Observational Study of the Relation between Parkinson's Disease and Sleep Apnea.

BACKGROUND: Parkinson's disease is characterized by numerous non-motor symptoms, including sleep disorders. Sleep apnea has been reported in a substantial proportion of patients with Parkinson's disease, but it is unclear whether it has significant consequences for the quality of life of those affected or whether it is associated with other manifestations of the disease. OBJECTIVE: To verify whether sleep apnea is associated with more severe motor and non-motor clinical features in Parkinson's disease. METHODS: Parkinson's disease patients underwent polysomnography to diagnose the presence of sleep apnea (apnea-hypopnoea index >10). Participants also underwent an extensive assessment, blinded to sleep apnea status, to determine disease severity, quantitative motor indices, motor subtypes, treatment complications, and sleep, autonomic, psychiatric, and sensory dysfunctions. Cognitive status was also determined with a complete neuropsychological assessment. Results were assessed using regression analysis adjusted for age, sex, and disease duration. RESULTS: Of 92 patients examined, 19 had sleep apnea (21%) and 73 did not. We found no significant differences in motor and non-motor symptoms or signs between apneic and non-apneic Parkinson's disease patients. The use of different apnea-hypopnoea index cut-offs (>5 and >15) produced similar results. CONCLUSIONS: Our results show that sleep apnea is not associated with more severe motor or non-motor manifestations in Parkinson's disease. More studies including control groups are needed to confirm the implications of those results.

Incidence and prevalence of multiple sclerosis in Europe: a systematic review.

BACKGROUND: Multiple sclerosis (MS) is the most common cause of neurological disability in young adults worldwide and approximately half of those affected are in Europe. The assessment of differential incidence and prevalence across populations can reveal spatial, temporal and demographic patterns which are important for identifying genetic and environmental factors contributing to MS. However, study methodologies vary and the quality of the methods can influence the estimates. This study aimed to systematically review European studies of incidence and prevalence of MS and to provide a quantitative assessment of their methodological quality. METHODS: A comprehensive literature search was performed to obtain all original population-based studies of MS incidence and prevalence in European populations conducted and published between January 1985 and January 2011. Only peer-reviewed full-text articles published in English or French were included. All abstracts were screened for eligibility and two trained reviewers abstracted the data and graded the quality of each study using a tool specifically designed for this study. RESULTS: There were 123 studies that met the inclusion criteria. The study estimates were highly heterogeneous, even within regions or countries. Quality was generally higher in the more recent studies, which also tended to use current diagnostic criteria. Prevalence and incidence estimates tended to be higher in the more recent studies and were higher in the Nordic countries and in northern regions of the British Isles. With rare exceptions, prevalence and incidence estimates were higher in women with ratios as high as 3:1. Few studies examined ethnicity. Epidemiological data at the national level was uncommon and there were marked geographical disparities in available data, with large areas of Europe unrepresented and other regions well-represented in the literature. Only 37% of the studies provided standardized estimates. CONCLUSIONS: Despite the breadth of the literature on the epidemiology of MS in Europe, inter-study comparisons are hampered by the lack of standardization. Further research should focus on regions not yet studied and the evaluation of ethnic differences in MS prevalence and incidence. National-level studies using current diagnostic criteria, validated case definitions and similar age- and sex-standardization would allow better geographical comparisons.

Incidence and prevalence of multiple sclerosis in the Americas: a systematic review.

BACKGROUND: The incidence and prevalence of multiple sclerosis (MS) varies considerably around the world. No previous study has performed a comprehensive review examining the incidence and prevalence of MS across the Americas. The purpose of this study was to systematically review and assess the quality of studies estimating the incidence and/or prevalence of MS in North, Central and South American regions. METHODS: A comprehensive literature search was performed using MEDLINE and EMBASE from January 1985 to January 2011. Search terms included 'multiple sclerosis', 'incidence', 'prevalence' and 'epidemiology'. Only full-text articles published in English or French were included. Study quality was assessed using an assessment tool based on recognized guidelines and designed specifically for this study. RESULTS: A total of 3,925 studies were initially identified, with 31 meeting the inclusion criteria. The majority of studies examined North American regions (n = 25). Heterogeneity was high among all studies, even when stratified by country. Only half of the studies reported standardized rates, making comparisons difficult. Quality scores ranged from 3/8 to 8/8. CONCLUSION: This review highlights the gaps that still exist in the epidemiological knowledge of MS in the Americas, and the inconsistencies in methodologies and quality among the published studies. There is a need for future studies of MS prevalence and incidence to include uniform case definitions, employ comparable methods of ascertainment, report standardized results, and be performed on a national level. Other factors such as sex distribution, ethnic make-up and population lifestyle habits should also be considered.

Uncovering the source of new benzodiazepine prescriptions in community-dwelling older adults'.

OBJECTIVE: Initiatives to reduce benzodiazepine use have been largely unsuccessful despite strong associations with adverse outcomes. Curtailing incident use of benzodizepines is an alternate strategy that has yet to be explored. This study aims to determine the source of incident benzodiazepine prescriptions by comparing the risk of receiving a new prescription upon hospital discharge versus after an ambulatory care clinic visit. METHODS: Data were derived from 1189 community-dwelling adults aged 65 years naive to benzodiazepine consumption, enrolled in the Étude sur la Santé des Ainés, a prospective 3-year cohort study conducted in Québec, Canada. Health survey questionnaires were linked with provincial administrative databases of prescription and health service claims. Analysis with multivariate Poisson regression models compared the risk of incident benzodiazepine use post-hospitalization versus after an ambulatory care visit. Models were adjusted for sex, age, antidepressant use, and concomitant drugs. Sub-analyses were conducted for chronic prescriptions. RESULTS: Incident benzodiazepine use was 11% over a 2-year period, with 18.3% of prescriptions leading to chronic use (> 90 days). Hospitalization conferred a 2.7-fold greater risk of incident use than an outpatient visit (OR 2.66, 95% CI 1.78-3.98) and a 4.7-fold (OR 4.74, 95% CI 1.63-13.78) increased risk of chronic use, after adjusting for potential confounders. Despite the increased risk, only 13% of new prescriptions originated post-hospital discharge, with the remainder prescribed during outpatient visits. CONCLUSION: Interventions are required to curb incident benzodiazepine prescriptions at their source both in hospitals and in ambulatory care settings.

Effect of external variables on the performance of the geriatric comorbidity score derived from prescription claims in the community-dwelling elderly.

BACKGROUND: Comorbidity scores based on medical or prescription claims data are frequently used to control for confounding in pharmacoepidemiological studies. Performance of such scores in predicting the risk of death in community-dwelling elderly adults may be compromised by the absence of mental health and socioeconomic characteristics not captured in claims data. OBJECTIVE: The aim of the study was to assess the impact of adding mental health status and sociodemographic characteristics to the Geriatric Comorbidity Score (GCS), a score derived from prescription claims data in the Quebec community-dwelling elderly population. METHODS: We used the cohort study from the longitudinal Quebec Seniors' Health Survey (n = 1,494) conducted between 2005 and 2006. For each participant, we obtained mental health and socioeconomic characteristics through validated questionnaires, which we linked with the medical and prescription claims databases of the Quebec Health Insurance Agency [Régie de l'assurance maladie du Québec (RAMQ)]. The main study outcome was death within 1 year, ascertained using the Quebec death registry. The GCS was calculated from prescription claims data, with the c statistic as a measure of performance. Using backward stepwise selection, external variables (marital status, region, family income, social support, daily hassles, perceived physical and mental health status, presence of mental health disorders) were added to the logistic regression model and the marginal effect assessed by comparing the c statistic with and without each covariate. RESULTS: Over 1 year, 77 deaths (5.15 %) were reported. The c statistic for the GCS was calculated as 0.67 (95 % confidence interval 0.64, 0.70). Addition of sex and age to the score yielded a 2.4 % increase. The variable with the greatest impact on the c statistic was marital status (6.1 % increase). Though important contributors, social support and perceived mental health status did not significantly improve performance of the score. CONCLUSIONS: While sex, age and marital status significantly improved performance of a predictive score in the community-dwelling elderly population, the absence of data on mental and physical health status did not appear to compromise the validity of claims-based scores. Combining comorbidity scores with other methods to control for confounding thus remains a useful tool in pharmacoepidemiological research.

Correlates of potentially inappropriate prescriptions of benzodiazepines among older adults: results from the ESA study.

ESA study data were paired with Quebec medical and pharmaceutical services records to document potentially inappropriate benzodiazepines (Bzs) prescriptions among community-dwelling adults aged 65 and older. Results indicate that 32 per cent of respondents took a mean daily dose of 6.1 mg of equivalent diazepam for, on average, 205 days per year. Almost half (48%) of Bzs users received a potentially inappropriate benzodiazepine prescription at least once during the year preceding the survey. About 23 per cent received at least one concomitant prescription of a Bz and another drug that could result in serious interaction. In addition, individuals aged 75 and older were more likely to receive Bzs for a longer period of time than those aged 65-74. Number of pharmacies used was associated with inappropriate Bzs prescriptions. Our results argue in favour of a more integrated health services system, including a regular review of older adults' drug regimens.

Antipsychotic use and myocardial infarction in older patients with treated dementia.

BACKGROUND: Antipsychotic agents (APs) are commonly prescribed to older patients with dementia. Antipsychotic use is associated with an increased risk of ischemic stroke in this population. Our study aimed to investigate the association of AP use with the risk of acute myocardial infarction (MI). METHODS: A retrospective cohort of community-dwelling older patients who initiated cholinesterase inhibitor treatment was identified between January 1, 2000, and December 31, 2009, using the Quebec, Canada, prescription claims database. From this source cohort, all new AP users during the study period were matched with a random sample of AP nonusers. The risk of MI was evaluated using Cox proportional hazards models, adjusting for age, sex, cardiovascular risk factors, psychotropic drug use, and propensity scores. In addition, a self-controlled case series study using conditional Poisson regression modeling was conducted. RESULTS: Among the source cohort of 37,138 cholinesterase inhibitor users, 10,969 (29.5%) initiated AP treatment. Within 1 year of initiating AP treatment, 1.3% of them had an incident MI. Hazard ratios for the risk of MI after initiation of AP treatment were 2.19 (95% CI, 1.11-4.32) for the first 30 days, 1.62 (95% CI, 0.99-2.65) for the first 60 days, 1.36 (95% CI, 0.89-2.08) for the first 90 days, and 1.15 (95% CI, 0.89-1.47) for the first 365 days. The self-controlled case series study conducted among 804 incident cases of MI among new AP users yielded incidence rate ratios of 1.78 (95% CI, 1.26-2.52) for the 1- to 30-day period, 1.67 (95% CI, 1.09-2.56) for the 31- to 60-day period, and 1.37 (95% CI, 0.82-2.28) for the 61- to 90-day period. CONCLUSION: Antipsychotic use is associated with a modest and time-limited increase in the risk of MI among community-dwelling older patients treated with cholinesterase inhibitors.

Economic impact of nonpersistence with antidepressant treatment in the adult population of Quebec: a comparative cost-effectiveness approach.

BACKGROUND: Although for the great majority of indications, practice guidelines recommend that antidepressants (ADs) be used for at least 6 months, premature discontinuation is very frequent in a "real-life" setting. Previous studies have assessed the economic impact of such nonpersistence, but differences across antidepressant products remain inadequately explored. OBJECTIVE: To compare treatment persistence and incremental cost/persistence ratios (ICPRs) across individual new ADs (selective serotonin reuptake inhibitors and atypical ADs) as well as the associated direct health-care costs in the adult population covered by the public drug program of Quebec. METHODS: A retrospective cohort study was conducted in 13,936 adults aged 18 to 64 years who started an AD treatment in 2003. Persistence was defined as treatment duration of at least 6 months regardless of whether a product switch had occurred. Economic impact was assessed over the first year of treatment through drug, medical services, hospitalization, and total health-care costs. Comparisons across products were conducted using the ICPR. RESULTS: Adjusting for confounders, treatment nonpersistence ranged from 60.4% (paroxetine) to 65.1% (citalopram). The product associated with the highest total health-care costs was citalopram (CDN$2653) and the lowest was venlafaxine (CDN$2168). Fluvoxamine had the lowest mean AD costs (CDN$215) and venlafaxine (CDN$309) the highest. CONCLUSIONS: Total health-care costs were similar across products except for citalopram, which was more costly. Comparisons based on the ICPR revealed that paroxetine, fluoxetine, and venlafaxine were more favorable than the other AD alternatives.

The impact of DSM-IV symptom and clinical significance criteria on the prevalence estimates of subthreshold and threshold anxiety in the older adult population.

OBJECTIVES: Subthreshold anxiety refers to a condition where individuals do not meet the full symptom criteria (i.e., the number of symptoms required for a formal diagnosis is not reached) and/or do not report significant impairment or distress in functioning (i.e., the clinical significance criterion is not met). The purpose of this study was to examine how the symptom and the clinical significance criteria may affect the prevalence estimates of anxiety problems in the older adult population and whether applying these criteria results in an identifiable older group showing more severe anxiety. SETTING AND PARTICIPANTS: Data came from a large representative sample of community-dwelling older adults age 65 years and older (N = 2,784). RESULTS: Results showed that the 12-month prevalence rate of any anxiety problem varied from 5.6% when DSM-IV criteria for anxiety disorders were used to 26.2% when all subthreshold manifestations of anxiety were considered. Findings also indicated that when compared with respondents without anxiety, older adults presenting different manifestations of subthreshold or threshold anxiety appear to be more similar than different in their health and health behavior characteristics. CONCLUSIONS: Subthreshold anxiety has a high prevalence and may cause significant impairment. Both symptom and clinical significance criteria do not perfectly discriminate between older adults with or without a severe anxiety problem presenting comorbid disorders and needing psychiatric help.

The association between length of benzodiazepine use and sleep quality in older population.

BACKGROUND: Sleep disturbances are frequently reported in the older adult population and benzodiazepines are the drugs most often prescribed to treat these problems. Nearly 25% of the older adult population uses these drugs and 83% of benzodiazepine users report sleep problems. Although the Collège des Médecins du Québec suggests a maximum length of use of 3 months, according to most studies the mean length of benzodiazepine use is longer. The goal of this study was to document the association between length of benzodiazepine use and sleep quality as reported by adults 65 years older and over. METHODS: Data used in this study came from the Seniors' Health Survey (ESA) conducted in a representative sample of the community-dwelling older population in Quebec, Canada. Inclusion criteria included the ability to speak and understand French. Data were analyzed using a structural equation modeling strategy. RESULTS: Long-term benzodiazepine users were more likely to report poor sleep quality. Sleep quality of initial probable problematic sleepers tended to increase over 1 year but sleep quality in benzodiazepines users increased less rapidly than in non-users. Also, women were more likely to report using benzodiazepines and having poorer sleep quality. CONCLUSION: Longitudinal studies using incident cases of benzodiazepine use should be conducted to better determine the causal relationship between sleep quality and benzodiazepine use in the older population.

Benzodiazepine use and quality of sleep in the community-dwelling elderly population.

BACKGROUND: About 50% of the elderly population report being dissatisfied with their sleep. Although benzodiazepines are the most prescribed drugs to treat sleep complaints, the effectiveness of their use on the quality of sleep is not well documented. OBJECTIVES: This study aimed to assess the association between benzodiazepine use and global sleep quality, as well as six components of sleep quality. METHODS: Data from the cross-sectional Quebec Survey on Seniors' Health (n = 2798) conducted in 2005-2006 were used. Quality of sleep was self-reported and use of benzodiazepines was assessed during the previous year. RESULTS: Benzodiazepine users reported poorer quality of sleep than non-users. The association between benzodiazepine use and each of the six quality of sleep components studied were similar except for the daytime dysfunction component. CONCLUSION: The results suggest that there is no evidence that using benzodiazepines is associated with better quality of sleep than non-users in the elderly population. Future longitudinal population-based studies are needed to assess improvements in quality of sleep in the elderly associated with the use of benzodiazepines.

The prevalence of benzodiazepine dependence among community-dwelling older adult users in Quebec according to typical and atypical criteria.

BACKGROUND: Use of benzodiazepines, common among older people, may lead to substance dependence. DSM-IV-TR criteria for this iatrogenic problem may apply poorly to older persons following a physician-prescribed regimen. This study, first of its kind, aimed to determine the prevalence rate of benzodiazepine dependence in older persons according to DSM-IV-TR and other atypical criteria. METHODS: Descriptive study based on face-to-face interviews conducted in the homes of 2,785 persons aged 65 years or older who were randomly selected from across the province of Quebec, Canada. RESULTS: Use of benzodiazepines was reported by 25.4% of respondents. Among them, 9.5% met DSM-IV-TR criteria for substance dependence. However, 43% of users reported being dependent, and one third agreed that it would be a good thing to stop taking benzodiazepines. INTERPRETATION: Benzodiazepine substance dependence is established at one tenth of community-dwelling older persons taking these medications, although a much larger proportion self-labels as dependent.

Use of health services for psychological distress symptoms among community-dwelling older adults.

ABSTRACTTo document the use of health services for psychological distress symptoms, we collected data from a cross-section of adults aged 65 years and over. Nearly 13 per cent met DSM-IV criteria for mood or anxiety disorders. In addition, 42.4 per cent of those having at least one DSM-IV diagnosis reported having used health services. Results show a direct association between the presence of a probable DSM-IV diagnosis and health service use. However, our results show no significant association between gender and health service use, and do not support the hypothesis that minimal social support increases the probability of older adults using health services for psychological distress. The analysis suggests unmarried elders are more likely than married elders to use health services. Furthermore, this study shows that older adults having a high level of daily hassles reported using health services for psychological distress than those reporting a low stress level. We conclude that a large proportion of elderly mental health needs in Quebec are potentially not being met.

Factors associated with benzodiazepine dependence among community-dwelling seniors.

BACKGROUND: Benzodiazepine (BZD) dependence among seniors is an understudied problem. OBJECTIVE: Identify the factors associated with BZD dependence. METHOD: Face-to-face computer-assisted interviews were conducted in the homes of 2,785 persons aged 65 years or older, randomly selected. RESULTS: Nine-and-a-half percent of BZD users met DSM-IV-TR criteria for BZD dependence. Factors associated with BZD dependence are being a woman, and having cognitive impairment, panic disorders, suicidal ideations, and a degree of embarrassment in obtaining help for emotional problem. DISCUSSION: Nurses should be better positioned to identify those elderly users of BZDs who are more likely to be dependent and to address the problem through BZD withdrawal program.