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).
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.
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.
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.
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.
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.
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.
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.
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.
This study aimed to assess the association between benzodiazepine use and global sleep quality, as well as six components of sleep quality.
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.
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.
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 WHI was stopped prematurely because of an increased risk of breast cancer, stroke and cardiovascular diseases (CVD) in the hormone replacement therapy (HRT) arm of the trial. Changes in the use of HRT are expected.
To assess the impact of the Women's Health Initiative (WHI) publication on the rate of HRT prescription, and the clinical characteristics and persistence rate of new users and its determinants.
From the RAMQ databases, the total numbers of HRT prescriptions, and of new HRT's users were calculated between 2 January 1998 and 31 May 2003. To assess the clinical characteristics of women, two retrospective cohorts of new HRT's users were constructed before (pre-WHI) and after (post-WHI) the WHI study publication. The persistence rate after 1 year of follow-up was estimated using a Kaplan-Meier analysis. Cox regression models were used to estimate the rate ratio of HRT cessation.
The total numbers of HRT users and of new users declined respectively by 28% and 50% in post-WHI. The standard dosage of HRT was significantly less used, while the proportion of women with risk factors of CVD or at very high risk of coronary artery disease (CAD) did not change. The rate of persistence in the pre-WHI cohort was 59% compared to 45% in the post-WHI (p
Health or disease management (DM) has emerged as a promising solution to improve the quality of healthcare and patient outcomes in a cost-efficient way. This solution is particularly relevant in the care of our increasing, and aging, patient populations with multiple chronic diseases. This article reviews the recent history and current status of DM in the province of Quebec and summarizes its evolving perspectives and future prospects. Most DM projects in Quebec have developed from a public-private partnership, and they have addressed several disease states. The results of completed programs confirmed the presence of care gaps--the differences between best and usual care in several disease states. They also identified process changes leading to improved practices and enhanced professional satisfaction among stakeholders. Priorities identified for further research include increased knowledge of the underlying causes of care gaps and greater concentration on the measurement of clinical, humanistic and fiscal outcomes and their causal links to DM structures and processes. Although still embryonic in Quebec and Canada, the available evidence suggests that DM partnerships are practical and functional vehicles to expedite knowledge creation and transfer in the care of whole populations of patients. Future projects offer the promise of updated knowledge and continuously improved care and outcomes.
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.
Age-related macular degeneration (AMD) is characterized by loss of central vision and is the leading cause of blindness among persons over the age of 50 years in Canada. The wet form of AMD has 3 subtypes-occult, minimally classic, and predominantly classic. Photodynamic therapy (PDT) with verteporfin is indicated only for the category of predominantly classic wet AMD. Currently, there are no treatments available for the other AMD subtypes. Pegaptanib sodium was the first pharmacologic therapy approved in Canada for the treatment of subfoveal wet AMD regardless of subtype.
The aim of this study was to examine the cost-effectiveness of pegaptanib versus PDT with verteporfin and versus standard care for the treatment of subfoveal wet AMD in patients aged 65 years in Canada.
A Markov model based on visual acuity in the better-seeing eye was developed. Clinical efficacy was taken from the clinical trials. Costs of treatment, comorbidities (eg, depression, fractures, need for assisted living), vision rehabilitation, visual aids, and adverse events were considered. Costs, utilities, and mortality were estimated from data from the available published literature. Costs were reported in 2004 Canadian dollars, and costs and outcomes were discounted at 3% per annum. Lifetime costs, quality-adjusted life-years (QALYs), and vision years gained (VYGs) were estimated. Sensitivity analyses were performed to determine model robustness.
Patients who received pegaptanib experienced more QALYs gained (4.17) and VYGs (3.83) compared with patients who received PDT (3.87 and 3.01, respectively) or standard care (3.96 and 3.26). Mean total costs per patient were greater in patients who received pegaptanib compared to those who received PDT or standard care ($20,016 vs $15,345 or $7669, respectively). The incremental cost per QALY in patients receiving pegaptanib compared to those receiving PDT was $49,052 and $59,039 for patients receiving pegaptanib versus standard care. The incremental cost per VYG was $20,401 and $21,559 with pegaptanib versus PDT and standard care, respectively. Sensitivity analyses found that the model was relatively robust to changes in various model parameters.
The results of this analysis suggest that in Canada, pegaptanib is a cost-effective treatment for subfoveal wet AMD in elderly patients, regardless of lesion subtype, compared to PDT with verteporfin and to standard care.
To determine whether prevalent delirium is an independent predictor of mortality in older patients seen in emergency departments (EDs) and discharged home without admission.
Prospective study with 18 months of follow-up.
EDs in two Montreal hospitals.
From a cohort study of prognosis for delirium (107 delirious and 161 nondelirious subjects), 30 delirious and 77 nondelirious subjects aged 66 and older who were discharged home without admission were identified.
Detailed interviews with patients and their proxies and review of medical charts were performed at enrollment. Trained lay interviewers determined delirium status using the Confusion Assessment Method. Subjects were followed up at 6-month intervals for a total of 18 months. Dates of death were obtained from the Ministère de la Santé et des Service Sociaux (Ministry of Health and Social Services). Survival analysis was performed using the Cox proportional hazards modeling adjusting for potential confounding variables.
The analysis revealed a statistically significant association between delirium and mortality after adjustments for age, sex, functional level, cognitive status, comorbidity, and number of medications for the first 6 months of follow-up (hazard ratio = 7.24; 95% confidence interval = 1.62-32.35). The subjects whose delirium was not detected by the ED physician or nurse had the highest mortality over 6 months (30.8%). The mortality of delirious subjects detected in the ED was similar to that of the nondelirious subjects (11.8 vs 14.3%).
The results of this study suggests that nondetection of delirium in the ED may be associated with increased mortality within 6 months after discharge. Further research is necessary to examine the effectiveness of improving detection on subsequent prognosis of older patients with delirium.
With the aging of the population, age-related macular degeneration (AMD) is becoming a public health concern. Few studies have assessed its consequences on morbidity and mortality, and the findings are conflicting.
To assess the risk of depression, fracture, institutionalization, and death among elderly patients with suspected exudative AMD and the impact of the depletion of susceptibles effect in a burden-of-illness study.
A population-based retrospective cohort study was conducted in the community-dwelling elderly population of Quebec. The cohort was assembled through the Quebec medical claims database (RAMQ). Among patients age 65 and older with a claim involving a diagnosis of AMD over the years 2000 to 2004, those with suspected exudative AMD (n=2,071) were retained, using fluorescein angiography as a marker. The reference cohort consisted of a sample of 16,932 elderly without a claim involving AMD or visual impairment.
Suspected exudative AMD was associated with an increased risk of depression (hazard ratio HR=1.3, 95%CI 1.18-1.43) and fracture (HR=1.19, 95%CI 1.03-1.37), but a decreased risk of institutionalization (HR=0.55, 95%CI 0.42-0.71) and death (HR=0.68, 95%CI 0.59-0.78). After adjustment for the incident/prevalent status of the AMD, the association between suspected exudative AMD and institutionalization was no longer statistically significant (HR=0.75, 95%CI 0.5-1.12).
These findings enhance the need to detect visual loss and to consider patients' ability to adapt to AMD, to maintain their quality of life. Failure to account for duration of illness and the depletion of susceptibles effect may bias results of burden-of-illness studies.
To assess the effect of visual impairment (VI) on the risk of depression or death in the community-dwelling elderly population.
A population-based, retrospective fixed cohort study was conducted in the community-dwelling elderly (age > or = 65 years) outpatient population of Quebec. The cohort was assembled through the Quebec medical services database and consisted of the 5063 patients aged > or = 65 years who received a diagnosis of VI during the years 2000-2004. The reference cohort consisted of 16 932 elderly subjects who were randomly selected among members of the public drug programme. The outcome variables were depression and death. The main independent variable was VI and covariates included age, gender, chronic disease score, fracture and diabetes.
Controlling for covariates, VI was associated with an increased risk of depression although the effect was not modified by severity (hazard ratio [HR] = 1.35, 95% confidence interval [CI] 1.10-1.66 for severe VI; HR = 1.35, 95% CI 1.09-1.69 for moderate VI). Visual impairment was associated with an increased risk of mortality; patients with moderate vision loss had a higher risk of death (HR = 1.70, 95% CI 1.55-1.87) than those with severe vision loss (HR = 1.34, 95% CI 1.21-1.48).
Given the ageing of the population, VI in elderly subjects is becoming a public health concern. These findings enhance the need to detect and treat VI in order to improve the quality of life and to prevent premature mortality in the elderly population.