[Prescribing psychotropic drugs to patients aged 80 and over]. / Réflexions sur l'usage des psychotropes chez la personne très âgée.

The management of psychotropic drugs is a daily preoccupation for geriatric psychiatrists and geriatricians alike. The lack of controlled clinical trials in very old patients (over 80 years old) often leads to empirical therapy. The multiple somatic co-morbidities of old patients, the high prevalence of potential drug-drug interactions and a wish to implement an increasingly patient centered approach all influence psychotropic drug prescription which tends to be simplified and individualized. This review is an attempt to depict the general principles and precautions we, as in-hospital geriatricians, geriatric clinical pharmacologists and geriatric psychiatrists in Geneva, Switzerland, have found helpful after many years of interaction with elderly patients and their families, and shared responsibility for the care of these very frail patients.

[Serotonin syndrome as a result of escitalopram and cyclosporin combination in an 84-year-old woman]. / 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 patient's condition improved rapidly. This report is a reminder of the clinical and pharmacological features of the serotonin syndrome from a recent literature review.

[Drug-induced arterial hypertension]. / Hypertension artériette induite par les médicaments.

In a few clinical cases, controlling arterial hypertension is really very difficult even when using the appropriate treatment(s) at the optimal dosage. In such cases, it is crafty to research any possible drug interferences with the antihypertensive treatment. Two clinical cases will illustrate that arterial hypertension can be either induced or very difficult to control due to opposite physiopathological mechanisms of drugs or to pharmacokinetic interactions. A review of the main interacting drug regimens will complete this paper, attesting that drugs as various as NSAID, corticosteroids, erythropoietin, cyclosporine, antidepressants, beta blockers, carbamazepine, sympathomimetics, antihistamines, tramadol and (...) can induce arterial hypertension.

[Anxiety in palliative care]. / Anxiété dans le cadre de soins palliatifs.

In palliative care, the intensity and duration of anxiety as well as its consequences on the patient's daily activities can significantly decrease his quality of life. Anxiety that does not incapacitate the patient to the point of his being unable to communicate or perform his usual activities does not necessarily require drug treatment. The non pharmacological treatments of anxiety are presented in some detail. Prescription of anxiolytic drugs in renal or hepatic failure, as well as when oral intake or venous access are difficult, is briefly discussed.

[Management of chronic pain in older persons]. / Prise en charge de la douteur chronique chez la personne âgée.

Chronic pain is common in older adults and its consequences are often severe. Several studies have demonstrated that pain in older adults is poorly controlled because they underreport pain and caregivers often underestimate patient's pain. Analgesics can be used safely and effectively in this population. Start with the lowest effective dose, monitor frequently on the basis of expected absorption and pharmacokinetics of the drugs and then titrate on the basis of clinically demonstrated effects and the side effects. Other aspects of the management of pain in older persons will be described in the article.

[Behavioural and psychological symptoms of dementia (BPSD): pharmacological management]. / Prise en charge médicamenteuse des symptômes comportementaux et psychologiques liés à la démence.

BPSD affect all demented patients during their illness. They are part of the process of the disease and can be correlated to neurotransmitter dysfunctions as well as to the coping difficulties due to the patient's cognitive decline. The major consequences of BPSD are a decreased quality of life of both patient and caregivers and an increased need of professional care. Physicians should exclude precipitating factors such as intercurrent somatic, psychiatric or drug-related problems first and then proceed with behavioural or environment therapy. Introduction of a pharmacological treatment should be the last resort. This systematic review discusses the causes and consequences of BPSD and focuses on the evidence-based pharmacological approach. Only three drugs can be recommended at the present time: risperidone, olanzapine and donepezil.

[Drug-induced refractory arterial hypertension]. / Hypertension artérielle résistant au traitement: une cause médicamenteuse.

Polymedication is frequent in geriatric everyday practice and often leads to unwanted drug-drug interactions. Physicians must be aware of the potential interaction-induced with intoxications or therapeutic ineffectiveness. The clinical case presented here illustrates the importance of entertaining the possibility of such an interaction every time that the expected therapeutical effect of a substance is not reached. Our patient had refractory arterial hypertension despite taking five different antihypertensive drugs in hospital, while on carbamazepine for a facial neuralgia. This substance induces the cytochrome P450, which catalyse the metabolism of most of the antihypertensives used. After the discontinuation of carbamazepine and on tritherapy, the blood pressure profile has significantly improved.

[QT prolongation and inhibition of the P glycoprotein: presentation of 2 geriatric cases]. / Allongement de l'espace QT et inhibition de la glycoprotéine P: à propos de deux observations gériatriques.

Two cases with QT prolongation associated with the administration of standard drug doses are reported. Drug effects are determined by pharmacological and biological parameters. Drugs may be metabolized or transported by two systems: the cytochrome enzymes or the less well-known but nevertheless relevant P-glycoprotein system. P-glycoprotein is a pump that limits intracellular reabsorption and favors the elimination of exogenous substances. These two systems interact with each other to influence drug effects. A better knowledge of their mechanisms of action and their genetic determinants should help provide more individualized pharmacologic treatment to patients, in particular older patients.

[Osteonecrosis of the jaws and bisphosphonates]. / Ostéonécrose des maxillaires et bisphosphonates.

Widely prescribed, bisphosphonates inhibit bone resorption. They are not metabolised and have long half-lives. Two cases of osteonecrosis of the jaws have recently been attributed to bisphosphonates at the University Hospital of Geneva. The recent literature reveals more than a hundred similar cases throughout the world. Bone exposure appears spontaneously or after dental care. Treatment of the osteonecrosis is controversial and cure very difficult. This pathology is usually seen in patients on chemotherapy, steroids and i.v. bisphosphonates, but is sometimes seen with low-dose p.o. bisphosphonates. In view of the strong association between bisphosphonate therapy and osteonecrosis of the jaw, specialists have recommended dental and oral evaluation during bisphosphonate therapy as well as for several years after drug discontinuation.