Limited data are available on characteristics associated with antipsychotic use in multimorbid older adults. Primary: to identify patient characteristics associated with antipsychotic prescribing in a multimorbid population of older inpatients with polypharmacy. Secondary: (1) to observe if antipsychotics use during an index hospitalisation was associated with a drug related admission (DRA) within one year, and (2) to describe these cases of antipsychotic-related readmissions. This was a secondary analysis of the OPERAM randomized controlled trial. Multivariate analysis assessed the association between characteristics and comorbidities with antipsychotic use. An expert team assessed DRA occurring during the one-year follow-up. Antipsychotics were prescribed to 5.5

Abstract Introduction An individualised glycated haemoglobin (HbA1c) target according to the patients’ health status is central in the glycaemic management of geriatric people with type 2 diabetes (T2D) in order to avoid hypoglycaemic events through an appropriate management of the glucose-lowering therapy (GLT). Current clinical practice guidelines (CPGs) provide different recommendations for patients’ HbA1c targets. Using real-life data from geriatric patients, this study aimed at assessing the concordance in interpretation of HbA1c values according to three current major CPGs from the Diabetes Canada-2018 (DC18), the Endocrine Society-2019 (ES19) and the American Diabetes Association-2020 (ADA20). Introduction Retrospective study in consecutive older patients (≥75 years) with T2D admitted to a Belgian geriatric ward, with GLT before admission and HbA1c measurement during the hospital stay. Patients were classified into three categories of HbA1c values according to the CPGs recommendations: in-target HbA1c (appropriate-GLT), too-low HbA1c (GLT-overtreatment) and too-high HbA1c (GLT-undertreatment). Concordance of health status classifications and GLT categories between the three CPGs was assessed using Cohen’s and Fleiss’ κ, respectively. Results Of the 318 patients (median age 84 years, 54% women), one-third were in intermediate health and two-thirds in poor health (κ = 0.86; excellent concordance). According to the DC18, ES19 and ADA20 CPGs, HbA1c was in-target for respectively 46%, 25% and 82% of the patients, and too-low HbA1c (GLT-overtreatment) was present in 28%, 57% and 0% (κ = 0.36; low concordance). Results Patients’ HbA1c values are interpreted differently according to these major CPGs, mainly because of differences in their recommendations about HbA1c target individualisation and specifically the definition of a too-low HbA1c value. In clinical practice, these diverging interpretations regarding overtreatment may lead to unsafe GLT prescribing and thereby to hypoglycaemic events in this high-risk population.

To the Editor,In the previous issue of Acta Gastro-Enterologica Belgica, a meta-analysis on the presence of gastrointestinal (GI) symptoms in patients with COVID-19 was published (1).The pooled prevalence of GI manifestations was 12% with diarrhea being the most frequent digestive symptom (8%).Other reports show an incidence rate of diarrhea ranging from 2% to 50%.A question emerges after reading this systematic review : is the presence of these GI symptoms associated with a particular prognosis?At Cliniques universitaires Saint-Luc, we analyzed the first cohort of geriatric patients admitted for

Objectives. To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients. Methods. This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used. Results. The 100 geriatric patients (85 +/- 5 years, 58 % women) received 7.7 +/- 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 +/- 21; dBP: 72 +/- 14 mm Hg). In a standing position, sBP and dBP fell by 12 +/- 17 and 11 +/- 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r(2) = 0.04; dBP: p = 0.59; r(2) = 0.004) nor with psychotropic DDD (sBP: p = 0.14, r(2) = 0.02; dBP: p = 0.82; r(2) = 0.0). In multivariate analysis, sBP drop was positively associated with age, diabetes, falls history, and number of medications, but not with the DDD of any of the medication classes, while dBP drop was positively associated with age, diabetes, stroke and anaemia, but again with the DDD of any of the medication classes. Conclusion. No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable

Atrial fibrillation (AF) is a cardiac arrhythmia that is associated with a higher risk of thromboembolic events, e.g. stroke. The prevention of thromboembolic events relies on the initiation of antithrombotic therapy, including oral anticoagulants (OAC). According to guidelines, patients at high risk of thromboembolic event, as defined by a CHADS2 score ≥ 2, must receive anticoagulants. Until recently, vitamin K antagonists (VKA) were the only OAC available on the market. In 2012, the first direct oral anticoagulant (DOAC) entered the Belgian market. DOACs have several advantages over VKAs that could increase the use of OACs in these patients, and especially in older ones in whom anticoagulation is often underused. Our objectives were to (1) describe the evolution of the underuse of anticoagulants in older people with AF at high risk of thromboembolic event since the marketing of DOACs and (2) describe factors associated with this underuse. We conducted a retrospective cross-sectional study including geriatric patients admitted during the pre-DOAC (2008–2011) and post-DOAC (2013–2015) periods in an academic hospital in Belgium. Five inclusion criteria were met: age ≥ 75 years, diagnosis of AF, indication for anticoagulation (CHADS2 score ≥ 2), risk of functional decline (Identification of Seniors at Risk [ISAR] score ≥ 2) and comprehensive geriatric assessment. The use of anticoagulants and antiplatelets at home before admission was recorded. Risks of stroke and bleeding were calculated using CHADS2 and HEMORR2HAGES scores, respectively. Factors associated with the underuse of anticoagulants were assessed through a multivariable logistic regression. To assess if the pre-DOAC vs post-DOAC marketing period was associated with anticoagulation underuse, three different models were used. First, the multivariable logistic regression described above was used (model 1). The two other models included propensity score (PS) techniques to reduce bias due to confounding variables that could be associated with the time period and/or the underuse of anticoagulants. The second model (model 2) was a mixed-effect logistic regression with PS matching to take into account he matched nature of the data. Variables that were associated with the underuse of anticoagulation in the univariate logistic regression (first model), and those that are clinically relevant (e.g. bleeding risk, antiplatelet use) were introduced in a logistic regression model, with the time period being the outcome, to assess the PS for each patient. The last model (model 3) consisted of a multivariable logistic regression using the inverse probability of treatment weighting. Anticoagulant underuse, present in 34% of geriatric patients with AF, was lower in patients with a history of stroke (OR (95%CI): 0.55 (0.35; 0.85), P = 0.008) or congestive heart failure (OR (95%CI): 0.67 (0.37; 0.86), P = 0.008) but higher in those receiving antiplatelets (OR [95%CI]: 8.45 [5.67; 12.85], P < 0.001) and in older individuals (P = 0.003). Anticoagulant underuse decreased significantly from the pre-DOAC (37.3%) to the post-DOAC (29.7%) era, as shown by the two analyses using PS. Indeed, time period 1 was significantly associated with OAC underuse in model 2 (OR [95%CI] = 1.58 [1.03; 2.41], P = 0.035) and model 3 (OR [95%CI] = 1.34 (1.05; 1.70), P = 0.017). In older patients with AF, anticoagulant underuse was mainly associated with anti-platelet use. Anticoagulant underuse and antiplatelet use have both decreased since DOAC marketing. We cannot ascertain whether this was solely a DOAC effect or the effect of other factors, e.g. the increased awareness of clinicians of the importance of anticoagulation in these patients coming along with information campaigns and published updated guidelines that accompanied DOAC marketing. Underuse of anticoagulants was still a concern for three in ten geriatric patients with AF at high risk of thromboembolic event.

Prescribing inappropriate medication (PIM) is a common public health problem. Mainly due to associated adverse drugs events (ADE), it results in major morbidity and mortality, as well as increased healthcare utilization. For a long time, the systematic review of medications prescribed appeared as a solution for limiting PIM and the ADE associated with such prescriptions. With this aim and since 2008, the list of STOPP-START criteria has appeared as attractive in its design, as well as logical and easy to use. The initial version has just been updated and improved. After having detailed all improvements provided to the 2008 version, we present the result of its adaptation into French language by a group of French-speaking expert from Belgium, Canada, France, and Switzerland.

Screening of orthostatic hypotension (OH) was performed in 285 patients aged 75 years. Current drugs, reasons for admission, geriatric syndromes, and confounding medical conditions were collected. Patients with OH (n=116, 41%) as compared to those without OH (n=169) more frequently (P<0.01) presented falls in the last 6 months (62 vs. 40%, P<0.001), a fall as the reason for the current admission (49 vs. 26%, P<0.001), feeling of fainting (20 vs. 6%, P=0.002), syncope (29 vs. 4%, P<0.001) or functional decline (71 vs. 47%, P=0.012). No difference was observed between the two groups in terms of age (85 +/- 5 vs. 84 +/- 4 years), gender (59 vs. 50% female), common geriatric conditions (e.g. malnutrition 46 vs. 58%, dementia 22 vs. 26%), comorbidity or confounding conditions (dehydration 28 vs. 30%, sepsis 2 vs. 6%). No difference was detected in the use of drugs with psychotropic cardiovascular or diuretic effect, or in their associations. Orthostatic hypotension is frequent upon hospital admission and should be screened, particularly in geriatric fallers. This absence of relation between OH and drugs use suggests that non-pharmacological interventions should be first attempted in older inpatients with OH before deciding to reduce or withdraw useful drugs.

STOPP/START est un outil de détection de la prescription médicamenteuse potentiellement inappropriée chez la personne de 65 ans ou plus. La version initiale de 2008 vient d’être mise à jour et améliorée par ses auteurs. Nous en présentons l’adaptation et la validation en langue française. L’adaptation en français de l’outil STOPP/START.v2 a été réalisée par deux experts, confirmée par la méthode de traduction-inverse, et finalisée d’après les commentaires de neufs évaluateurs francophones, gériatres, pharmaciens cliniciens, et médecin généraliste de quatre pays (France, Belgique, Suisse, Canada). La validation a été complétée par une analyse de concordance inter-juge (CCI) des critères STOPP/START.v2 appliqués à dix vignettes cliniques standardisées. Les 115 critères de STOPP/START.v2 en français sont, par rapport à la version originale anglaise, identiques par leur classification mais adaptés en termes de présentation (critères START.v2 commençant par la condition clinique, et accompagnés par une justification du caractère inapproprié de l’omission) voire de formulation de certains critères. Cette adaptation en français est validée par (i) la traduction-inverse montrant le respect du sens clinique de la version originale, (ii) l’identification semblable des critères lorsque appliqués à dix vignettes cliniques par les neuf évaluateurs, et (iii) le haut niveau de concordance de ces neuf évaluations tant pour STOPP.v2 (CCI 0,849) que pour START.v2 (CCI 0,921). L’adaptation en langue française des critères STOPP/START.v2 fournit aux cliniciens un outil de détection de la prescription médicamenteuse potentiellement inappropriée chez les personnes de 65 ans et plus qui est logique, fiable et facile à utiliser. STOPP/START is a screening tool to detect potentially inappropriate prescribing in persons aged 65 or older. Its Irish authors recently updated and improved the initially published version of 2008. We present the adaptation and validation into French language of this updated tool. STOPP/START.v2 was adapted into French by two experts, then confirmed by a translation-back translation method and finalised according to the comments of nine French-speaking assessors – geriatricians, pharmacologists and a general physician – from four countries (France, Belgium, Switzerland, and Canada). The validation was completed by an inter-rater reliability (IRR) analysis of the STOPP/START.v2 criteria applied to 10 standardized clinical vignettes. In comparison to the original English version, the 115 STOPP/START.v2 criteria in French language classify in identical manner, but the presentation has been adjusted (START.v2 first specifies the clinical condition followed by an explanation of the inappropriateness of the prescription or omission). This adaptation into French language was validated by means of (i) the translation/back-translation, which showed that the French version complied with the clinical meaning of the original criteria; (ii) the similar screening results when applied by the nine specialists to the 10 cases; and (iii) the high level of inter-rater reliability of these 9 evaluations, for both STOPP (IRR 0.849) and START.v2 (IRR 0.921). The adaptation into French of the STOPP/START.v2 criteria provides clinicians with a screening tool to detect potentially inappropriate prescribing in patients aged 65 and older that is more logical, more reliable and easier to use.