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An educational intervention to reduce the use of potentially inappropriate medications among older adults (EMPOWER study): protocol for a cluster randomized trial.

https://arctichealth.org/en/permalink/ahliterature115389
Source
Trials. 2013;14:80
Publication Type
Article
Date
2013
Author
Philippe Martin
Robyn Tamblyn
Sara Ahmed
Cara Tannenbaum
Author Affiliation
Faculté de Pharmacie, InstitutUniversitaire de Gériatrie de Montréal, Université de Montréal, Montréal, QC, Canada.
Source
Trials. 2013;14:80
Date
2013
Language
English
Publication Type
Article
Keywords
Age Factors
Benzodiazepines - adverse effects - therapeutic use
Community Pharmacy Services
Drug Interactions
Health Knowledge, Attitudes, Practice
Humans
Inappropriate Prescribing - prevention & control
Intention to Treat Analysis
Interdisciplinary Communication
Patient care team
Patient Education as Topic
Patient Safety
Physician-Patient Relations
Polypharmacy
Quebec
Research Design
Risk assessment
Risk factors
Self Efficacy
Time Factors
Abstract
Currently, far too many older adults consume inappropriate prescriptions, which increase the risk of adverse drug reactions and unnecessary hospitalizations. A health education program directly informing patients of prescription risks may promote inappropriate prescription discontinuation in chronic benzodiazepine users.
This is a cluster randomized controlled trial using a two-arm parallel-design. A total of 250 older chronic benzodiazepine users recruited from community pharmacies in the greater Montreal area will be studied with informed consent. A participating pharmacy with recruited participants represents a cluster, the unit of randomization. For every four pharmacies recruited, a simple 2:2 randomization is used to allocate clusters into intervention and control arms. Participants will be followed for 1 year. Within the intervention clusters, participants will receive a novel educational intervention detailing risks and safe alternatives to their current potentially inappropriate medication, while the control group will be wait-listed for the intervention for 6 months and receive usual care during that time period. The primary outcome is the rate of change in benzodiazepine use at 6 months. Secondary outcomes are changes in risk perception, self-efficacy for discontinuing benzodiazepines, and activation of patients initiating discussions with their physician or pharmacist about safer prescribing practices. An intention-to-treat analysis will be followed.The rate of change of benzodiazepine use will be compared between intervention and control groups at the individual level at the 6-month follow-up. Risk differences between the control and experimental groups will be calculated, and the robust variance estimator will be used to estimate the associated 95% confidence interval (CI). As a sensitivity analysis (and/or if any confounders are unbalanced between the groups), we will estimate the risk difference for the intervention via a marginal model estimated via generalized estimating equations with an exchangeable correlation structure.
Targeting consumers directly as catalysts for engaging physicians and pharmacists in collaborative discontinuation of benzodiazepine drugs is a novel approach to reduce inappropriate prescriptions. By directly empowering chronic users with knowledge about risks, we hope to imitate the success of individually targeted anti-smoking campaigns.
ClinicalTrials.gov identifier: NCT01148186.
Notes
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PubMed ID
23514019 View in PubMed
Less detail

Antipsychotics and mortality in Parkinsonism.

https://arctichealth.org/en/permalink/ahliterature127644
Source
Am J Geriatr Psychiatry. 2012 Feb;20(2):149-58
Publication Type
Article
Date
Feb-2012
Author
Connie Marras
Andrea Gruneir
Xuesong Wang
Hadas Fischer
Sudeep S Gill
Nathan Herrmann
Geoffrey M Anderson
Christopher Hyson
Paula A Rochon
Author Affiliation
Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, ON, Canada. cmarras@uhnresearch.ca
Source
Am J Geriatr Psychiatry. 2012 Feb;20(2):149-58
Date
Feb-2012
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Antipsychotic Agents - adverse effects - therapeutic use
Benzodiazepines - adverse effects - therapeutic use
Case-Control Studies
Cohort Studies
Dibenzothiazepines - adverse effects - therapeutic use
Female
Humans
Male
Ontario - epidemiology
Parkinsonian Disorders - complications - drug therapy - mortality
Psychotic Disorders - drug therapy - etiology - mortality
Retrospective Studies
Risk
Risperidone - adverse effects - therapeutic use
Abstract
: The use of antipsychotic medications is associated with an increased risk of death in older adults with dementia. The risk of death in patients with preexisting parkinsonism who receive antipsychotic drugs is not known.
: Using a nested case-control design, we examined the risk of death within 30 days of newly starting antipsychotic medications among people with Parkinsonism aged 70 years and older in Ontario, Canada. Data were obtained from Ontario's healthcare administrative databases.
: Among 5,391 individuals with parkinsonism who died during the study period (2002-2008) and a matched comparison group of 25,937 who were still alive, individuals exposed to atypical antipsychotic drugs had a higher risk of death (unadjusted odds ratio [OR] = 2.8, 95% CI: 2.1-3.8, adjusted OR: 2.0, 95% CI: 1.4-2.7). Results were similar for quetiapine use compared with no antipsychotic use (unadjusted OR: 2.5, 95% CI: 1.6-4.0, adjusted OR = 1.8, 95% CI: 1.1-3.0). Typical antipsychotics were associated with an increased odds of death compared with atypical antipsychotics (unadjusted OR = 2.4, 95% CI 1.1-5.2, adjusted OR = 2.4, 95% CI: 1.1-5.7).
: Individuals with parkinsonism who are newly prescribed antipsychotic medications have a higher risk of death within 30 days than those who do not start these medications. Although it is not possible to establish causality, the results suggest an increased risk. It is important to be vigilant for accompanying serious medical conditions that may increase mortality in individuals requiring treatment with antipsychotics and to consider alternative approaches to treating psychosis, agitation, and aggression in this population.
PubMed ID
22273735 View in PubMed
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Benzodiazepine use in COPD: empirical evidence from Norway.

https://arctichealth.org/en/permalink/ahliterature272220
Source
Int J Chron Obstruct Pulmon Dis. 2015;10:1695-702
Publication Type
Article
Date
2015
Author
Thomas Halvorsen
Pål E Martinussen
Source
Int J Chron Obstruct Pulmon Dis. 2015;10:1695-702
Date
2015
Language
English
Publication Type
Article
Keywords
Aged
Benzodiazepines - adverse effects - therapeutic use
Comorbidity
Drug Prescriptions
Drug Utilization Review
Female
Humans
Lung - drug effects - physiopathology
Male
Mental Disorders - diagnosis - drug therapy - epidemiology - psychology
Middle Aged
Norway - epidemiology
Pulmonary Disease, Chronic Obstructive - diagnosis - epidemiology - physiopathology
Risk assessment
Risk factors
Sex Factors
Abstract
The common comorbidities associated with COPD include, among others, anxiety, depression, and insomnia, for which the typical treatment involves the use of benzodiazepines (BZD). However, these medicines should be used with extra caution among COPD patients, since treatment with traditional BZD may compromise respiratory function.
This study investigated the use of BZD among persons suffering from COPD by analyzing three relevant indicators: 1) the sum of defined daily doses (DDD); 2) the number of prescribers involved; and 3) the number of different types of BZD used.
The study builds on a linkage of national prescription data and patient-administrative data, which includes all Norwegian drug prescriptions to persons hospitalized with a COPD diagnosis during 2009, amounting to a total of 5,380 observations. Regression techniques were used to identify the patients and the clinical characteristics associated with BZD use.
Of the 5,380 COPD patients treated in hospital during 2009, 3,707 (69%) were dispensed BZD during the following 12 months. Moreover, they were dispensed on average 197.08 DDD, had 1.22 prescribers, and used 0.98 types of BZD during the year. Women are more likely to use BZD for all levels of BZD use. Overnight planned care not only increases the risk of BZD use (DDD), but also the number of prescribers and the types of BZD in use.
In light of the high levels of BZD prescription found in this study, especially among women, it is recommended that general practitioners, hospital specialists, and others treating COPD patients should aim to acquire a complete picture of their patients' BZD medication before more is prescribed in order to keep the use to a minimum.
Notes
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PubMed ID
26356249 View in PubMed
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Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies.

https://arctichealth.org/en/permalink/ahliterature174335
Source
Bipolar Disord. 2005;7 Suppl 3:5-69
Publication Type
Conference/Meeting Material
Article
Date
2005
Author
Lakshmi N Yatham
Sidney H Kennedy
Claire O'Donovan
Sagar Parikh
Glenda MacQueen
Roger McIntyre
Verinder Sharma
Peter Silverstone
Martin Alda
Philippe Baruch
Serge Beaulieu
Andree Daigneault
Roumen Milev
L Trevor Young
Arun Ravindran
Ayal Schaffer
Mary Connolly
Chris P Gorman
Author Affiliation
Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
Source
Bipolar Disord. 2005;7 Suppl 3:5-69
Date
2005
Language
English
Publication Type
Conference/Meeting Material
Article
Keywords
Adolescent
Adult
Age of Onset
Anticonvulsants - adverse effects - therapeutic use
Antipsychotic Agents - adverse effects - therapeutic use
Anxiety Disorders - diagnosis - drug therapy - epidemiology
Benzodiazepines - adverse effects - therapeutic use
Bipolar Disorder - diagnosis - drug therapy - epidemiology
Canada
Chronic Disease
Comorbidity
Diagnostic and Statistical Manual of Mental Disorders
Drug Monitoring
Female
Humans
Lithium Carbonate - adverse effects - therapeutic use
Mass Screening - methods
Mood Disorders - diagnosis - drug therapy - epidemiology
Personality Disorders - epidemiology
Prevalence
Quality of Life
Risk factors
Substance-Related Disorders - epidemiology
Triazines - adverse effects - therapeutic use
Valproic Acid - adverse effects - therapeutic use
Abstract
Since the previous publication of Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines in 1997, there has been a substantial increase in evidence-based treatment options for bipolar disorder. The present guidelines review the new evidence and use criteria to rate strength of evidence and incorporate effectiveness, safety, and tolerability data to determine global clinical recommendations for treatment of various phases of bipolar disorder. The guidelines suggest that although pharmacotherapy forms the cornerstone of management, utilization of adjunctive psychosocial treatments and incorporation of chronic disease management model involving a healthcare team are required in providing optimal management for patients with bipolar disorder. Lithium, valproate and several atypical antipsychotics are first-line treatments for acute mania. Bipolar depression and mixed states are frequently associated with suicidal acts; therefore assessment for suicide should always be an integral part of managing any bipolar patient. Lithium, lamotrigine or various combinations of antidepressant and mood-stabilizing agents are first-line treatments for bipolar depression. First-line options in the maintenance treatment of bipolar disorder are lithium, lamotrigine, valproate and olanzapine. Historical and symptom profiles help with treatment selection. With the growing recognition of bipolar II disorders, it is anticipated that a larger body of evidence will become available to guide treatment of this common and disabling condition. These guidelines also discuss issues related to bipolar disorder in women and those with comorbidity and include a section on safety and monitoring.
Notes
Comment In: Bipolar Disord. 2005;7 Suppl 3:83-615952961
Comment In: Bipolar Disord. 2005;7 Suppl 3:87-815952962
Comment In: Bipolar Disord. 2005;7 Suppl 3:77-8215952960
Comment In: Bipolar Disord. 2005;7 Suppl 3:73-615952959
Comment In: Bipolar Disord. 2005;7 Suppl 3:70-215952958
PubMed ID
15952957 View in PubMed
Less detail

Cohort profile: the Finnish Medication and Alzheimer's disease (MEDALZ) study.

https://arctichealth.org/en/permalink/ahliterature287549
Source
BMJ Open. 2016 Jul 13;6(7):e012100
Publication Type
Article
Date
Jul-13-2016
Author
Anna-Maija Tolppanen
Heidi Taipale
Marjaana Koponen
Piia Lavikainen
Antti Tanskanen
Jari Tiihonen
Sirpa Hartikainen
Source
BMJ Open. 2016 Jul 13;6(7):e012100
Date
Jul-13-2016
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Alzheimer Disease - complications - diagnosis - drug therapy
Antidepressive Agents - adverse effects - therapeutic use
Benzodiazepines - adverse effects - therapeutic use
Cohort Studies
Diagnostic and Statistical Manual of Mental Disorders
Drug Evaluation
Drug Monitoring
Female
Finland
Humans
Male
Middle Aged
Patient Acceptance of Health Care
Psychotropic Drugs - adverse effects - therapeutic use
Abstract
The aim of the Medicine use and Alzheimer's disease (MEDALZ) study is to investigate the changes in medication and healthcare service use among persons with Alzheimer's disease (AD) and to evaluate the safety and effectiveness of medications in this group. This is important, because the number of persons with AD is rapidly growing and even though they are a particularly vulnerable patient group, the number of representative, large-scale studies with adequate follow-up time is limited.
MEDALZ contains all residents of Finland who received a clinically verified diagnosis of AD between 2005 and 2011 and were community-dwelling at the time of diagnosis (N=70 719). The diagnosis is based on the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCS-ADRDA) and Diagnostic and Statistical Manual Fourth Edition (DSM-IV) criteria for Alzheimer's disease. The cohort contains socioeconomic data (education, occupational status and taxable income, 1972-2012) and causes of death (2005-2012), data from the prescription register (1995-2012), the special reimbursement register (1972-2012) and the hospital discharge register (1972-2012). Future updates are planned.The average age was 80.1 years (range 34.5-104.6 years). The majority of cohort (65.2%) was women. Currently, the average length of follow-up after AD diagnosis is 3.1 years and altogether 26 045 (36.8%) persons have died during the follow-up.
Altogether 53% of the cohort had used psychotropic drugs within 1 year after AD diagnoses. The initiation rate of for example, benzodiazepines and related drugs and antidepressants began to increase already before AD diagnosis.
We are currently assessing if these, and other commonly used medications are related to adverse events such as death, hip fractures, head injuries and pneumonia.
Notes
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PubMed ID
27412109 View in PubMed
Less detail

Exploring the risk of diabetes mellitus and dyslipidemia among ambulatory users of atypical antipsychotics: a population-based comparison of risperidone and olanzapine.

https://arctichealth.org/en/permalink/ahliterature175614
Source
Pharmacoepidemiol Drug Saf. 2005 Jun;14(6):427-36
Publication Type
Article
Date
Jun-2005
Author
Jocelyne Moisan
Jean-Pierre Grégoire
Michel Gaudet
Dan Cooper
Author Affiliation
Faculty of Pharmacy, Université Laval, Québec, Que., Canada.
Source
Pharmacoepidemiol Drug Saf. 2005 Jun;14(6):427-36
Date
Jun-2005
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Ambulatory Care - statistics & numerical data
Antipsychotic Agents - adverse effects - therapeutic use
Benzodiazepines - adverse effects - therapeutic use
Cohort Studies
Databases, Factual - statistics & numerical data
Diabetes Mellitus - chemically induced - epidemiology
Drug Utilization - statistics & numerical data
Female
Humans
Hyperlipidemias - chemically induced - epidemiology
Incidence
Insurance, Pharmaceutical Services - statistics & numerical data
Male
Middle Aged
Quebec - epidemiology
Risk Assessment - methods
Risk factors
Risperidone - adverse effects - therapeutic use
Survival Analysis
Abstract
To compare the incidence rates of diabetes mellitus and dyslipidemia in ambulatory first-time users of risperidone and olanzapine.
The database for the Prescription Drug Insurance Plan in the province of Quebec was used as the data source for a population-based cohort study. Denominalized data were extracted for all ambulatory patients who first received an atypical antipsychotic between 1 January 1997 and 31 August 1999. Eligible patients were categorized as taking: no antidiabetic medication; no lipid reducing medication; neither type of medication. Those who started to use an outcome drug (an antidiabetic or lipid-lowering medication) before the end of the follow-up period (31 August 2000) were considered to have developed the corresponding outcome disease. Incidence rate ratios (IRR) (and 95% confidence intervals) for initiating antihyperglycemic or lipid-lowering drug treatment, or both were calculated. Outcomes on risperidone were compared to those on olanzapine.
A total of 19 582 eligible patients were included in the analysis. Relative to risperidone, olanzapine was associated with a higher risk of initiating a pharmacologic treatment for diabetes [IRR: 1.33 (1.03-1.74)], dyslipidemia [IRR: 1.49 (1.22-1.83)], or either condition [1.47 (1.23-1.76)].
Olanzapine seems to be associated with a higher risk of developing diabetes and/or dyslipidemia than risperidone. Further prospective studies are needed to rigorously assess the safety of olanzapine.
PubMed ID
15786513 View in PubMed
Less detail

Fracture risk from psychotropic medications: a population-based analysis.

https://arctichealth.org/en/permalink/ahliterature156158
Source
J Clin Psychopharmacol. 2008 Aug;28(4):384-91
Publication Type
Article
Date
Aug-2008
Author
James M Bolton
Colleen Metge
Lisa Lix
Heather Prior
Jitender Sareen
William D Leslie
Author Affiliation
Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada. jbolton@hsc.mb.ca
Source
J Clin Psychopharmacol. 2008 Aug;28(4):384-91
Date
Aug-2008
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Antidepressive Agents - adverse effects - therapeutic use
Antipsychotic Agents - adverse effects - therapeutic use
Benzodiazepines - adverse effects - therapeutic use
Case-Control Studies
Dose-Response Relationship, Drug
Female
Fractures, Bone - epidemiology - etiology
Humans
Male
Manitoba - epidemiology
Mental Disorders - drug therapy
Middle Aged
Risk factors
Abstract
Selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, and antipsychotics have each been associated with an increased risk of fracture in older individuals. The aim of this study was to better define the magnitude of fracture risk with psychotropic medications and to determine whether a dose-effect relationship exists.
Population-based administrative databases were used to examine psychotropic medication exposure and fractures in persons aged 50 years and older in Manitoba between 1996 and 2004. Persons with osteoporotic fractures (vertebral, wrist, or hip [n = 15,792]) were compared with controls (3 controls for each case matched for age, sex, ethnicity, and comorbidity [n = 47,289]). Medications examined included antidepressants (SSRIs vs other monoamines), antipsychotics, lithium, and benzodiazepines.
Selective serotonin reuptake inhibitors were associated with the highest adjusted odds of osteoporotic fractures (odds ratio [OR] = 1.45; 95% confidence interval [CI], 1.32-1.59). Other monoamine antidepressants (OR = 1.15; 95% CI, 1.07-1.24) and benzodiazepines (OR = 1.10; 95% CI, 1.04-1.16) were also associated with greater fracture risk, although the relationship was weaker. Lithium was associated with lower fracture risk (OR = 0.63; 95% CI, 0.43-0.93), whereas the relationship with antipsychotics was not significant in the models that adjusted for diagnoses. A dose-effect relationship was seen with SSRIs and benzodiazepines.
This study provides novel insight into the relationship between fractures and psychotropic medications in the elderly. Selective serotonin reuptake inhibitors seem to have a greater risk than other psychotropic classes, and higher doses may further increase that risk. Lithium seems to be protective against fractures.
Notes
Comment In: Evid Based Ment Health. 2009 Feb;12(1):2519176784
PubMed ID
18626264 View in PubMed
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In a randomized placebo-controlled add-on study orlistat significantly reduced clozapine-induced constipation.

https://arctichealth.org/en/permalink/ahliterature118619
Source
Int Clin Psychopharmacol. 2013 Mar;28(2):67-70
Publication Type
Article
Date
Mar-2013
Author
Evgeny Chukhin
Pirjo Takala
Helinä Hakko
Mirjam Raidma
Hanna Putkonen
Pirkko Räsänen
Viacheslav Terevnikov
Jan-Henry Stenberg
Markku Eronen
Grigori Joffe
Author Affiliation
Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland. evgeny.chukhin@hus.fi
Source
Int Clin Psychopharmacol. 2013 Mar;28(2):67-70
Date
Mar-2013
Language
English
Publication Type
Article
Keywords
Anti-Obesity Agents - adverse effects - therapeutic use
Antipsychotic Agents - adverse effects - therapeutic use
Benzodiazepines - adverse effects - therapeutic use
Clozapine - adverse effects - therapeutic use
Colon - drug effects - physiopathology
Constipation - chemically induced - physiopathology - prevention & control
Cross-Sectional Studies
Diarrhea - chemically induced
Double-Blind Method
Finland - epidemiology
Humans
Incidence
Lactones - adverse effects - therapeutic use
Laxatives - adverse effects - therapeutic use
Obesity - drug therapy - psychology
Overweight - drug therapy - psychology
Patient Dropouts
Prevalence
Psychotic Disorders - complications - drug therapy
Schizophrenia - complications - drug therapy
Severity of Illness Index
Weight Loss - drug effects
Abstract
Constipation is a common and potentially fatal side effect of clozapine treatment. Another important side effect of clozapine may also be significant weight gain. Orlistat is a weight-control medication that is known to induce loose stools as a common side effect. This study aimed to explore whether orlistat used to control clozapine-induced weight gain can simultaneously tackle clozapine-related constipation. In this 16-week randomized-controlled study, clozapine-treated patients received add-on orlistat (n=30) or add-on placebo (n=24). Colonic function was measured using the Bristol Stool Form Scale. There was a significant (P=0.039) difference in the prevalence of constipation in favor of orlistat over placebo in completers (n=40) at the endpoint. A decrease in the prevalence of constipation within the orlistat group (P=0.035) was observed (vs. no statistically significant changes in the placebo group). In clozapine-treated patients, orlistat may be beneficial not only for weight control but also as a laxative. As no established treatments for clozapine-induced constipation exist, orlistat can be considered for this population, although more studies are required.
PubMed ID
23187856 View in PubMed
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Insomnia, depression and anxiety disorders and their association with benzodiazepine drug use among the community-dwelling elderly: implications for mental health nursing.

https://arctichealth.org/en/permalink/ahliterature176142
Source
Int J Psychiatr Nurs Res. 2005 Jan;10(2):1093-116
Publication Type
Article
Date
Jan-2005
Author
Philippe Voyer
Philippe Landreville
Jocelyne Moisan
Michel Tousignant
Michel Préville
Author Affiliation
Faculty of Nursing Sciences at Laval University, Quebec. Philippe.Voyer@fsi.ulaval.ca
Source
Int J Psychiatr Nurs Res. 2005 Jan;10(2):1093-116
Date
Jan-2005
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Anxiety Disorders - drug therapy - epidemiology - etiology - nursing
Benzodiazepines - adverse effects - therapeutic use
Cross-Sectional Studies
Depressive Disorder - epidemiology - etiology - nursing
Drug Utilization
Female
Humans
Logistic Models
Male
Prevalence
Psychiatric Nursing
Quebec - epidemiology
Sleep Initiation and Maintenance Disorders - drug therapy - epidemiology - etiology - nursing
Abstract
Benzodiazepine (BZD) drug use among seniors is an important public health issue because the benefit from their use is moderate and of short duration and numerous adverse events have been linked to their use. Furthermore, there is a significant discrepancy between the prevalence of mental health disorders and BZD drug use in the elderly population, which can be attributed to a measurement issue. The goal of this cross-sectional descriptive study was to determine the prevalence of mental health disorders among seniors using BZD and living in the community, basing this information on both a thorough face-to-face interview and a pair of self-reported validated instruments. Among the 216 seniors recruited in our study, nearly 20 % were users of BZD and over three quarters of them had been using this drug for more than a year. Thirteen subjects were recognized as depressed according to a self-report measure compared to 18 according to the interview. Likewise, 13 seniors were categorized as anxious, based on a self-report questionnaire compared to 39 based on the interview. Among self-reported measures of mental health variables, logistic regression indicated that insomnia increases by 7 the likelihood of using BZD (odds ratio: 7.2) and is the only statistically significant variable associated with BZD consumption. Based on thorough interviews, logistic regression showed that insomnia (odds ratio: 6.9) is still the dominant symptom associated with BZD drugs. In conclusion, our results clearly support the assertion that mental health status is influenced according to how it is measured. Finally, nurses should be aware that not all individuals are capable of expressing their mental health problems using either psychological or emotional terminologies. They may opt for expressing their psychological suffering as a physical symptom such as sleeping problems.
PubMed ID
15715320 View in PubMed
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