Impact of modifications to antidementia drug reimbursement in France: Analysis of the FRA-DEM cohort.

AIMS: Alzheimer's disease and related diseases (ADRD) is a progressive and inexorable disease. In France, acetylcholinesterase inhibitors and memantine were reimbursed for subjects with ADRD, until 2 modifications of their reimbursement rate (2012, 2018). We aimed to study the consequences of these measures on ADRD subjects' healthcare use. METHODS: We analysed data from the FRA-DEM cohort, including subjects with presumed incident ADRD identified since 2011 in the French health insurance system. We studied the healthcare use of subjects identified with incident ADRD in 2011, 2013, 2015, 2017 and 2019, notably the annual number of defined daily doses of various psychotropic groups. We performed 2 multivariate multinomial logistic regressions with the subcohort year as the dependent variable. RESULTS: In total, 165 120 subjects were included. A progressive decrease in exposure to antidementia drugs was observed between 2011 and 2019. Consultations with private neurologists or psychiatrists, and exposure to risperidone, antidepressants and benzodiazepines increased in the 2019 subcohort, following the 2018 reimbursement withdrawal. Meanwhile, the use of nursing/allied healthcare and emergency care increased over the subcohort years, whereas we observed a decrease in general practitioner consultations. CONCLUSION: These results suggest increases in private neurologist or psychiatrist consultations and exposure to recommended drugs after the reimbursement withdrawal, contrary to the fears expressed. However, antidementia drug exposure decreased long before the reimbursement modifications, probably due to the growing evidence of the modest effect of these drugs, and exposure to benzodiazepines increased after the reimbursement withdrawal.

Healthcare use according to deprivation among French Alzheimer's Disease and Related Diseases subjects: a national cross-sectional descriptive study based on the FRA-DEM cohort.

Introduction: Pluriprofessional and coordinated healthcare use is recommended for Alzheimer's Disease and Related Diseases (ADRD). Despite a protective health system, France is characterized by persistent and significant social inequalities in health. Although social health inequalities are well documented, less is known about social disparities in healthcare use in ADRD, especially in France. Therefore, this study aimed to describe healthcare use according to socioeconomic deprivation among ADRD subjects and the possible potentiating role of deprivation by age. Methods: We studied subjects identified with incident ADRD in 2017 in the French health insurance database (SNDS). We described a large extent of their healthcare use during the year following their ADRD identification. Deprivation was assessed through French deprivation index (Fdep), measured at the municipality level, and categorized into quintiles. We compared healthcare use according to the Fdep quintiles through chi-square tests. We stratified the description of certain healthcare uses by age groups (40-64 years, 65-74 years, 75-84 years, 85 years, and older), number of comorbidities (0, 1, 2-3, 4 comorbidities and more), or the presence of psychiatric comorbidity. Results: In total, 124,441 subjects were included. The most deprived subjects had less use of physiotherapy (28.56% vs. 38.24%), ambulatory specialists (27.24% vs. 34.07%), ambulatory speech therapy (6.35% vs. 16.64%), preventive consultations (62.34% vs. 69.65%), and were less institutionalized (28.09% vs. 31.33%) than the less deprived ones. Conversely, they were more exposed to antipsychotics (11.16% vs. 8.43%), benzodiazepines (24.34% vs. 19.07%), hospital emergency care (63.84% vs. 57.57%), and potentially avoidable hospitalizations (12.04% vs. 10.95%) than the less deprived ones. Discussion and conclusion: The healthcare use of subjects with ADRD in France differed according to the deprivation index, suggesting potential health renunciation as in other diseases. These social inequalities may be driven by financial barriers and lower education levels, which contribute to health literacy (especially for preventive care). Further studies may explore them.

Which factors preceding dementia identification impact future healthcare use trajectories: multilevel analyses in administrative data.

BACKGROUND: Healthcare use patterns preceding a diagnosis of Alzheimer's Disease and Related Diseases (ADRD) may be associated with the quality of healthcare use trajectories (HUTs) after diagnosis. We aimed to identify determinants of future favorable HUTs, notably healthcare use preceding ADRD identification. METHODS: This nationwide retrospective observational study was conducted on subjects with incident ADRD identified in 2012 in the French health insurance database. We studied the 12-month healthcare use ranging between 18 and 6 months preceding ADRD identification. The five-year HUTs after ADRD identification were qualified by experts as favorable or not. In order to take into account geographical differences in healthcare supply, we performed mixed random effects multilevel multivariable logistic regression model to identify determinants of future favorable HUTs. Analyses were stratified by age group (65-74, 75-84, ≥ 85). RESULTS: Being a woman, and preventive and specialist care preceding ADRD identification increased the probability of future favorable HUT, whereas institutionalization, comorbidities, medical transportation and no reimbursed drug during [-18;-6] months decreased it. Besides, some specificities appeared according to age groups. Among the 65-74 years subjects, anxiolytic dispensing preceding ADRD identification decreased the probability of future favorable HUT. In the 75-84 years group, unplanned hospitalization and emergency room visit preceding ADRD identification decreased this probability. Among subjects aged 85 and older, short hospitalization preceding ADRD identification increased the probability of future favorable HUTs. CONCLUSION: Regular healthcare use with preventive and specialist care preceding ADRD identification increased the probability of future favorable HUTs whereas dependency decreased it.

How general practitioners perceive the aging trajectory of oldest-old - A qualitative study.

BACKGROUND: A new population of older people is growing: the oldest-old. The care of the oldest-old (individuals aged 90 and over) is a new challenge in primary care. This study aimed to analyze the perception of General Practitioners (GP) on (1) the aging process of their patients up to a very advanced age, (2) how to adapt their practice to the care of these patients. METHODS: We conducted a qualitative study using focus group (face to face) and individual (video call) interviews of GPs in southwest France. The sampling was purposive. We analyzed the interviews using an inductive approach based on the phases of thematic analysis. We used researchers' triangulation during the process. Collection was concluded when saturation was reached. RESULTS: Three focus groups and one individual interview were conducted with a total of seventeen general practitioners. GP perception concerning aging and very advanced age were based on their personal experience and their daily clinical practice. Aging was perceived as an individual, unconscious, unpredictable and irreversible phenomenon. The shift towards "very old age" appeared inevitable. It could be a physical or psychological shift, or patients neglecting themselves or lacking a project. The care of the oldest-old became more specific and individual, adapted to the wishes of the patient. Those adaptations involve medical disengagement to focus on the most essential outcomes. The objectives of health care needed to be less strict with limited invasive practices. Prevention needed to focus mainly on prevention of falls and limitation of functional decline. CONCLUSION: GPs identified an inevitable and unpredictable shift from old age to very old age. The adaption of the theory of disengagement allowed us to identify a medical disengagement of the GPs in the care of their oldest patients.

Healthcare use patterns before Alzheimer's disease and related diseases identification and future healthcare trajectory.

OBJECTIVES: A frequent late Alzheimer's Disease and Related Diseases (ADRD) identification is described and may induce erratic health resource use. We aimed to describe healthcare use patterns preceding ADRD identification. METHODS: We studied persons aged 65 or older, identified with incident ADRD in 2012 in the French health insurance database. Healthcare use covering a wide range of care in ambulatory and hospital settings during the period ranging from 18 to six months before ADRD identification was studied. The main dimensions of healthcare use patterns before ADRD identification were investigated in three age groups (65-74, 75-84, ≥85) through a multiple correspondence analysis. These dimensions were secondarily interpreted according to the 5-year healthcare trajectory following ADRD identification, qualified as favorable (or not) by experts in the field. RESULTS: This research studied 36,990 subjects. Four dimensions raised in each age group. Two dimensions' interpretations were retrieved in all age groups: intensity of healthcare use, functional dependency. However, their rank differed along with the qualification of the future healthcare trajectory. Some specificities appeared in some age group. In the 65-74 and 75-84 years groups, there were dimensions reflecting healthcare use related to psychiatric or psycho-behavioral disorders. In the ≥85 group, two dimensions reflected dependency related to other comorbidities, and organised medical follow-up. CONCLUSION: Several dimensions emerged in line with erratic trajectories before ADRD identification. They underlined the need for actions towards ADRD identification.

The elderly in French Guiana: health status and challenges for the Guianese health system / La population âgée en Guyane : état des lieux et enjeux pour le système de santé

INTRODUCTION: With the increase in life expectancy of the population, the progression of chronic diseases, in particular cardiovascular diseases, neurodegenerative diseases (NDD) and their complications, health and medico-social care represents a major public health issue. OBJECTIVE: The aim of this article is to present an overview of the situation of the elderly and the current organization of the healthcare system for their care in French Guiana. METHOD: A review of the literature and analysis of the most recent data related to demographics, socioeconomics, morbidity and mortality, supply and use of care, were carried out. For comparative purposes, these data were compared with those for mainland France and the other French overseas departments and regions when available. RESULTS: With an average annual growth rate of +6.7% among people aged 65 and over, the highest in France (excluding Mayotte), the aging phenomenon has begun in French Guiana, although its population is still young. The health status of the elderly in French Guiana, characterized by an early onset of dependency and a greater prevalence of silent diseases (arterial hypertension, diabetes, hypercholesterolemia), is less favorable than in mainland France. In addition, the health and medico-social provision for the elderly remain incomplete or even embryonic, with little adapted support for elderly people with NND. CONCLUSION: This review highlights the situation of elderly people and the challenges for the health system.

Introduction: Avec l'allongement de l'espérance de vie de la population, la progression des maladies chroniques, notamment des maladies cardioneurovasculaires, maladies neurodégénératives (MND) et leurs complications, la prise en charge sanitaire et médico-sociale représente un enjeu majeur de santé publique. Objectif: Cet article a pour objectif de présenter un état des lieux de la situation des personnes âgées (PA) et de l'organisation actuelle du système de santé pour leur prise en charge en Guyane. Méthode: Une revue de la littérature et l'analyse de données démographiques, socioéconomiques, de morbidité et de mortalité, d'offre et de recours aux soins les plus récentes ont été réalisées. À des fins de comparaison, ces données ont été confrontées avec celles de la France hexagonale et des autres départements et régions d'outre-mer lorsque celles-ci étaient disponibles. Résultats: Avec un taux d'accroissement annuel moyen de +6,7 % chez les 65 ans et plus le plus élevé de France (hors Mayotte), le phénomène de vieillissement est amorcé en Guyane, bien que sa population reste encore jeune. L'état de santé des PA en Guyane, caractérisé par une entrée en dépendance précoce et une plus grande prévalence des maladies silencieuses (hypertension artérielle, diabète, hypercholestérolémie), est moins favorable qu'en France hexagonale. De plus, l'offre sanitaire et médico-sociale pour les PA reste lacunaire, voire embryonnaire, avec peu d'accompagnement adapté pour PA atteintes de MND. Conclusion: Cet état des lieux met en exergue la situation des PA et des enjeux pour le système de santé.

Predictors of nursing home placement at 2 years in Alzheimer's disease: A follow-up survey from the THERAD study.

OBJECTIVES: Nursing Home Placement (NHP) can prove to be the only solution to some dead-end situations in Alzheimer's disease (AD). The predictors of NHP are known and can be related to either the person with dementia or his/her caregiver. We aimed to identify predictors of NHP among people with AD over a 2-year follow-up period, with a particular interest in the modifiable predictors, notably those involving caregivers. METHODS: We studied data from the THERAD study, a French monocentric randomized controlled trial, involving 196 community-dwelling dyads, primarily assessing an educational intervention in AD. We performed a bivariate analysis followed by a multivariate Cox model, with a backward stepwise procedure. RESULTS: The mean age of the patients was 82 years old, 67.7% were women and 56.9% were living with a partner. The mean age of the caregivers was 65.8 years old, 64.6% were women and half were spouses of the patients with a moderate burden. During the follow-up, 23 patients died and 49 were institutionalized. The majority of NHPs occurred during the first year (35 NHP). The mean time to NHP was 27.77 months after the diagnosis. Five independent predictors of NHP were found: a higher patient education level (aHR 6.31; CI95% = 1.88-21.22), a high caregiver Burden (aHR 3.97; CI95% = 1.33-11.85), the caregiver being the offspring of the patient (aHR 2.92; CI95% = 1.43-5.95), loss of autonomy (aHR 2.75; CI95% = 1.13-6.65) and disinhibition as a behavioural and psychological symptoms of dementia (BPSD) (aHR 2.38; CI95% = 1.26-4.47). CONCLUSIONS: Our data are in accordance with the literature in identifying loss of autonomy, burden and BPSD (disinhibition) as risk factors of NHP. We also found high patient education level and status of offspring caregiver as additional factors. It is essential to take into account the caregiver status when designing psychoeducational trials aiming to delay NHP. Further studies need to take into account both the modifiable risk factors related to the patient (productive BPSD) and the needs of offspring caregivers (work-life balance, mental load).

The shift from old age to very old age: an analysis of the perception of aging among older people.

BACKGROUND: The oldest-old (individuals over 90 years) are a fast-growing population. Understanding the perceptions of older people about very old age is the first step towards developing optimal geriatric care for an aging population. This study aimed to explore the potential shift from old age to very old age through the exploration of older people's perception of aging. METHODS: Qualitative study conducted through individual interviews in the homes of older people. We voluntarily chose to include persons a decade under and above 90 years old to explore other factors than age that could participate in the shift from old age to very old age. The sampling was theoretical. We carried out the analyses using an inductive approach based on the phases of grounded theory. The researchers used triangulation. Collection was concluded when theoretical saturation was reached. RESULTS: Fourteen participants were interviewed. The shift from old age to very old age was not based on age but occurred when participants became conscious of the irreversibility of aging and its effects, and when they started living day-by-day, renouncing to any plan in a near future. The transition to very old age seemed to be preceded by a progressive disengagement from non-essentials activities. Participants reported a sensation of progressive social exclusion due to the loss of contemporaries or spouse, the difficulty to connect with younger generations or the absence of relationships in their neighborhood. The last step of life was feared, not because of the idea of death itself but because of the associated suffering and loss of autonomy. CONCLUSION: Precipitating and slowing factors of the shift to very old age were identified to help general practitioners support older patients throughout their life trajectories.

Potential determinants of unfavourable healthcare utilisation trajectories during the last year of life of people with incident Alzheimer Disease or Related Syndromes: a nationwide cohort study using administrative data.

BACKGROUND: people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs). OBJECTIVE: to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings. DESIGN: nationwide cohort study using administrative database. SETTING: French community and nursing-home residents. SUBJECTS: incident ADRS people identified in 2012, who died up to 31 December 2017. METHODS: we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models. RESULTS: 62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities. CONCLUSIONS: Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities.

Impact of an educational programme on Alzheimer's disease patients' quality of life: results of the randomized controlled trial THERAD.

BACKGROUND: Although educational interventions are recommended in Alzheimer's disease (AD), studies assessing the impact of interventions such as "therapeutic patient education" are scarce. Indeed, the intrinsic nature of the disease is considered a barrier to patients' involvement in such approaches. We aimed to evaluate an intervention by using a "dyadic" approach (patient and caregiver) in both intervention and assessment. METHODS: THERAD is a monocentric, randomized, controlled trial assessing the effects of a 2-month educational programme in mild to moderately severe AD patients among 98 dyads (caregiver/patient) on caregiver-reported patient quality of life (QOL) at 2 months. Community-dwelling patients and their caregivers were recruited in ambulatory units of the French Toulouse University Hospital. Self-reported patient QOL, autonomy, behavioural and psychological symptoms and caregiver QOL and burden were collected at 2, 6 and 12 months. Linear mixed models were used in modified intention-to-treat populations. We also performed sensitivity analysis. RESULTS: A total of 196 dyads were included, 98 in each group. The mean age of the patients was 82 years, 67.7% were women, diagnosed with AD (+/- cerebrovascular component) (mean MMSE =17.6), and 56.9% lived with a partner. The mean age of the caregivers was 65.7 years, and 64.6% were women (52.3% offspring/42.6% spouses), with a moderate burden (mean Zarit score = 30.9). The mean caregiver-reported patient QOL was lower than the self-reported QOL (28.61 vs. 33.96). We did not identify any significant difference in caregiver-reported patients' QOL (p = 0.297) at 2 months, but there was a significant difference in self-reported patients' QOL at 2 months (p = 0.0483) or 6 months (p = 0.0154). No significant difference was found for the secondary outcomes. The results were stable in the sensitivity analyses. CONCLUSIONS: This randomized controlled trial assessing an educational intervention in 196 dyads (Alzheimer's disease affected patient/caregiver) highlights the need to better consider the patient's point of view, since only the self-reported QOL was improved. Additional studies using this dyadic approach are necessary in targeted subpopulations of caregivers (spouse vs. child, gender) and of patients (severity of cognitive impairment or behavioural disturbances) TRIAL REGISTRATION: THERAD study NCT01796314 . Registered on February 19, 2013.

Development and Validation of a Model to Identify Alzheimer's Disease and Related Syndromes in Administrative Data.

BACKGROUND: Administrative data are used in the field of Alzheimer's Disease and Related Syndromes (ADRS), however their performance to identify ADRS is unknown. OBJECTIVE: i) To develop and validate a model to identify ADRS prevalent cases in French administrative data (SNDS), ii) to identify factors associated with false negatives. METHODS: Retrospective cohort of subjects ≥ 65 years, living in South-Western France, who attended a memory clinic between April and December 2013. Gold standard for ADRS diagnosis was the memory clinic specialized diagnosis. Memory clinics' data were matched to administrative data (drug reimbursements, diagnoses during hospitalizations, registration with costly chronic conditions). Prediction models were developed for 1-year and 3-year periods of administrative data using multivariable logistic regression models. Overall model performance, discrimination, and calibration were estimated and corrected for optimism by resampling. Youden index was used to define ADRS positivity and to estimate sensitivity, specificity, positive predictive and negative probabilities. Factors associated with false negatives were identified using multivariable logistic regressions. RESULTS: 3360 subjects were studied, 52% diagnosed with ADRS by memory clinics. Prediction model based on age, all-cause hospitalization, registration with ADRS as a chronic condition, number of anti-dementia drugs, mention of ADRS during hospitalizations had good discriminative performance (c-statistic: 0.814, sensitivity: 76.0%, specificity: 74.2% for 2013 data). 419 false negatives (24.0%) were younger, had more often ADRS types other than Alzheimer's disease, moderate forms of ADRS, recent diagnosis, and suffered from other comorbidities than true positives. CONCLUSION: Administrative data presented acceptable performance for detecting ADRS. External validation studies should be encouraged.

Clustering 5-Year Multidimensional Health Care Trajectory Patterns in Alzheimer's Disease and Related Syndromes.

OBJECTIVE: After diagnosis of Alzheimer's disease and related syndromes (ADRS), personalized care adapted to each patient's needs is recommended to provide a care plan and start symptomatic treatments according to guidelines. Over the past decade, dedicated structures and care have been implemented in various settings. Equal access to ADRS care, health care providers and services is crucial to ensure potential health benefits for everyone. However, the extent of use of recommended services and favorable health care utilization trajectories (HUT) may vary according to individual and contextual characteristics. The aim of this article was to (1) describe HUT patterns after multidimensional clustering of similar trajectories, (2) assess the proportion of individuals presenting favorable HUTs, and (3) identify factors associated with favorable HUTs. DESIGN: Cohort study. SETTING AND PARTICIPANTS: A cohort of 103,317 people newly diagnosed with ADRS identified in the French health reimbursement system (SNDS) was followed for 5 years with their monthly utilization on 11 health care dimensions. METHODS: For 3 age groups (65-74, 75-84, ≥85 years), 15 clusters of patients were identified using partitioning around medoids applied to Levenshtein distances. They were qualitatively assessed by pluridisciplinary experts. Individual and contextual determinants of clusters denoting favorable trajectories were identified using mixed random effects multivariable logistic regression models. RESULTS: Clusters with favorable HUTs denoting slow, progressive trajectories centered on at-home care, represented approximatively 25% of the patients. Determinants of favorable HUTs were mostly individual (age, female gender, absence of certain comorbidities, circumstances of ADRS identification, lower deprivation). Contextual determinants were also identified, in particular accessibility to nurses and nursing homes. Inter-territories variance was small but significant in all age groups (from 0.9% to 1.8%). CONCLUSION AND IMPLICATIONS: Favorable HUTs remain the minority and many efforts can still be made to improve HUTs. Qualitative studies could help understanding underlying barriers to favorable HUTs.

Morbidity and Mortality Review in a University Dental Hospital: A Necessary Tool to Improve Quality of Care.

OBJECTIVE: The study aimed to describe and to analyze the first morbidity and mortality review (MMRs) set up within a Dental University Hospital using detailed case reports to highlight the benefits of MMRs for patients, practitioners, teachers and to implement appropriate protocols to prevent recurrence. MATERIALS AND METHODS: The MMRs were performed within the dentistry departments of the hospital over the 1-year study period. Each case was reviewed according to a protocol based on a tool defined by the Clinical Risk Unit and the Association of Litigation and Risk Management (ALARM). RESULTS: Four cases were selected based on an oral report by a doctor from the dental service, a downstream service, or by the attending physician. The first case report related to a patient who suffered a breathing shock. The second concerned a tooth inhalation by a young disabled boy. The third was a therapeutic failure instigated by a student during a tooth preparation, and the fourth case involved an unexpected face-to-face meeting between a prisoner accompanied by police guards and an ancient victim at the dental hospital. DISCUSSION: Clinical incidents were investigated with the ALARM protocol. This process is also less focused on the individual who makes the error and more on contributing systemic factors. The systematic analysis of cases associated with bibliographic reviews improves learning and performance outcomes. Clear answers were given in response to the problems raised during these MMRs. CONCLUSION: In dental hospitals, the culture of MMRs needs to be integrated into resident training like in medical hospitals.

Benzodiazepine exposure in subjects with incident Alzheimer's disease and related syndromes in France: a longitudinal study 2011-2017.

Benzodiazepines are commonly used for behavioral and psychiatric symptoms of dementia, despite their numerous adverse effects and the lack of evidence regarding their efficacy in this context. We studied longitudinal benzodiazepines exposure in incident cases of Alzheimer's disease and related syndromes (ADRS) in France. We used a cohort of incident ADRS patients identified in 2012 within the national health data system. Benzodiazepines exposure was measured 1 year before, to 5 years after ADRS identification. Quarterly benzodiazepines prevalence and incidence were computed. We identified factors associated with long half-life benzodiazepines initiation. A total of 106 508 subjects were included. Quarterly benzodiazepines prevalence was stable (around 25%) but we saw an important decrease in long half-life benzodiazepines compensated by an increase in short half-life benzodiazepines. In most benzodiazepine initiations, the first episode lasted less than 3 months. Factors associated with initiating a long half-life benzodiazepine were young age, male gender, no registration with ADRS as a long-term disease, having consulted an ADRS specialist, antipsychotic reimbursement before the index date, no admission in nursing home. Prevalence of benzodiazepines use remains high in subjects with ADRS despite guidelines for their avoidance. However, indicators regarding benzodiazepine initiations (duration, benzodiazepine type) suggest some caution in their use.

Benzodiazepine Dispensing to Persons With Dementia in France, 2011-2016: A Nationwide Study.

OBJECTIVE: To study temporal trends of benzodiazepine exposure among incident Alzheimer's disease and related dementia (ADRD) cohorts between 2011 and 2016. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Three nationwide incident ADRD cohorts (community-dwelling and institutionalized subjects) were identified in 2011, 2013, and 2016 through the French health insurance database. Subjects were followed 4 semesters around ADRD identification [Semester -2 (S-2) to Semester 2 (S2)]. MEASURES: Odds ratios (ORs) for semestrial prevalent exposure, initiation, and adherence to benzodiazepine prescription recommendations (prescription duration <3 months, single reimbursement) were computed using multivariate logistic regressions for each cohort and according to benzodiazepine half-life. RESULTS: Among 262,024 community-dwelling subjects, as compared to 2011, overall benzodiazepine prevalence risk decreased slightly immediately after ADRD identification [S1: aOR2013 = 0.93 (0.91-0.95), aOR2016 = 0.95 (0.93-0.97)] and did not differ during S2. Among 72,013 institutionalized subjects, it increased over time [S2: aOR2013 = 1.16 (1.11-1.21), aOR2016 = 1.26 (1.21-1.32)]. Long half-life benzodiazepine prevalence risk decreased in the 4 semesters among recent cohorts, for both populations [S2: community-dwelling: aOR2013 = 0.77 (0.74-0.79), aOR2016 = 0.61 (0.59-0.64); institutionalized: aOR2013 = 0.74 (0.68-0.80), aOR2016 = 0.58 (0.54-0.63)]. Short half-life benzodiazepine prevalence risk increased [S2: community-dwelling: aOR2013 = 1.13 (1.10-1.16), aOR2016 = 1.22 (1.20-1.25); institutionalized: aOR2013 = 1.26 (1.21-1.32), aOR2016 = 1.44 (1.38-1.50)]. The same patterns were observed for benzodiazepine initiation. Adherence to benzodiazepine prescription recommendations (based on French prescription duration) worsened over years [prescription duration <3 months: aOR2013 = 0.90 (0.86-0.95), aOR2016 = 0.90 (0.85-0.95), single reimbursement: aOR2013 = 0.95 (0.91-1.00), aOR2016 = 0.94 (0.90-0.99)]. CONCLUSIONS AND IMPLICATIONS: Long half-life benzodiazepine exposure was reduced whereas short half-life benzodiazepine exposure increased, and adherence to recommendations worsened (prescription duration longer than 3 months and more than a single reimbursement in recent cohorts). Efforts from prescribers and authorities are required in order to restrict psychotropic exposure among the ADRD population. Further research among institutionalized ADRD subjects could provide useful data to disentangle the effects of changes in prescribing practices and in patients' characteristics.

Cognitive, functional, physical, and nutritional status of the oldest old encountered in primary care: a systematic review.

BACKGROUND: The oldest old (individuals over 90 years) are a fast-growing population. Characterizing their specificity would be helpful to adapt health care. This study aimed to characterize the cognitive, functional, nutritional, and physical status of individuals over 90. METHODS: We conducted a systematic review of cross-sectional or cohort studies of individuals aged 90 years old or more, living at home or in a nursing home, in April 2018. Two reviewers selected eligible articles, extracted data, and evaluated the risk of bias (assessed by the Newcastle-Ottawa Scale). RESULTS: The search strategy identified 3086 references; 35 articles were included referring to 8 cross-sectional and 27 longitudinal studies. Dementia was diagnosed in 30-42.9% of study participants, cognitive impairment in 12-50%, and 31-65% had no cognitive impairment. In terms of activities of daily living, 14-72.6% of individuals had no difficulty, 35.6-38% had difficulty, and 14.4-55.5% were dependent. For instrumental activities of daily living, 20-67.9% needed help. Regarding nutritional status, the Mini Nutritional Assessment Short Form mean score ranged from 10.3 (SD: 1.8) to 11.1 (SD: 2.4). Eight to 32% of individuals could not stand up from a chair, 19-47% could stand without the use of their arms; and 12.9-15% were not able to walk 4 m. CONCLUSIONS: These results suggest a heterogeneous population with a certain proportion of oldest old with a low level of disability. These findings suggest that a specific approach in the care of the oldest old could help prevent disability.

Suicide Prevention Interventions for Older People in Nursing Homes and Long-Term Care Facilities: A Systematic Review.

BACKGROUND: The death rate due to suicide among older people is high, especially among men. Because many older people live in nursing homes or long-term care facilities in high-income countries, reviewing the impact of prevention strategies on the suicidal behavior of residents in these settings is of interest. METHODS: Following PRISMA guidelines, we performed a systematic review of the existing literature found in Pubmed, Scopus, Web of Science, PsycINFO, and Sociological Abstracts, focusing on interventions to prevent suicidal behavior or ideation in nursing home residents. The studies' quality was evaluated according to TIDieR and MMAT. RESULTS: Only 6 studies met the inclusion criteria. Four of them described various "gatekeeper" trainings for nursing home staff and 2 described interventions focused on residents. Only 1 study was randomized. Gatekeeper training studies were mostly before/after comparisons. No intervention demonstrated a direct effect on suicidal ideation or behaviors. One study showed that "life review" had a long-lasting effect on depression scores and another that gatekeeper training led to changes in the care of suicidal residents. CONCLUSIONS: Interventions to prevent suicidal ideation or behaviors in nursing homes are not rigorously evaluated, and no conclusion can be drawn on their effectiveness in preventing suicidal behaviors. We propose to better evaluate gatekeeper training for staff as well as peer support. Individual interventions targeting residents could be modified for broader implementation.

Association between anticholinergic (atropinic) drug exposure and cognitive function in longitudinal studies among individuals over 50 years old: a systematic review.

PURPOSE: With increasing age, adults are often exposed to anticholinergic drugs and are prone to potential adverse drug reaction, among which cognitive impairment. If the short-term cognitive effects of anticholinergic drugs are well established, their long-term cognitive effects have less been studied. OBJECTIVE: To provide a systematic review of longitudinal studies which assessed the effect of anticholinergic exposure on cognition in individuals over 50 years. MATERIALS: We searched the MEDLINE database for studies with a minimal 6-month follow-up, assessing anticholinergic exposure through a biological measure or a clinical list and reporting at least one cognitive outcome. We used the modified Newcastle-Ottawa scale and additional criteria regarding the anticholinergic exposure to assess studies' methodological quality. Given the heterogeneity of the studies, we performed a systematic review. RESULTS: Among the 1574 references retrieved, 25 studies were included. Anticholinergic medications were mostly defined through the Anticholinergic Cognitive Burden Scale (n = 14/25). Six studies evaluated baseline drug collection, 14 used longitudinal aggregated measure, and 5 multiple drug exposure measures over time. Seventeen studies assessed anticholinergic burden. Cognitive function was assessed by mild cognitive impairment/dementia incidence (n = 15) or neuropsychological tests (n = 14). Most studies were of poor quality and retrieved discordant results. However, studies with good quality (n = 4) suggested a relationship between anticholinergic drug exposure and/or burden and cognitive function. CONCLUSION: Our review suggests a deleterious effect of anticholinergic exposure on mid/long-term cognitive function but should be confirmed in studies with improved methodology. Meanwhile, prescription of anticholinergic drugs should remain cautious.

Anticholinergic exposure and cognitive decline in older adults: effect of anticholinergic exposure definitions in a 3-year analysis of the multidomain Alzheimer preventive trial (MAPT) study.

AIM: The aim of the present study was to assess the association between anticholinergic (atropinic) burden and cognitive decline in older adults over the course of 3 years. METHODS: We used data from Multidomain Alzheimer Preventive Trial (MAPT) study participants aged ≥70 years and at risk of cognitive decline. Cognitive function was assessed with a composite score [Mini-Mental State Examination (MMSE) orientation, Free and Cued Selective Reminding Test, Category Naming Test, Digit Symbol Substitution Test] at 12, 24 and 36 months. Participants declining by more than 0.236 points on the composite score (representing the lowest quintile of 1-year cognitive change) during any 1-year period were considered to have undergone cognitive decline. Anticholinergic exposure was defined by four methods for each of four anticholinergic scales (Anticholinergic Drug Scale, Anticholinergic Cognitive Burden, Anticholinergic Risk Scale, the Durán list). The association between cognitive decline and time-varying anticholinergic exposure [primary analysis using the Durán list and maximal anticholinergic score (0, 1 or 3)] was assessed using Cox proportional hazards models. Other cognitive decline definitions were used in sensitivity analyses. RESULTS: At baseline, among 1396 patients included, 7.4-23.5% were exposed to anticholinergic agents, depending on the anticholinergic scale used. Sixty-four per cent of participants experienced cognitive decline during follow-up. Regardless of the anticholinergic scale/exposure measurement used, no significant association was observed with cognitive decline {primary analysis: compared with non-anticholinergic agent users, hazard ratio [HR] = 1.14 [95% confidence interval (CI) = 0.95, 1.38] for anticholinergic score = 1; HR = 0.92 [95% CI = 0.65, 1.30] for score = 3}. Results were stable in sensitivity analyses. CONCLUSION: We found no significant association between anticholinergic exposure and cognitive decline in older adults using anticholinergic scales and definitions of exposure.

Diabetes Care and Dementia Among Older Adults: A Nationwide 3-Year Longitudinal Study.

OBJECTIVES: To compare diabetes monitoring and the incidence of acute diabetic complications between patients with and without incident Alzheimer's Disease and Related Syndromes (ADRS). DESIGN: Longitudinal observational study from 2010 to 2014. SETTING: Data from the French national health system database. PARTICIPANTS: The France-Démence cohort: individuals aged 65 years or older suffering from incident ADRS, based on long-term disease registry, hospitalization for dementia, or antidementia drug delivery. They were matched (1:1) to a pair free of ADRS on age, sex, residence area, and insurance scheme. This study included France-Démence population with known diabetes for at least 2 years. MEASUREMENTS: Data related to diabetes control and complications: biological monitoring such as glycated hemoglobin A1c (HbA1c, ≥1/y, ≥2/y), lipid profile, microalbuminuria; eye examination; hospitalization for diabetes-related complications such as coma with ketoacidosis; and hospitalization for hypoglycemia were studied between the year prior to ADRS identification (Y-1) and the 2 following years (Y0; Y1). Incidences between the 2 groups (ADRS/non-ADRS) were compared using age-standardized incidence ratios (SIR). RESULTS: The studied population included 87,816 individuals. HbA1c determination was less frequent in ADRS group, no matter the study period and the minimal annual threshold used. Respectively, 82.6% and 88.5% of ADRS and non-ADRS group had at least 1 HbA1c testing during Y-1 [SIR = 0.94, 95% confidence interval (CI) 0.93-0.95], 73.4% and 89.0% during Y0 (SIR = 0.83, 95% CI 0.82-0.84), and 75.4% and 89.3% during Y1 (SIR = 0.85, 95% CI 0.83‒0.86). Subjects with ADRS were also consistently more hospitalized than non-ADRS peers. The gap was maximal in the year following the diagnosis, as observed for hospitalizations for any cause related to diabetes (SIR Y-1: 2.04, Y0: 3.14, Y1: 1.67), diabetes mellitus with coma (SIR Y-1: 3.84, Y0: 9.30, Y1: 3.06), and hypoglycemia (SIR Y-1: 4.20, Y0: 5.25, Y1: 2.27). CONCLUSIONS: Incident ADRS is associated with a less frequent diabetes monitoring and an increased risk of diabetes complications compared with older people without ADRS. Our study questions healthcare quality offered to participants with ADRS in comorbidity control. Further investigations are required to explain the mechanisms underlying our results and to propose actions to improve care of patients with ADRS.