RESUMEN
BACKGROUND: Rates of overweight and obesity are disproportionately high among youth with serious emotional disturbance (SED). Little is known about community mental health providers' delivery of weight loss interventions to this vulnerable population. OBJECTIVE: This study examined attitudinal predictors of their providers' intentions to deliver weight loss interventions to youth with SED using the theory of planned behaviour. DESIGN: This study used a cross-sectional, single-time-point design to examine the relationship of the theory of planned behaviour constructs with behavioural intention. SETTING AND PARTICIPANTS: Community mental health providers (n = 101) serving youth with SED in the United States completed online clinical practice and theory of planned behaviour surveys. MAIN VARIABLES STUDIED: We examined the relationship of direct attitude constructs (i.e., attitude towards the behaviour, social norms and perceived behavioural control), role beliefs and moral norms with behavioural intention. Analyses included a confirmatory factor analysis and two-step linear regression. RESULTS: The structure of the model and the reliability of the questionnaire were supported. Direct attitude constructs, role beliefs and moral norms predicted behavioural intention to deliver weight loss interventions. DISCUSSION: While there is debate about the usefulness of the theory of planned behaviour, our results showed that traditional and newer attitudinal constructs appear to influence provider intentions to deliver weight loss interventions to youth with SED. Findings suggest preliminary strategies to increase provider intentions. PUBLIC CONTRIBUTION: This study was designed and the results were interpreted as part of a larger, community-based participatory research effort that included input from youth, families, providers, administrators and researchers. Collaborative discussions with community mental health providers and administrators particularly contributed to the study question asked as well as interpretation of results.
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Síntomas Afectivos , Salud Mental , Humanos , Adolescente , Estudios Transversales , Reproducibilidad de los Resultados , Pérdida de Peso , Intención , Encuestas y CuestionariosRESUMEN
AIMS: To estimate the association between patterns of anticholinergic, benzodiazepine and Z-drug medication use and change in cognitive function in middle-aged and older adults. METHODS: This prospective cohort study used data from the first three waves of The Irish Longitudinal Study on Ageing (TILDA), including community-dwelling adults aged ≥50 years followed for up to 4 years (n = 7027). Cognitive function was assessed using the Mini Mental State Examination, animal naming test and word recall tests. Regular medication use was self-reported at baseline and follow-up interviews at 2 and 4 years. Pharmacy dispensing claims for a subset (n = 2905) allowed assessment of medication use between interviews and cumulative dosage. Medication use at consecutive waves of TILDA was analysed in relation to change in cognitive function between waves. RESULTS: Strongly anticholinergic medications (Anticholinergic Cognitive Burden scale 3), benzodiazepines and Z-drugs were reported by 7.3%, 5.8% and 5.1% of participants, respectively, at any time during the study. Adjusting for potential confounders, new anticholinergic use between interviews was associated with change in recall score (-1.09, 95% confidence interval -1.64, -0.53) over 2 years compared to non-use, but not with MMSE (0.07; 95% CI -0.21, 0.34) or animal naming (-0.70; 95% CI -1.43, 0.03). The pharmacy claims analysis was consistent with this finding. Other hypothesised associations were not supported. CONCLUSIONS: Except for new use of anticholinergic medications, no other findings supported a risk of cognitive decline over 2-year periods in this middle-aged and older cohort. Patients and prescribers should weigh this potential risk against potential benefits of commencing anticholinergic medications.
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Disfunción Cognitiva , Preparaciones Farmacéuticas , Anciano , Envejecimiento , Benzodiazepinas/efectos adversos , Antagonistas Colinérgicos/efectos adversos , Disfunción Cognitiva/inducido químicamente , Disfunción Cognitiva/epidemiología , Humanos , Estudios Longitudinales , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND: Sleep disturbance is common in dementia and often treated with Z-drugs (zopiclone, zaleplon, and zolpidem). While some observational studies suggest that Z-drugs are associated with adverse events such as falls and fracture risks in older people, this has not been studied in dementia. METHODS: We used data from 27,090 patients diagnosed with dementia between January 2000 and March 2016 from the Clinical Practice Research Datalink linked to Hospital Episodes Statistics data in England. We compared adverse events for 3532 patients newly prescribed Z-drugs by time-varying dosage to (1) 1833 non-sedative-users with sleep disturbance; (2) 10,214 non-sedative-users with proximal GP consultation matched on age, sex, and antipsychotic use; and (3) 5172 patients newly prescribed benzodiazepines. We defined higher dose Z-drugs and benzodiazepines as prescriptions equivalent to ≥ 7.5 mg zopiclone or > 5 mg diazepam daily. Cox regression was used to estimate hazard ratios (HRs) for incident fracture, hip fracture, fall, mortality, acute bacterial infection, ischaemic stroke/transient ischaemic attack, and venous thromboembolism over a 2-year follow-up, adjusted for demographic- and health-related covariates. RESULTS: The mean (SD) age of patients was 83 (7.7) years, and 16,802 (62%) were women. Of 3532 patients prescribed Z-drugs, 584 (17%) were initiated at higher doses. For patients prescribed higher dose Z-drugs relative to non-users with sleep disturbance, the HRs (95% confidence interval) for fractures, hip fractures, falls, and ischaemic stroke were 1.67 (1.13-2.46), 1.96 (1.16-3.31), 1.33 (1.06-1.66), and 1.88 (1.14-3.10), respectively. We observed similar associations when compared to non-sedative-users with proximal GP consultation. Minimal or inconsistent excess risks were observed at ≤ 3.75 mg zopiclone or equivalent daily, and for mortality, infection, and venous thromboembolism. We observed no differences in adverse events for Z-drugs compared to benzodiazepines, except lower mortality rates with Z-drugs (HR [95% confidence interval] of 0.73 [0.64-0.83]). CONCLUSIONS: Higher dose Z-drug use in dementia is associated with increased fracture and stroke risks, similar or greater to that for higher dose benzodiazepines. Higher dose Z-drugs should be avoided, if possible, in people living with dementia, and non-pharmacological alternatives preferentially considered. Prescriptions for higher dose Z-drugs in dementia should be regularly reviewed. TRIAL REGISTRATION: ENCePP e-register of studies, EUPAS18006.
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Acetamidas/efectos adversos , Compuestos de Azabiciclo/efectos adversos , Demencia/tratamiento farmacológico , Piperazinas/efectos adversos , Pirimidinas/efectos adversos , Trastornos del Sueño-Vigilia/tratamiento farmacológico , Zolpidem/efectos adversos , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: the long-term effect of the use of drugs with anticholinergic activity on cognitive function remains unclear. METHODS: we conducted a systematic review and meta-analysis of the relationship between anticholinergic drugs and risk of dementia, mild cognitive impairment (MCI) and cognitive decline in the older population. We identified studies published between January 2002 and April 2018 with ≥12 weeks follow-up between strongly anticholinergic drug exposure and the study outcome measurement. We pooled adjusted odds ratios (OR) for studies reporting any, and at least short-term (90+ days) or long-term (365+ days) anticholinergic use for dementia and MCI outcomes, and standardised mean differences (SMD) in global cognition test scores for cognitive decline outcomes. Statistical heterogeneity was measured using the I2 statistic and risk of bias using ROBINS-I. RESULTS: twenty-six studies (including 621,548 participants) met our inclusion criteria. 'Any' anticholinergic use was associated with incident dementia (OR 1.20, 95% confidence interval [CI] 1.09-1.32, I2 = 86%). Short-term and long-term use were also associated with incident dementia (OR 1.23, 95% CI 1.17-1.29, I2 = 2%; and OR 1.50, 95% CI 1.22-1.85, I2 = 90%). 'Any' anticholinergic use was associated with cognitive decline (SMD 0.15; 95% CI 0.09-0.21, I2 = 3%) but showed no statistically significant difference for MCI (OR 1.24, 95% CI 0.97-1.59, I2 = 0%). CONCLUSIONS: anticholinergic drug use is associated with increased dementia incidence and cognitive decline in observational studies. However, a causal link cannot yet be inferred, as studies were observational with considerable risk of bias. Stronger evidence from high-quality studies is needed to guide the management of long-term use.
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Disfunción Cognitiva , Demencia , Preparaciones Farmacéuticas , Antagonistas Colinérgicos/efectos adversos , Cognición , Disfunción Cognitiva/inducido químicamente , Disfunción Cognitiva/diagnóstico , Disfunción Cognitiva/epidemiología , Demencia/inducido químicamente , Demencia/diagnóstico , Demencia/epidemiología , HumanosRESUMEN
BACKGROUND: Anticholinergic medication use is linked with increased cognitive decline, dementia, falls and mortality, and their use should be limited in older people. Here we estimate the prevalence of anticholinergic use in England's older population in 1991 and 2011, and describe changes in use by participant's age, sex, cognition and disability. METHODS: We compared data from participants aged 65+ years from the Cognitive Function and Ageing Studies (CFAS I and II), collected during 1990-1993 (N = 7635) and 2008-2011 (N = 7762). We estimated the prevalence of potent anticholinergic use (Anticholinergic Cognitive Burden [ACB] score = 3) and average anticholinergic burden (sum of ACB scores), using inverse probability weights standardised to the 2011 UK population. These were stratified by age, sex, Mini-Mental State Examination score, and activities of daily living (ADL) or instrumental ADL (IADL) disability. RESULTS: Prevalence of potent anticholinergic use increased from 5.7% (95% Confidence Interval [CI] 5.2-6.3%) of the older population in 1990-93 to 9.9% (9.3-10.7%) in 2008-11, adjusted odds ratio of 1.90 (95% CI 1.67-2.16). People with clinically significant cognitive impairment (MMSE [Mini Mental State Examination] 21 or less) were the heaviest users of potent anticholinergics in CFAS II (16.5% [95% CI 12.0-22.3%]). Large increases in the prevalence of the use medication with 'any' anticholinergic activity were seen in older people with clinically significant cognitive impairment (53.3% in CFAS I to 71.5% in CFAS II). CONCLUSIONS: Use of potent anticholinergic medications nearly doubled in England's older population over 20 years with some of the greatest increases amongst those particularly vulnerable to anticholinergic side-effects.
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Antagonistas Colinérgicos , Demencia , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Envejecimiento , Antagonistas Colinérgicos/efectos adversos , Cognición , Inglaterra/epidemiología , Humanos , PrevalenciaRESUMEN
Background: Despite extensive literature examining perceptions of recovery from severe mental illness, literature focusing on recovery from depression in adults is limited.Aim: Systematically review the existing literature investigating patients' and clinicians' perceptions of, and factors associated with, recovery from depression.Method: Studies investigating perceptions of, and factors associated with, recovery from depression in adults were identified through database searches. Studies were assessed against inclusion criteria and quality rating checklists.Results: Fourteen studies met the inclusion criteria. Recovery from depression is perceived as a complex, personal journey. The concept of normalised, biomedical definitions of recovery is not supported, with the construction of self and societal gender expectations identified by women as central to recovery. Recovery from depression was associated with higher levels of perceived social support and group memberships. A range of factors are identified as influencing recovery. However, physicians and patients prioritise different factors assessing what is important in being "cured" from depression.Conclusions: Recovery from depression is perceived by patients as a complex, personal process, influenced by a range of factors. However, greater understanding of clinicians' perceptions of client recovery from depression is essential to inform clinical practice and influence future research.
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Trastorno Depresivo/terapia , Conocimientos, Actitudes y Práctica en Salud , Personal de Salud/psicología , Humanos , Factores Sexuales , Apoyo Social , Resultado del TratamientoRESUMEN
Previous estimates of whether long-term exposure to benzodiazepines increases dementia risk are conflicting and are compromised by the difficulty of controlling for confounders and by reverse causation. We investigated how estimates for the association between benzodiazepine use and later dementia incidence varied based on study design choices, using a case-control study nested within the United Kingdom's Clinical Practice Research Datalink. A total of 40,770 dementia cases diagnosed between April 2006 and July 2015 were matched on age, sex, available data history, and deprivation to 283,933 control subjects. Benzodiazepines and Z-drug prescriptions were ascertained in a drug-exposure period 4-20 years before dementia diagnosis. Estimates varied with the inclusion of new or prevalent users, with the timing of covariate ascertainment, and with varying time between exposure and outcome. There was no association between any new prescription of benzodiazepines and dementia (adjusted odds ratio (OR) = 1.03, 95% confidence interval (CI): 1.00, 1.07), whereas an inverse association was observed among prevalent users (adjusted OR = 0.91, 95% CI: 0.87, 0.95), although this was likely induced by unintentional adjustment for colliders. By considering the choice of confounders and timing of exposure and covariate measurement, our findings overall are consistent with no causal effect of benzodiazepines or Z-drugs on dementia incidence.
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Benzodiazepinas/uso terapéutico , Demencia/inducido químicamente , Demencia/epidemiología , Prescripciones de Medicamentos/estadística & datos numéricos , Anciano , Sesgo , Estudios de Casos y Controles , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Masculino , Prevalencia , Factores de Riesgo , Reino Unido/epidemiologíaRESUMEN
AIMS: Older individuals with diabetes are susceptible to harm as the result of hypoglycaemia; however, the consequences of hypoglycaemia in older individuals with dementia are not known. We aimed to test the association between hypoglycaemia and serious adverse events in older patients with diabetes and dementia, and whether the consequences of hypoglycaemia were affected by the presence of dementia. MATERIALS AND METHODS: This was a cohort study using the Clinical Practice Research Datalink in England (1997-2016). We selected participants, intervention (exposure) and follow-up to mirror two hypothetical target randomized controlled trials. The exposure of target trial 1 was hypoglycaemia in patients with dementia. Target trial 2 examined adverse effects of hypoglycaemia according to dementia status. We used Cox proportional hazard regression to estimate adjusted hazard ratios (aHR) for falls, fractures, cardiovascular events and mortality. RESULTS: In target trial 1, hypoglycaemia was associated with increased risk during a 12-month follow-up period for falls and fractures (aHR, 1.94 [95% CI, 1.67-2.24]), for cardiovascular events (aHR, 2.00 [95% CI, 1.61-2.48]) and for mortality (aHR, 2.36 [95% CI, 2.09-2.67]). In target trial 2, the presence of dementia was associated with increased risk of adverse events, following hypoglycaemia, during a 12-month follow-up period for falls and factures (aHR, 1.72 [95% CI, 1.51-1.96]) and for mortality (aHR, 1.27 [95% CI, 1.15-1.41]), but dementia had no effect on cardiovascular events (aHR, 1.14 [95% CI, 0.95 to 1.36]). CONCLUSIONS: Hypoglycaemia is associated with early increased risk of serious adverse events in older individuals with diabetes and dementia.
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Accidentes por Caídas/mortalidad , Demencia/mortalidad , Complicaciones de la Diabetes/mortalidad , Diabetes Mellitus/mortalidad , Fracturas Óseas/mortalidad , Hipoglucemia/mortalidad , Anciano , Anciano de 80 o más Años , Causas de Muerte , Demencia/etiología , Inglaterra/epidemiología , Femenino , Fracturas Óseas/etiología , Humanos , Hipoglucemia/etiología , Masculino , Estudios RetrospectivosRESUMEN
BACKGROUND: Studies suggest that anticholinergic medication or benzodiazepine use could increase dementia risk. We tested this hypothesis using data from a UK cohort study. METHODS: We used data from the baseline (Y0), 2-year (Y2) and 10-year (Y10) waves of the Medical Research Council Cognitive Function and Ageing Study. Participants without dementia at Y2 were included (n = 8216). Use of benzodiazepines (including nonbenzodiazepine Z-drugs), anticholinergics with score 3 (ACB3) and anticholinergics with score 1 or 2 (ACB12) according to the Anticholinergic Cognitive Burden scale were coded as ever use (use at Y0 or Y2), recurrent use (Y0 and Y2), new use (Y2, but not Y0) or discontinued use (Y0, but not Y2). The outcome was incident dementia by Y10. Incidence rate ratios (IRR) were estimated using Poisson regression adjusted for potential confounders. Pre-planned subgroup analyses were conducted by age, sex and Y2 Mini-Mental State Examination (MMSE) score. RESULTS: Dementia incidence was 9.3% (N = 220 cases) between Y2 and Y10. The adjusted IRRs (95%CI) of developing dementia were 1.06 (0.72, 1.60), 1.28 (0.82, 2.00) and 0.89 (0.68, 1.17) for benzodiazepines, ACB3 and ACB12 ever-users compared with non-users. For recurrent users the respective IRRs were 1.30 (0.79, 2.14), 1.68 (1.00, 2.82) and 0.95 (0.71, 1.28). ACB3 ever-use was associated with dementia among those with Y2 MMSE> 25 (IRR = 2.28 [1.32-3.92]), but not if Y2 MMSE≤25 (IRR = 0.94 [0.51-1.73]). CONCLUSIONS: Neither benzodiazepines nor ACB12 medications were associated with dementia. Recurrent use of ACB3 anticholinergics was associated with dementia, particularly in those with good baseline cognitive function. The long-term prescribing of anticholinergics should be avoided in older people.
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Benzodiazepinas/uso terapéutico , Antagonistas Colinérgicos/efectos adversos , Demencia/inducido químicamente , Demencia/epidemiología , Anciano , Anciano de 80 o más Años , Benzodiazepinas/efectos adversos , Antagonistas Colinérgicos/uso terapéutico , Cognición/efectos de los fármacos , Cognición/fisiología , Estudios de Cohortes , Demencia/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Pruebas de Estado Mental y Demencia , Reino Unido/epidemiologíaRESUMEN
BACKGROUND: The incidence of herpes zoster (HZ) is increasing and poses a significant health concern to aging populations. Several studies suggest an increased risk of stroke following zoster infection, but the results are conflicting. We conducted a systematic review and meta-analysis to determine if stroke risk is increased following HZ infection. METHODS: A search of MEDLINE, EMBASE, Google scholar, Web of Science, CAB Direct, Cumulative Index to Nursing and Allied Health Literature, and Evidence Based Medicine Reviews was conducted for observational studies of adults with HZ infection that examined stroke and TIA risk from January 1, 1966 to May 31, 2016. Adjusted relative risks reported for similar follow-up durations were pooled across studies separately using random-effects inverse variance models. RESULTS: Data were pooled from nine studies. Relative risk for stroke after zoster was 1.78 (95% CI 1.70-1.88) for the first month following herpes zoster, dropping progressively to 1.43 (95% CI 1.38-1.47) after 3 months, to 1.20 (95% CI 1.14-1.26) after 1 year. We found that stroke risk increases by a larger margin during the first month after a herpes zoster ophthalmicus episode: relative risk 2.05 (95% CI 1.82-2.31). The risk remains elevated one year after the acute episode. CONCLUSIONS: Herpes zoster is an established risk factor for increasing the risk of stroke, especially shortly after infection. Vaccination should be encouraged in patients at high risk of cardiovascular disease.
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Herpes Zóster/complicaciones , Accidente Cerebrovascular/virología , Humanos , Factores de RiesgoRESUMEN
Background: Primary care is an ideal setting for physical activity interventions to prevent and manage common long-term conditions. To identify those who can benefit from such interventions and to deliver tailored support, primary care professionals (e.g. GPs, practice nurses, physiotherapists, health care assistants) need reliable and valid tools to assess physical activity. However, there is uncertainty about the best-performing tool. Objective: To identify the tools used in the literature to assess the physical activity in primary care and describe their psychometric properties. Method: A systematic review of published and unpublished literature was undertaken up to 1 December 2016). Papers detailing physical activity measures, tools or approaches used in primary care consultations were included. A synthesis of the frequency and context of their use, and their psychometric properties, was undertaken. Studies were appraised using the Downs and Black critical appraisal tool and the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) initiative checklist. Results: Fourteen papers reported 10 physical activity assessment tools. The General Practice Physical Activity Questionnaire (GPPAQ) was most frequently reported. None of the assessment tools identified showed high reliability and validity. Intra-rater reliability ranged from kappa: 0.53 [Brief Physical Activity Assessment Tool (BPAAT)] to 0.67 (GPPAQ). Criterion validity ranged from Pearson's rho: 0.26 (GPPAQ) to 0.52 (Physical Activity Vital Sign). Concurrent validity ranged from kappa: 0.24 (GPPAQ) to 0.64 (BPAAT). Conclusion: The evidence base about physical activity assessment in primary care is insufficient to inform current practice.
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Ejercicio Físico/fisiología , Atención Primaria de Salud , Psicometría , Encuestas y Cuestionarios , Humanos , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: polypharmacy is an important risk factor for falls, but recent studies suggest only when including medications associated with increasing the risk of falls. DESIGN: a prospective, population-based cohort study. SUBJECTS: 6,666 adults aged ≥50 years from The Irish Longitudinal study on Ageing. METHODS: participants reported regular medication use at baseline. Any subsequent falls, any injurious falls and the number of falls were reported 2 years later. The association between polypharmacy (>4 medications) or fall risk-increasing medications and subsequent falls or injurious falls was assessed using modified Poisson regression. The association with the number of falls was assessed using negative binomial regression. RESULTS: during follow-up, 231 falls per 1,000 person-years were reported. Polypharmacy including antidepressants was associated with a greater risk of any fall (adjusted relative risk (aRR) 1.28, 95% CI 1.06-1.54), of injurious falls (aRR 1.51, 95% CI 1.10-2.07) and a greater number of falls (adjusted incident rate ratio (aIRR) 1.60, 95% CI 1.19-2.15), but antidepressant use without polypharmacy and polypharmacy without antidepressants were not. The use of benzodiazepines was associated with injurious falls when coupled with polypharmacy (aRR 1.40, 95% CI 1.04-1.87), but was associated with a greater number of falls (aIRR 1.32, 95% CI 1.05-1.65), independent of polypharmacy. Other medications assessed, including antihypertensives, diuretics and antipsychotics, were not associated with outcomes. CONCLUSION: in middle-aged and older adults, polypharmacy, including antidepressant or benzodiazepine use, was associated with injurious falls and a greater number of falls.
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Accidentes por Caídas/estadística & datos numéricos , Antidepresivos/efectos adversos , Benzodiazepinas/efectos adversos , Polifarmacia , Factores de Edad , Anciano , Envejecimiento , Femenino , Humanos , Vida Independiente , Irlanda , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
OBJECTIVE: To obtain the distribution of Thai Mental State Examination (TMSE) scores in the Thai population across different age groups and educational levels in men and women aged 50 years and older and its relationship with demographic factors. The different cutpoints in literate and illiterate participants and item performance in both groups were also determined. MATERIAL AND METHOD: Community-dwelling participants aged 50 years and over were invited to join the study. Personal information, general health history, and specific illness questionnaires including the activities of daily living, designed by the Survey in Europe on Nutrition and the Elderly, a ConcertedAction (SENECA), and the Thai Mental State Examination (TMSE) were completed in the face-to-face interview. RESULTS: There were 4,459 participants with no specific reported conditions that could potentially influence cognitive performance. The mean (SD) age was 64.2 (7.9) years and mostparticipants were women (71.7%). The median (interquartile range) of the TMSE was 27 (25-29) and 23 (19-26) in literate and illiterate participants, respectively. The distribution of TMSE scores were reported here determined by age, gender and educational level. Percentage of correct response in each TMSE item was low in recall and calculation performance. TMSE score declined with age in both genders and had greater variation with increasing age. TMSE score also increased with increasing levels of education and better financial status. Gender was not associated with the TMSE score adjusting for age, educational level, and economic status. CONCLUSION: Age, education, and economic status have an influence on the TMSE performance. Controllingfor these three factors, genders does not contribute to significant differences in TMSE performance. Norms adjustedfor these factors should be considered before employing single cutpoints to identify impairment.
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Pruebas de Inteligencia , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores Socioeconómicos , TailandiaRESUMEN
PURPOSE: Differing healthcare access has implications for public health. In Ireland, eligibility for free public health care is means tested. Here, we examine the association between healthcare access and polypharmacy while accounting for underlying socio-economic and health status differences. METHODS: Self-reported regular medication use, history of diagnosed health conditions, disability, socio-demographics, and objective measures of depression and anxiety for adults aged 50-69 years (n = 5796) were ascertained from the population-representative Irish Longitudinal Study on Ageing. Objective measures of frailty, cognition, hypertension, and body mass index were also assessed for 4241 participants. The associations between free healthcare access and polypharmacy and use of 15 medication classes were estimated using multivariable modified Poisson regression, adjustment for the propensity score, and inverse probability of treatment weighting by the propensity score. RESULTS: Polypharmacy was reported by 22% and 7% of the 1932 and 3864 participants with and without public healthcare coverage. Public patients had a 21-38% greater risk of polypharmacy depending on the method used to account for confounding. Results were less robust using propensity score weighting. There was evidence that classes of cardiovascular drugs, drugs for acid-related disorders, and analgesics were used more commonly in public patients. Associations were mostly unaffected after also accounting for objective health measures but were significantly attenuated after accounting for frequency of healthcare visits. CONCLUSIONS: Publically funded health care in Ireland leads to greater medication use in people aged 50-69 years. This may reflect over-prescribing to public patients or restricted use among those who pay out of pocket.
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Atención a la Salud/economía , Prescripción Inadecuada/economía , Programas Nacionales de Salud/economía , Polifarmacia , Puntaje de Propensión , Anciano , Factores de Confusión Epidemiológicos , Atención a la Salud/tendencias , Femenino , Humanos , Prescripción Inadecuada/tendencias , Irlanda/epidemiología , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Programas Nacionales de Salud/tendenciasRESUMEN
Youth with mental health disorders (MHD), particularly those who take psychotropic medications, are at increased risk of being overweight or obese (OW/OB) when compared to typical youth. Parents are important resources for interventions addressing OW/OB. However, parents of youth with MHD may face challenges that require interventions designed to address their needs. Prior to investing research funding in the development of interventions for this group, research is needed to understand factors associated with parents' decisions to enroll in these programs. The theory of planned behavior (TPB) provided a framework for examining parents' salient beliefs, direct attitudes, and intention to enroll in a hypothetical online healthy lifestyle intervention for their youth (ages 11-17) with OW/OB and treated with psychotropic medication. Parents who were enrolled in the study (n = 84) completed demographic questionnaires and a TPB questionnaire which was constructed for this study. A confirmatory factor analysis (CFA) of the direct attitude (i.e., attitude toward the behavior, subjective norm, perceived behavioral control) questions generally supported the three-factor model (i.e., RMSEA = .07, 90% CI .03-.11, p = .18; CFI = .96, SRMR = .06). Results from a multiple regression analysis demonstrated that direct attitudes predicted parent intention to participate in an online healthy lifestyle intervention for this sample of youth accounting for 84% of variance. In this preliminary study, the TPB appears to be a promising framework for understanding direct attitudes associated with parent intentions toward intervention participation in this population of youth. Interventions for parents of youth with OW/OB who are prescribed psychotropic medication should consider addressing these direct attitudes to improve intention.
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Conductas Relacionadas con la Salud , Intención , Padres , Psicotrópicos , Adolescente , Niño , Femenino , Humanos , Masculino , Intervención basada en la Internet , Trastornos Mentales/terapia , Trastornos Mentales/tratamiento farmacológico , Trastornos Mentales/psicología , Sobrepeso/terapia , Sobrepeso/psicología , Padres/psicología , Obesidad Infantil/psicología , Obesidad Infantil/terapia , Teoría Psicológica , Psicotrópicos/uso terapéutico , Encuestas y Cuestionarios , Teoría del Comportamiento PlanificadoRESUMEN
[This corrects the article DOI: 10.1371/journal.pone.0288938.].
RESUMEN
OBJECTIVE: This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy). METHODS: Expert practitioners in each discipline traditionally utilized in the treatment of CRPS systematically reviewed the available and relevant literature; due to the paucity of levels 1 and 2 studies, less rigorous, preliminary research reports were included. The literature review was supplemented with knowledge gained from extensive empirical clinical experience, particularly in areas where high-quality evidence to guide therapy is lacking. RESULTS: The research quality, clinical relevance, and "state of the art" of diagnostic criteria or treatment modalities are discussed, sometimes in considerable detail with an eye to the expert practitioner in each therapeutic area. Levels of evidence are mentioned when available, so that the practitioner can better assess and analyze the modality under discussion, and if desired, to personally consider the citations. Tables provide details on characteristics of studies in different subject domains described in the literature. CONCLUSIONS: In the humanitarian spirit of making the most of all current thinking in the area, balanced by a careful case-by-case analysis of the risk/cost vs benefit analysis, the authors offer these "practical" guidelines.
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Distrofia Simpática Refleja/rehabilitación , Agonistas alfa-Adrenérgicos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Anestésicos Locales/uso terapéutico , Antiinflamatorios/uso terapéutico , Anticonvulsivantes/uso terapéutico , Antidepresivos Tricíclicos/uso terapéutico , Conservadores de la Densidad Ósea/uso terapéutico , Síndromes de Dolor Regional Complejo/diagnóstico , Síndromes de Dolor Regional Complejo/tratamiento farmacológico , Síndromes de Dolor Regional Complejo/rehabilitación , Humanos , Terapia Ocupacional , Modalidades de Fisioterapia , Receptores de N-Metil-D-Aspartato/antagonistas & inhibidores , Terapia Recreativa , Distrofia Simpática Refleja/diagnóstico , Distrofia Simpática Refleja/tratamiento farmacológico , Rehabilitación VocacionalRESUMEN
INTRODUCTION: The Médecins Sans Frontières (MSF) Goyalmara Hospital in Cox's Bazar, Bangladesh is a referral centre offering the highest level of care available in the Rohingya camps for pediatrics and neonatology. Efforts are underway to integrate pediatric palliative care due to high mortality and medical complexity of patients, yet little is known about the experiences of staff delivering palliative and end-of-life care. The purpose of this study was to understand the moral experiences of MSF staff to inform program planning and implementation. METHODS: This focused ethnography was conducted between March-August 2021 at Goyalmara Hospital. Data collection involved participant-observation, individual interviews (22), focus group discussions (5), and analysis of documents including MSF clinical guidelines, admission and referral criteria, reports, and training materials. Data analysis followed a modified version of the Qualitative Analysis Guide of Leuven and data were coded using NVivo software. RESULTS: The prevailing understanding of pediatric palliative care among national and international staff was care that prioritized comfort for infants and children who were not expected to survive. Staff's views were informed by their sense of obligation to do no harm, to do their best on behalf of their patients, and religious beliefs about God's role in determining the child's outcome. The authority of doctors, international staff, as well as protocols and guidelines shaped palliative care decision-making. Staff saw clinical guidelines as valuable resources that supported a consistent approach to care over time, while others were concerned that palliative care guidelines were rigidly applied. CONCLUSION: When integrating palliative care into humanitarian programs, it is important to emphasize the active role of palliative care in reducing suffering. Advocacy for access to the highest level of care possible should continue alongside palliative care integration. While palliative care guidelines are valuable, it is essential to encourage open discussion of staff concerns and adapt care plans based on the family's needs and preferences.
Asunto(s)
Hospitales Pediátricos , Cuidados Paliativos , Lactante , Humanos , Niño , Bangladesh , Antropología Cultural , Principios MoralesRESUMEN
Youth who are prescribed psychotropic medication are disproportionally affected by overweight/obesity (OW/OB), yet few interventions have been tailored to their needs. To develop new interventions, it is important to address the needs, preferences, and intentions of target users. Qualitative methods within the theory of planned behavior (TPB) framework were used in this study to identify salient beliefs which may influence attitudes associated with parents' intentions to participate in a future online intervention designed to develop behavioral health coaching skills among parents and guardians. Twenty parents and guardians of youth with OW/OB who were taking psychotropic medications, and were eligible for the study, were recruited through TurkPrime. Parents and guardians identified key salient beliefs consistent with the theory of planned behavior including behavioral beliefs (e.g., access and convenience), normative beliefs (e.g., family), and control beliefs (e.g., cost) that may influence their decision to enroll in a future, parent-oriented intervention. The results of this study suggest important salient beliefs which may be included in future research, as well as specific preferences which may be used to guide the development of a future intervention. Future work should focus on the creation of a salient belief quantitative measure and assess the relationships of these beliefs to attitudinal constructs and behaviors.
Asunto(s)
Intención , Intervención basada en la Internet , Adolescente , Conductas Relacionadas con la Salud , Humanos , Obesidad/tratamiento farmacológico , Sobrepeso/tratamiento farmacológicoRESUMEN
Background: Palliative care is an essential component of health responses in humanitarian settings, yet it remains largely unavailable in these settings, due to limited availability of palliative care training for healthcare professionals. Online training programs which connect experts to clinicians in the field have been proposed as an innovative strategy to build palliative care capacity humanitarian settings. Objective: To describe the implementation and evaluate the impact of delivering palliative care education using an established virtual learning model (Project ECHO) for healthcare clinicians working in the Rohingya refugee response in Bangladesh. Program acceptability and the impacts on learners' self-reported knowledge, comfort, and practice changes were evaluated. Methods: Using the Project ECHO model, an education program consisting of 7 core sessions and monthly mentoring sessions was developed. Each session included a didactic lecture, case presentation and interactive discussion. Surveys of participants were conducted before and after the program to assess knowledge, confidence, and attitudes about palliative care as well as learning experiences from the program. Results: This virtual palliative care training program engaged 250 clinicians, including nurses (35%), medical assistants (28%) and physicians (20%). Most participants rated the program as a valuable learning experience (96%) that they would recommend to their colleagues (98%). Participants reported improvements in their knowledge and comfort related to palliative care after participation in the program, and had improved attitudes towards palliative care with demonstrated statistical significance (p < 0.05). Conclusions: Virtual training is a feasible model to support healthcare providers in a humanitarian health response. Project ECHO can help to address the urgent need for palliative care in humanitarian responses by supporting healthcare workers to provide essential palliative care to the growing number of individuals with serious health-related suffering in humanitarian settings.