a process based on trust and coordination

TRANSCRIPTION

VIDAL News. Expert word. David Paitraud receives Dr Sandrine Khalifa, geriatrician, coordinating doctor of the “Les Rives de Sèvres” nursing home (Deux-Sèvres department).

David Paitraud. The medical agreement signed between Health Insurance and private doctors in May 2024 establishes the establishment of a deprescription consultation. It is aimed at elderly patients who are prescribed at least ten lines of treatment. In less than ten years, the approach of reducing drug prescriptions has become established in medical practice. It is today encouraged within the framework of a broader issue, that of medication sobriety. But how do we go about deprescribing, so that doctors and patients can understand each other? What are the conditions for successful deprescription and perpetuation of fair and appropriate drug prescription?

Dr Sandrine Khalifa, your experience interests us and will certainly interest our physician listeners. You are a geriatrician, coordinating doctor in a nursing home in the Deux-Sèvres department. In this establishment, you have initiated the process of deprescribing when possible.

What motivated you to engage in this process?

Dr Sandrine Khalifa. I am also a hospital doctor and I participated in medication reconciliations with the hospital pharmacists. I found this very interesting process of re-evaluating our prescriptions. Since then, I have always been interested in this approach in my own prescriptions.

Has an inventory been carried out within your nursing home to assess polypharmacy among residents?

Indeed, in my annual report, I took stock of the requirements. For example, in 2024, 96% of residents had at least 5 molecules and 41% of residents had at least 10 molecules for a population with an average age of 89 years. It is a medium-sized nursing home with a protected unit, a classic nursing home population.

What were the steps in implementing deprescribing within your nursing home?

I have worked at the nursing home for three years.

Create a climate of trust, work and cooperation

The first step was a phase d’observation et dating of the different health professionals and of the residents pour establish a bond of trust among all, since the different people involved in the prescription are the doctors, but also the nursing team, the pharmacist and the patient who is at the center. It took about a year to create this climate of trust.

Securing the drug circuit

Then, we worked on the drug circuit and its security by entering into an agreement with a community pharmacy which delivers the medicines to us in blister packs, and with whom we have also concluded a partnership for a medication assessment.

Concerning securing the medication circuit, we realized that the nurses were crushing medications, which was not necessary, and were crushing them together. So we worked with pharmacists, nurses and doctors to review the galenics and limit the number of crushed medications, crush them in good conditions.

The second thing that was worked on in the drug circuit is our reserve which we call urgent needs allocation for unforeseen prescriptions. In this endowment of urgent needs, I have no not mis inappropriate medications to the elderly person for limit iatrogenic risks.

Deprescribing implies that certain medications should be removed from prescription because they are no longer relevant. How do you evaluate this?

Often patients have old prescriptionsprescribed by specialist doctors. But when they evolve over time and in age, it happens that centenarians who still have primary prevention medications even though they are malnourished and have difficulty eating. We can, for example, in these cases, remove certain medications.

There is also medicines who are given as symptomatic. We can sometimes try to find non-drug treatments.

You work line by line, medication by medication, with the attending physician, and also with the pharmacist. Do you meet up regularly? How does it work in practice?

Until now, we have only worked on certain medications for which we have noticed risks of adverse effects. For example, medications that caused falls.

Currently, we planned for the year 2024 to meet regularly with the pharmacistto look line by line at the prescription of residents who had more than 10 molecules, and to do suggestions for general practitioners. They agree to re-evaluate their prescription, but ask for a little help to be able to sort and also to do education for residents. Indeed, general practitioners often have difficulty convincing their patients to stop a medication they have started. The fact that we come and explain to residents that we have reached an agreement and that ultimately we can do differently, sometimes leads to better results. But it can be difficult.

What are the other obstacles to deprescribing?

Time above all and the patient who sticks to his medication. For example, a lady arrived at the nursing home with long-term antibiotics to prevent urinary infections. The general practitioner, who was taking over the file, wanted to stop the treatment, but the resident absolutely insisted on her antibiotics. I then suggested that the nursing home provide her with cranberry juice, saying that we had not observed frequent urinary infections and that she needed something. She agreed to take cranberries as long as they were capsules to swallow. It is also important to work with residents on their beliefs. But this often takes several months.

Another obstacle, doctors sometimes encounter legitimacy difficulties compared to a prescription that was made by a specialist. In this case, we discuss by bringing out the literature. As there are several of us deciding, there is a consensus that arises between us.

How to avoid falling back into overmedication? Especially since we are addressing an elderly audience, among whom new health problems may arise.

I think thatwith each prescription, you have to question the entire prescription and on the interest of continuing all the lines. And also ask yourself the question of whether we should reintroduce a new drug, or should we not rather increase another treatment?

Is this symptom not related to an undiagnosed problem? For example, in the case of dizziness, rather than using anti-dizziness treatment, is there not underlying orthostatic hypotension which would lead us to prescribe either compression stockings or to stop a medication? hypotensive?

I think that every time, it’s necessary review the entire problem from another angle. And this is why collaborative work in a nursing home can be interesting, since we will ask ourselves questions and think together about the problem.

Interview: David Paitraud, pharmacist

Montage : Robin Benatti & David Paitraud

Thanks: Dr Sandrine Khalifa, geriatrician, coordinating doctor of the “Les Rives de Sèvres” nursing home (Deux-Sèvres department)