Five years ago, Yvette Racette was taking 11 medication pills every day. This lady from Montreal, now 86 years old, wanted to treat her osteoarthritis, of course, but wondered about the merits of taking so many medications. When she changed doctors, it was an opportunity for him to dust off her list of prescriptions.
“Why take so many pills? Just because you’re old doesn’t mean you have to take so much,” says Ms.me Racette on the phone. Gradually, her new doctor withdrew one pill, then another, until her prescriptions were considerably reduced. “I have lost a lot, a lot. The ones I take now, I really need them, ”she observes, satisfied.
Antihypertensives, antipsychotics, benzodiazepines, hypoglycemics, statins, etc. The list of medications prescribed to seniors is dizzying. More than a third of Quebecers aged 65 and over take at least ten prescription drugs a year, according to data from the National Institute of Public Health. In CHSLDs, residents are prescribed an average of 14 medications, 11 of which must be taken each day.
In these pharmaceutical cocktails, often certain ingredients do not provide any benefit, but rather cause undesirable effects. It is not uncommon for these medications to remain on patients’ prescription lists, however, as healthcare professionals lack the time and resources to clean them up.
“Deprescribing”
A new software facilitating “deprescribing” is, however, emerging, and it could change the lives of elderly people who live in the meanders of side effects without jeopardizing their health, according to doctoral student in experimental medicine Émilie Bortolussi-Courval.
“As much as we have to know how to prescribe, we have to know how to deprescribe,” says the young woman, who has seen the misery of seniors in massively medicated CHSLDs up close during internships carried out in these environments as a nurse.
In January, a Canada-wide team of researchers based at McGill University, including Ms.me Bortolussi-Courval is one of them, published the results of a study on deprescribing — probably “the largest ever” in the world, according to Caroline Sirois, a professor of pharmacy at Laval University who did not participate in the works.
The study aimed to test the effectiveness of a digital “decision support” tool that tells healthcare professionals which drugs in a patient’s prescribed package could be safely withdrawn. .
The algorithm, named MedSécure, ranks drugs in order of priority, starting with those that have the best chance of being useless. It assesses drug interactions to spot a dangerous combination. He also estimates whether, based on the patient’s medical file, a product is contraindicated.
Mme Bortolussi-Courval gives a typical example: “Let’s imagine a 78-year-old patient. He takes three medications for pressure, an antipsychotic and a medication for cholesterol. In addition, he is known to take falls. The algorithm may recommend eliminating a pressure medication first, because they are known to increase the risk of falling. »
Between 2017 and 2020, nearly 6,000 patients aged 65 and over were recruited from 11 hospitals across Canada for this research project. At the time of their hospitalization, these patients were taking at least five medications a day.
Before being discharged, half of the group saw their pharmaceutical file analyzed by a doctor who guided their decision thanks to MedSécure. The rest of the cohort received usual care, i.e. chart assessment without the algorithm.
In the control group, 30% of patients saw at least one of their drugs being deprescribed. In the group that received MedSecure, the proportion rose to 55%. Thirty days after discharge from hospital, the same proportion of patients in both groups (5%) had suffered an ‘adverse drug event’.
“In an ideal world”, observes Mme Bortolussi-Courval, the researchers immediately noticed a reduction in side effects in the MedSécure group. However, she points out, it is already an excellent starting point to see that, even with less medication, patients are doing just as well.
“By limiting ourselves to 30 days of follow-up, we get answers that are really only the beginning,” explains the doctoral student. You should go see 6 months later, 12 months later, 18 months after the deprescription. This is where we will see an effect [de réduction] on medication-related hospitalizations.
The researchers also believe that no benefit normally provided by the drugs is sacrificed. Professor Sirois thinks that this hypothesis is very likely. “In basic deprescribing studies, these are elements that are extremely rare,” she explains, because the withdrawal of drugs is done gradually.
In CHSLDs
As part of her doctorate, Émilie Bortolussi-Courval has the mission of carrying out a study similar to the one published in January, but in CHSLDs in Quebec. However, the task promises to be difficult, in particular because patient records are rarely digitized.
“Such a digital tool would be of great value, judge Sophie Zhang, co-president of the Community of Practice of Physicians in CHSLDs. Using a computer to find out which drug to deprescribe is more effective and reduces the risk of error. »
Usually, it is the pharmacists who do the “clearing” of the residents’ prescriptions. However, explains the DD Zhang, there is a lack of pharmacists on the floors of CHSLDs. Physicians, also overwhelmed and in short supply, lack the time to analyze residents’ prescriptions in detail.
The “vast majority” of establishments do not have digitized medical records, confirms the DD Zhang. “But since the pandemic, we have seen things that are unblocking in CHSLDs. It’s realistic to think that we can digitize fairly quickly, but it won’t be immediate. »
Questioned by The dutythe Ministry of Health and Social Services of Quebec, which finds the work of Mme Bortolussi-Courval “interesting”, says that the researcher’s request to test the MedSécure algorithm in CHSLDs is “currently under evaluation”. He says he is “aware and concerned” about the problem of medication in these environments and recalls that two other projects are on track in the network.