REALLON Elsa

Title : Anticholinergic and sedative drug exposure in older patients: from identification to deprescription.

Directors : Dr Teddy NOVAIS & Pr Christelle MOUCHOUX

It is estimated that 20% of hospital admissions to emergency departments for people over 75 years of age are due to drug-related iatrogenia, favored in particular by inappropriate polymedication (drugs prescribed with an uncertain or even unfavorable benefit/risk balance). Among the most deleterious potentially inappropriate medications (PIMs) in older patients are those with anticholinergic and/or sedative (AC/S) properties. A French study showed that 59% of older patients living at home were being treated with such drugs, even though the literature has shown that their use was associated with cognitive decline, the occurrence of falls, functional decline (loss of autonomy), excess mortality, reduced quality of life and the occurrence of hospital admissions.

Reducing AC/S drug exposure in older patients is therefore a priority in the prevention of iatrogenic risk. De-prescribing is one of the strategies developed to meet this need. It is defined as the supervised cessation of inappropriate treatment, with the aim of limiting polymedication and improving the patient's state of health. A multi-center research project (DIOPAS), centered on the evaluation of a multi-disciplinary deprescribing pathway, has won the DGOS PREPS 2023 call for projects. Prior to its implementation, the project will require the creation and validation of algorithms to support healthcare professionals in deprescribing, as well as a phase of co-construction of the intervention to be tested, which will be the subject of this thesis project.

Part 1 will answer the following research question: what is the level of AC/S drug exposure and its impact on older patients in France? It will focus on pharmaco-epidemiological studies describing AC/S drug exposure in older patients, the impact on cognition, and deprescribing practices observed in routine care without the implementation of specific interventions.

The 2nd part will answer the following question: how can AC/S drug deprescribing be implemented safely and effectively in ambulatory and hospitalized older patients? This will involve the development, validation and implementation of algorithms for the deprescribing of AC/S drugs. These algorithms, formalized and transposable in real life within the patient's care pathway, will be built from literature data and the recommendations of a multidisciplinary group of experts set up for this work (geriatricians, psychiatrists, pharmacists and pharmacologists). They will then be validated and implemented with outpatient and inpatient healthcare professionals, during several pilot studies carried out within cohorts of older inpatients and outpatients, ensuring their feasibility and acceptability to future users.

The 3rd part of this thesis will focus on the co-construction of the DIOPAS study intervention (PREPS 2023) through implementation sciences and participatory research, and the effective integration of deprescribing algorithms within the DIOPAS multicenter study. In response to the many obstacles identified in the literature concerning the implementation of deprescription pathways, the project will be co-constructed with all healthcare professionals involved in the care of older patients, and with patient partners who will be able to contribute their knowledge. This approach will culminate in the publication of the final protocol for the DIOPAS study: a randomized controlled trial designed to assess the effectiveness of a multidisciplinary, participatory deprescription pathway for older outpatients treated with drugs with AC/S properties.