Geriatric Choosing Wisely choice of recommendations in France: a pragmatic approach based on clinical audits.

BACKGROUND: The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication. METHODS: In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign. RESULTS: The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication. DISCUSSION: The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing.

[Ethical approach to the issue of confinement of the elderly in the context of the COVID-19 pandemic: Prevention of frailty versus risk of vulnerability]. / Une approche éthique de la question du confinement des personnes âgées en contexte de pandémie COVID-19 : la prévention des fragilités face au risque de vulnérabilité.

COVID-19 pandemic particularly affects older people and exposes them to a higher risk of mortality. Containment, social distancing and isolation measures have been implemented to limit viral transmission. While there is a clear rationale for reducing the contagiousness of the infection through this means, the adverse consequences of this social isolation, especially for this heterogeneous, aged and frail people, are difficult to apprehend. In particular, the disruption of the usual support and care ecosystems at home or in institutions may paradoxically increase the frailty of these people and lead to adverse events we wanted to avoid. On the other hand, the risk of a decrease in the older person's empowerment regarding his or her own health and social life decisions requires particular vigilance to prevent the risk of societal ageism. Regarding this population in particular, a possible conflict of values between individual and collective protection on one hand and respect for autonomy and independence on the other hand could exist. This article proposes an ethical reflection on the issue of containment of frail ageing people, based on medical ethics principles, in order to open up positive approaches of vulnerability that guarantee respect for the dignity of the person and equity in care access.

Multifactorial immunodeficiency in frail elderly patients: Contributing factors and management.

Immunodeficiency in the elderly is multifactorial. The analysis of etiological factors demonstrates the major role of immunosenescence and protein-energy malnutrition (PEM) with high prevalence deficiencies in micronutrients such as vitamin D, zinc, or vitamin E in people aged above 75 years. PEM contributes to the numerous consequences of frailty syndrome, and mainly to susceptibility to infections including fungal infections, which are usually observed in immunodeficient patients. Particular attention should thus be paid to these patients. However, these peculiarities of the immune system aging and the aging-related vulnerability can lead to diagnostic delays and treatment escalation, mainly with antibiotics, as well as to a loss of time resulting in a loss of opportunity for patients. Antibiotic escalation also leads to microbiological selection pressure in frail elderly people, which can be deleterious in the long-term in case of opportunistic infections. Guidelines are mainly based on the identification and management of frailty, especially in terms of nutrition. The identification of nutritional risk, dietary management, mood vigilance, and a functional approach are the four pillars of the management strategy. These elements are part of a global geriatric assessment and care.