) were included and 4412 (29.14%) had a prescription for AM. The latter were more frequently men than those without AM (43% vs 36.93%, P < .0001) and more frequently had chronic comorbidities (77.24% vs 64.65%, P < .0001). Compared with ambulatory subjects without AM, those with AM more frequently had coronary heart disease (35.15% vs 14.49%), severe hypertension (30% vs 25.65%), diabetes (27.42% vs 20.64%), peripheral arterial diseases (16.28% vs 5.96%) and disabling stroke (9% vs 5.56% (all P < .0001). In addition, they had more prescriptions of beta-blockers (45.24% vs 36.90%), angiotensin conversion enzyme inhibitor (31.35% vs 25.44%), calcium channel blockers (33.34% vs 27.90%), nitrate derivatives (10.6% vs 6.03%) or hypolipidemic agents (HA; 49.81% vs 29.72%) (all P < .0001) than those without AM. CONCLUSION: In this study, which is very interested for its size and the advanced age of the subjects, long-course AM was prescribed in one third of ambulatory elderly patients. Coronary heart disease, severe hypertension and diabetes were more frequent in AM subjects. However, the low percentage of declared strokes was surprising. We provide additional data to doctors following subjects with AM.

Potentially inappropriate use of furosemide in a very elderly population: An observational study.

OBJECTIVE: Little is known about furosemide prescription modalities in elderly people. We describe furosemide prescription in ambulatory elderly patients. METHODS: All patients aged over 80 years, affiliated to Mutualité Sociale Agricole de Bourgogne, a French regional health insurance plan, with a medical prescription delivered in March 2015, were retrospectively included. RESULTS: Among 15 141 patients with a median age of 86 years, comprising 61.3% of women, 3937 patients (26%) had a prescription for furosemide. Severe heart failure was the most common chronic comorbidity (27.7%). Furosemide was considered a long-term therapy for almost all patients (98.7% with prescriptions for 3 months or more). Recommended indications for long-term furosemide therapy included severe heart failure (50.9%), chronic nephropathy (3%) and cirrhosis (0.1%). The furosemide prescription rate increased with age (81-85: 20.4%, 86-90: 28.5%, 91-95: 35.6%, >95: 42.7%, P<.001), and the increase was associated with a decrease in recommended heart failure therapeutics (beta-blockers, angiotensin-conversion-enzyme-inhibitors or angiotensin-receptor-blockers). Prescribers were mostly general practitioners (81.3%). Plasma electrolytes were controlled in less than a half of the patients with furosemide. CONCLUSIONS: In this large study, long-course furosemide was prescribed in a quarter of ambulatory patients. Half of those taking furosemide suffered from severe heart failure. Age was associated with a linear increase in furosemide use and a decrease in recommended heart failure therapeutic prescriptions. A large part of these prescriptions do not seem to be in accordance with recommendations.

Analysis of Inappropriate Admissions of Residents of Medicalized Nursing Homes to Emergency Departments: A Prospective Multicenter Study in Burgundy.

OBJECTIVES: To determine the rate of inappropriate admissions to emergency departments (EDs) and to identify determinants of these admissions. DESIGN: Prospective multicenter study. SETTING: Burgundy (France), EDs and medical nursing homes (MNHs). PARTICIPANTS: 1000 Burgundy MNH residents admitted to EDs, from April 17 to June 20, 2013. MEASUREMENTS: For each subject, a questionnaire was completed. Data included age, gender, type of health professional who referred the resident to the ED (THP), whether or not a medical dispatcher organized the transfer to the ED, transport mode, reason for admission to the ED, level of independence according to the Groupes Iso-Ressource score (GIRS), and diagnosis made in the ED. The French version of the Appropriateness Evaluation Protocol grid was applied to each admission to the ED, and in some situations, the expert committee ruled on the appropriateness of the admission to the ED. MNH characteristics were also recorded. Two groups were constituted according to the appropriateness or not of admission to the ED. RESULTS: Mean age of the 1000 residents was 87. There were 706 women. Two-thirds were referred to the EDs by a physician, mainly a general practitioner. In 91.7%, the transfer to the ED was organized by a medical dispatcher, and 8.8% were transported by medicalized transport. More than 95% had a GIRS ≤4. Among the admissions to EDs, 18.1% were inappropriate. Female gender (P = .017), nonmedicalized transport (P = .002), public MNH (P = .044), and nonaccess to a geriatric opinion in an emergency (P = .043) were determinants of inappropriate admission to EDs. CONCLUSION: In this first study on admissions to EDs of MNH residents using French data, we found a lower rate of admissions to the ED than that reported in the literature. Female gender, nonmedicalized transport, public MNH, and nonaccess to a geriatric opinion in an emergency were associated with inappropriate admission to EDs.

Assessment of the use of hypolipidemic agents (HAs), mainly statins, in elderly subjects aged 80 years and more in Burgundy: analysis of 13,211 patients.

Only few studies have investigated the use of HA in elderly subjects and there are no data in very elderly subjects. We assessed the prescription of HA and analyzed the relationship between such prescriptions and frailty markers among persons aged 80 and more in an observational study. We recorded the prescriptions for 13,211 patients aged 80-109 years and affiliated to the "Mutualité-Sociale-Agricole (MSA)" of Burgundy over a 1-month period. The prescription of a HA among all included patients, and the existence of serious long-term disease(s) (LTD), polypharmacy or a prescription of cardiovascular drugs among patients receiving a HA were recorder. Among the 13,211 patients, 3412 aged 80-98 years were treated with an HA. The main HA were statins (70.4%), and fibrates were used in 27.3% of cases. Of these 3412 patients, 2250 had one or several LTD mainly coronaropathy, hypertension, diabetes mellitus or peripheral artery disease. The mean number of drugs per prescription was 6.37. Among subjects treated with HA, 40% also received antiplatelets, 35.6% ß-blockers and 30% inhibitors of the renin-angiotensin system. For 99% of the patients, the prescription of HA was a renewal. Prescribers were mainly general practitioners (96.8%). Statins are the most widely prescribed HA even among very elderly subjects. However, after 80 years the prescription of HA, mainly statins, decreases with aging. This could be explained by polypathology, polypharmacy and the deterioration in metabolic functions which are markers of frailty. This study should encourage research into the use of statins in very elderly subjects.