Brief Intervention as a Method to Reduce Z-Hypnotic Use by Older Adults: Feasibility Case Series.

BACKGROUND: Z-hypnotics or z-drugs are commonly prescribed for insomnia and sleep difficulties in older adults. These drugs are associated with adverse events and dependence and are not recommended for long-term use. Despite evidence of older adults being more sensitive to a wide array of adverse events and clinical guidelines advocating limiting use, inappropriate use in this population is still prevalent. Previous intervention studies have focused mainly on prescriber information. Simple, individually focused intervention designs are less studied. Brief intervention (BI) is a simple, easily transferable method mainly used to treat patients at risk of alcohol overuse. OBJECTIVE: Our objective was to design and test the feasibility and acceptability of a BI intervention adapted to address individual, inappropriate use of z-hypnotics among older adults. This preparatory study aimed to optimize the intervention in advance of a quantitative randomized controlled trial investigating the treatment effect in a larger population. METHODS: This feasibility case series was conducted at Akershus University Hospital, Norway, in autumn 2021. We included 5 adults aged ≥65 years with long-term (≥4 weeks) use of z-hypnotics and 2 intervening physicians. Additionally, 2 study investigators contributed with process evaluation notes. The BI consists of information on the risk of inappropriate use and individualized advice on how to reduce use. The focus of the intervention is behavioral and aims, in cooperation with the patient and based on shared decision-making, to change patient behavior regarding sleep medication rather than physician-based detoxification and termination of z-hypnotic prescriptions. Qualitative and descriptive quantitative data were collected from intervening physicians, study investigators, and participants at baseline, immediately after the intervention, and at the 6-week follow-up. RESULTS: Data were obtained from 2 physicians, 2 study investigators, and 5 participants (4 women) with a median age of 84 years. The average time spent on the BI consultation was 15 minutes. All 5 participants completed the intervention without problems. The participants and 2 intervening physicians reported the intervention as acceptable and were satisfied with the delivery of the intervention. After the intervention, 2 participants stopped their use of z-hypnotics completely and participated in the follow-up interview. Study investigators identified logistical challenges regarding location and time requirements. Identified aspects that may improve the intervention and reduce dropouts included revising the intervention content, focusing on rebound insomnia, adding an information leaflet, and supporting the patient in the period between the intervention and follow-up. The notion that the intervention should best be located and conducted by the patient's own general practitioner was supported by the participants. CONCLUSIONS: We identified important aspects to improve the designed intervention and found that the BI is feasible and acceptable for incorporation into a larger randomized trial investigating the treatment effect of BI for reducing z-hypnotic use by older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT03162081; http://tinyurl.com/rmzx6brn.

Mortality and health-related quality of life in older adults with long-term use of opioids, z-hypnotics or benzodiazepines: a prospective observational study at 5 years follow-up.

OBJECTIVES: Disease and medication use in older age is a consequence of age-related declining health. Multimorbidity followed by polypharmacy is common. Central nervous system depressing (CNSD) drugs such as opioids, benzodiazepines and z-hypnotics are not recommended for long-term use in older adults but are in use by many. We aimed to assess mortality and change in health-related quality of life (HRQoL) in older adults with long-term use of CNSDs. METHOD: A prospective observational study was conducted at Akershus University Hospital, Norway, 2017-2019, with follow-up in 2021-2022, including 246 participants aged 65-90. At 5-year follow-up, 78 (32%) participants had passed away. Mortality data were collected from patient electronic health records. Of the surviving 168 (68%), we collected further follow-up data from 38 (16%) participants. Follow-up included demographic and clinical data. The EuroQuol Group EQ-5D-5L questionnaire was used to measure HRQoL. Analysis include Cox regression model for survival data and linear mixed model for change in HRQoL over time. RESULTS: At follow-up, 78 (31.7%) were deceased. Mean survival time was 3.3 years. Total time for survival data was 4.7 years. Mortality was higher among participants with long-term use of CNSD (HR 1.9 95% CI (1.2 to 3.2), p=0.01). The multivariable analysis found being older (HR 1.1 95% CI (1.0 to 1.1), p=0.020) and male sex (HR 2.1 95% CI (1.2 to 3.5), p=0.008) to be associated with increased risk of mortality. According to the linear mixed model (n=38), there was no significant difference between surviving users and non-users in change in HRQoL EQ-5D-5L index from baseline to follow-up. CONCLUSION: Mortality was higher for long-term users of CNSDs at 5-year follow-up. Being older and male sex were associated with mortality. Among survivors, there was no significant difference between the groups in change of HRQoL over time. TRIAL REGISTRATION NUMBER: NCT03162081; 22 May 2017.

Measuring pain intensity in older adults. Can the visual analogue scale and the numeric rating scale be used interchangeably?

OBJECTIVES: Visual analogue scale (VAS) and numeric rating scale (NRS) are two commonly used instruments for measuring pain intensity. Both instruments are validated for use in both clinical and research settings, and share a range of similar aspects. Some studies have shown that the two instruments may be used interchangeably, but the results are conflicting. In this study we assessed whether the VAS and the NRS instruments may be used interchangeably when measuring pain intensity in older adults. METHODS: Data were collected in a cross-sectional study, as part of the follow-up in a larger longitudinal study conducted at the Akershus University Hospital, Norway 2021 to 2022 and included 39 older adults aged ≥65. Participants were regarded as a normal older adult population as they were not recruited on basis of a specific condition or reports of pain. The participants were asked to rate their pain intensity on an average day using VAS and NRS. Bland-Altman analysis was performed to assess agreement between the two instruments. RESULTS: Thirty-seven participants with mean (SD) age of 77 (5.9) were included in the analysis. Mean (SD) pain assessed by VAS and NRS was 2.8 (1.8) and NRS 4.7 (2.2), respectively. A mean difference (SD) of 2.0 (1.9) between the scores of the two instruments was statistically significantly different from zero (p < 0.001) confirming bias. The 95% limits of agreement were estimated to be -1.7 to 5.7. A post-hoc analysis, removing an outlier, resulted in similar conclusions. CONCLUSION: There was poor agreement between the VAS and NRS scale for measuring pain intensity in older adults. This suggests that the two instruments should not be used interchangeably when assessing pain intensity in this population. ETHICAL APPROVAL: Regional Committees for Medical and Health Research Ethics [2016/2289]. TRIAL REGISTRATION: NCT03162081, 22 May 2017.

Stroke unit demand in Norway - present and future estimates.

BACKGROUND: All stroke patients should receive timely admission to a stroke unit (SU). Consequently, most patients with suspected strokes - including stroke mimics (SM) are admitted. The aim of this study was to estimate the current total demand for SU bed capacity today and give estimates for future (2020-2040) demand. METHODS: Time trend estimates for stroke incidence and time constant estimates for length of stay (LOS) were estimated from the Norwegian Patient Registry (2010-2015). Incidence and LOS models for SMs were based on data from Haukeland University Hospital (2008-2017) and Akershus University Hospital (2020), respectively. The incidence and LOS models were combined with scenarios from Statistic Norway's population predictions to estimate SU demands for each health region. A telephone survey collected data on the number of currently available SU beds. RESULTS: In 2020, 361 SU beds are available, while demand was estimated to 302. The models predict a reduction in stroke incidence, which offsets projected demographic shifts. Still, the estimated demand for 2040 rose to 316, due to an increase in SMs. A variation of this reference scenario, where stroke incidence was frozen at the 2020-level, gave a 2040-demand of 480 beds. CONCLUSIONS: While the stroke incidence is likely to continue to fall, this appears to be balanced by an increase in SMs. An important uncertainty is how long the trend of decreasing stroke incidence can be expected to continue. Since the most important uncertainty factors point toward a potential increase, which may be as large as 50%, we would recommend that the health authorities plan for a potential increase in the demand for SU bed capacity.

Impact of introducing capacity-based mental health legislation on the use of community treatment orders in Norway: case registry study.

BACKGROUND: In 2017, a capacity-based criterion was added to the Norwegian Mental Health Act, stating that those with capacity to consent to treatment cannot be subjected to involuntary care unless there is risk to themselves or others. This was expected to reduce incidence and prevalence rates, and the duration of episodes of involuntary care, in particular regarding community treatment orders (CTOs). AIMS: The aim was to investigate whether the capacity-based criterion had the expected impact on the use of CTOs. METHOD: This retrospective case register study included two catchment areas serving 16% of the Norwegian population (aged ≥18). In total, 760 patients subject to 921 CTOs between 1 January 2015 and 31 December 2019 were included to compare the use of CTOs 2 years before and 2 years after the legal reform. RESULTS: CTO incidence rates and duration did not change after the reform, whereas prevalence rates were significantly reduced. This was explained by a sharp increase in termination of CTOs in the year of the reform, after which it reduced and settled on a slightly higher leven than before the reform. We found an unexpected significant increase in the use of involuntary treatment orders for patients on CTOs after the reform. CONCLUSIONS: The expected impact on CTO use of introducing a capacity-based criterion in the Norwegian Mental Health Act was not confirmed by our study. Given the existing challenges related to defining and assessing decision-making capacity, studies examining the validity of capacity assessments and their impact on the use of coercion in clinical practice are urgently needed.

Are labor pain and birth experience associated with persistent pain and postpartum depression? A prospective cohort study.

Background and aims A considerable research-literature focuses on pain during labor and associations with postpartum persistent pain and depression, with findings pointing in various directions. The aim of this study was to examine the role of labor pain and overall birth experience in the development of pain and depression 8 weeks after delivery. Methods The study sample was drawn from the Akershus Birth Cohort. Data from multiple sources were used, including the hospital's birth record (n = 4,391), questionnaire data from gestational week 17 of pregnancy (n = 3,752), 8 weeks postpartum (n = 2,217), and two questions about pain and birth experience asked within 48 h after delivery (n = 1,221). The Edinburgh Postnatal Depression Scale was used to measure postpartum depression, a single question was used to measure persistent pain 8 weeks postpartum, while pain and birth experience were measured by numeric rating scales. A history of pre-pregnant depression and chronic pain were measured through self-report questions in gestational week 17. A total of 645 women had complete data from all sources. We applied multiple imputation techniques to handle missing responses on the two questions about pain and birth experience. Results The results showed that neither labor pain nor birth experience were associated with persistent pain 8 weeks postpartum, whereas pain before pregnancy (OR 3.70; 95% CI 2.71-5.04) and a history of depression (OR 2.31; 95% CI 1.85-2.88) were statistically significant predictors of persistent pain. A negative birth experience was significantly (OR 1.16; 95% CI 1.04-1.29) associated with postpartum depression, whereas labor pain intensity was not. A history of depression (OR 3.95; 95% CI 2.92-5.34) and pre-pregnancy pain (OR 2.03; 95% CI 1.37-3.01) were important predictors of postpartum depression 8 weeks after delivery. Conclusions and implications Whilst the relationship between labor pain intensity and postpartum pain and depression remain unclear, our results do imply the need to screen for previous depression and chronic pain conditions in pregnant women, as well as consider preventive measures in those who screen positive.

Capacity and patient flow planning in post-term pregnancy outpatient clinics: a computer simulation modelling study.

BACKGROUND: The demand for a large Norwegian hospital's post-term pregnancy outpatient clinic has increased substantially over the last 10 years due to changes in the hospital's catchment area and to clinical guidelines. Planning the clinic is further complicated due to the high did not attend rates as a result of women giving birth. The aim of this study is to determine the maximum number of women specified clinic configurations, combination of specified clinic resources, can feasibly serve within clinic opening times. METHODS: A hybrid agent based discrete event simulation model of the clinic was used to evaluate alternative configurations to gain insight into clinic planning and to support decision making. Clinic configurations consisted of six factors: X0: Arrivals. X1: Arrival pattern. X2: Order of midwife and doctor consultations. X3: Number of midwives. X4: Number of doctors. X5: Number of cardiotocography (CTGs) machines. A full factorial experimental design of the six factors generated 608 configurations. RESULTS: Each configuration was evaluated using the following measures: Y1: Arrivals. Y2: Time last woman checks out. Y3: Women's length of stay (LoS). Y4: Clinic overrun time. Y5: Midwife waiting time (WT). Y6: Doctor WT. Y7: CTG connection WT. Optimisation was used to maximise X0 with respect to the 32 combinations of X1-X5. Configuration 0a, the base case Y1 = 7 women and Y3 = 102.97 [0.21] mins. Changing the arrival pattern (X1) and the order of the midwife and doctor consultations (X2) configuration 0d, where X3, X4, X5 = 0a, Y1 = 8 woman and Y3 86.06 [0.10] mins. CONCLUSIONS: The simulation model identified the availability of CTG machines as a bottleneck in the clinic, indicated by the WT for CTG connection effect on LoS. One additional CTG machine improved clinic performance to the same degree as an extra midwife and an extra doctor. The simulation model demonstrated significant reductions to LoS can be achieved without additional resources, by changing the clinic pathway and scheduling of appointments. A more general finding is that a simulation model can be used to identify bottlenecks, and efficient ways of restructuring an outpatient clinic.

The use of outpatient commitment in Norway: Who are the patients and what does it involve?

PURPOSE: Despite one of the longest histories of using Outpatient Commitment (OC), little is known about the use in the Norwegian context. Reporting from the Norwegian Outpatient Commitment Study, this article aims to: establish the profile of the OC population in Norway; ascertain the legal justification for the use of OC and what OC involves for patients; investigate possible associations between selected patient and service characteristics and duration of OC, and; explore potential differences based on gender or rurality. METHODS: A retrospective multi-site study, extracting data from the medical records of all patients on OC in six large regional hospitals in 2008-12, with detailed investigation over 36 months of the subsample of patients on first ever OC-order in 2008-09. We use descriptive statistics to establish the profile of the OC population and the legal justification for and the content of OC, and logistic regression to examine factors associated with duration of OC over 36 months. RESULTS: 1414 patients were on OC over the 5 years, and 274 had their first OC in 2008-09. The sample included more men than woman, and three-quarters were diagnosed with schizophrenia. They had long service histories, including involuntary admissions. The legal justification for all OC-orders was the need for treatment, and 18% were additionally justified by dangerousness. The option to initiate OC directly from the community was not used in any of the 274 first ever OC-orders. While 98% of patients were prescribed psychotropic medication, under half had an Involuntary Treatment Order, which under the Norwegian OC regime is required in addition to the OC-order to oblige patients to accept treatment (usually medication). 60% of patients had ≥2 clinical contacts monthly. There were some gender differences in descriptive analyses with men generally being worse off, but no clear pattern in terms of rurality. Patients in the sample had been on OC between one week and 20 years. The median duration of OC over 36 months was 365 days. Three factors contributed to longer duration: the use of the dangerousness criterion; a diagnosis of schizophrenia disorder, and; considerable problems with substance abuse. CONCLUSION: The characteristics of the OC population in Norway are very similar to that reported in other jurisdictions. Medication seems to be the central focus of OC, yet additional Involuntary Treatment Orders are imposed for less than half of patients. While all OC-orders were justified by the need to ensure treatment, risk seems to be a concern for a subgroup of patients who are kept on for longer. How the 2017 amendment to the mental health act, which precludes compulsion for competent patients unless danger is present, will affect OC use, remains to be seen. Further studies should specifically focus on variation in the use of OC, including at the level of individual clinicians.

The Impact of Perinatal Depression on Children's Social-Emotional Development: A Longitudinal Study.

Objectives This longitudinal population study aimed to investigate if maternal depression at different time points during the perinatal period impacts children's social-emotional development at 2 years of age. Methods Participants were women (n = 1235) who gave birth at Akershus University Hospital in Norway. Maternal depressive symptoms were assessed by using the Edinburgh Postnatal Depression Scale at pregnancy week 32 and at 8 weeks and 2 years postpartum, whereas children's social-emotional development at the age of 2 years was assessed by using the Ages and Stages Questionnaire: Social-Emotional. Bi- and multivariate logistic regression analyses were conducted to examine the linkage between maternal perinatal depression and children's early social-emotional development. Results Multivariate analyses showed that social-emotional problems in the child 2 years after birth were strongly associated with maternal depression at pregnancy week 32 (adjusted odds ratio (aOR) 3.4; 95 % CI 1.4-8.0), depression at 8 weeks postpartum (aOR 3.8; 95 % CI 1.7-8.6), and with depression at both time points (aOR 3.7; 95 % CI 1.5-10.1). Conclusion Findings indicate pre- and postnatal depression each bears an independent, adverse impact on children's social-emotional development.

Pre-contact by telephone increases response rates to postal questionnaires in a population of stroke patients: an open ended randomized controlled trial.

BACKGROUND: A follow-up study on a cohort of stroke patients through a postal survey questionnaire 3 and 12 months after discharge from hospital was performed. The response rate at 3-months follow-up was lower than desired, and pre-contact by phone as a measure for increasing the response rate at 12 months was studied. METHODS: The study design was a randomized controlled trial on a cohort of 3 months follow-up-non-responders where the intervention group was pre-contacted with an aim to obtain an informal 'consent to receive' the questionnaire before the 12-months survey was mailed, and the control group was not. The primary outcome was 45 days response rate; secondary outcome was 365 days response rate. The main analysis followed the intention to treat principle. A secondary, per-protocol analysis (i.e. subjects who were not reached by phone were reassigned to the control group) is included. Also included is a rudimentary cost-utility analysis, where we estimated the cost per additional response. RESULTS: Of the 235 subjects, 116 were randomized to the intervention group and 119 to the control group. 10 were excluded due to death (7 in the IG and 3 in the CG), 6 due to dementia (3 in the IG and 3 in the CG), and 2 (1 in the IG and 1 in the CG) for other reasons. The primary outcome was a response rate of 42.9 % in the intervention group, and 26.8 % in the control group, giving p =0.014, with estimated OR of 2.04 (95 % CI [1.16,3.64]). The secondary outcome had p =0.009 with OR 2.10 (95 % CI [1.20,3.70]). The as-per-protocol analyses gave stronger results with p =0.001 and p =0.003, respectively. The cost-utility analysis gave a time cost of 1 working hour per additional response. CONCLUSIONS: The results are in line with previous research, and show that pre-contact has a positive effect on response rate also for a population of elderly with reduced health. Given the importance of high response rate in surveys, a cost of 1 working hour per additional response is likely to be worth while. TRIAL REGISTRATION: Registration with ISRCTN initiated on 05/21/2013 and finalised on 06/30/2014 with http://www.isrctn.com/ISRCTN31304930 . Following the prospective submission in May 2013, there were no subsequent changes to the protocol. The recruitment started on 01/06/13, after initiation of public registration.

The influence of women's preferences and actual mode of delivery on post-traumatic stress symptoms following childbirth: a population-based, longitudinal study.

BACKGROUND: This study aimed to examine whether a mismatch between a woman's preferred and actual mode of delivery increases the risk of post-traumatic stress symptoms after childbirth. METHODS: The study sample consisted of 1,700 women scheduled to give birth between 2009 and 2010 at Akershus University Hospital, Norway. Questionnaire data from pregnancy weeks 17 and 32 and from 8 weeks postpartum were used along with data obtained from hospital birth records. Post-traumatic stress symptoms were measured with the Impact of Event Scale. Based on the women's preferred and actual mode of delivery, four groups were established: Match 1 (no preference for cesarean section, no elective cesarean section, N = 1,493); Match 2 (preference for cesarean section, elective cesarean section, N = 53); Mismatch 1 (no preference for cesarean section, elective cesarean section, N = 42); and Mismatch 2 (preference for cesarean section, no elective cesarean section, N = 112). Analysis of variance (ANOVA) and analysis of covariance (ANCOVA) were conducted to examine whether the level of post-traumatic stress symptoms differed significantly among these four groups. RESULTS: Examining differences for all four groups, ANOVA yielded significant overall group differences (F = 11.96, p < 0.001). However, Bonferroni post-hoc tests found significantly higher levels of post-traumatic stress symptoms only in Mismatch 2 compared to Match 1. This difference could be partly explained by a number of risk factors, particularly psychological risk factors such as fear of childbirth, depression, and anxiety. CONCLUSIONS: The results suggest increased post-traumatic stress symptoms in women who preferred delivery by cesarean section but delivered vaginally compared to women who both preferred vaginal delivery and delivered vaginally. In psychologically vulnerable women, such mismatch may threaten their physical integrity and, in turn, result in post-traumatic stress symptoms. These women, who often fear childbirth, may prefer a cesarean section even though vaginal delivery is usually the best option in the absence of medical indications. To avoid potential trauma, fear of childbirth and maternal requests for a cesarean section should be taken seriously and responded to adequately.

[Do previous abortions cause fear of childbirth?]. / Gir tidligere aborter fødselsangst?

BACKGROUND: Abortion is a matter that concerns many women, and we have little knowledge about the effects of such experiences with regard to later pregnancies. The objective of the study was to investigate whether a previous history of abortion has an effect on later development of fear of childbirth, adjusted for the woman's mental health, parity, previous stillbirths and socio-demographic factors. MATERIAL AND METHODS: The study included 2,753 pregnant women from Akershus University Hospital. Information was collected with the aid of questionnaires in the 18th and 32nd week of gestation, as well as retrievals from the hospital's system of birth records. Fear of childbirth was measured on the Wijma scale (W-DEQ). RESULTS: The prevalence of fear of childbirth (defined as W-DEQ ≥ 85) amounted to 11.7% among women who had undertaken two or more elective abortions and 7.8% among those who had no previous abortions. This trend was not statistically significant and disappeared completely in the adjusted analyses. Nor did we find any correlation between spontaneous abortions and fear of childbirth. The mental health of the woman was the one factor that was most strongly associated with fear of childbirth, an association that we have found also on a previous occasion in analyses of a smaller proportion of this cohort. INTERPRETATION: We found no co-variance between previous abortion history and fear of childbirth.