Carl D’Arcy

Education and Dementia in the Context of the Cognitive Reserve Hypothesis: A Systematic Review with Meta-Analyses and Qualitative Analyses

Background Cognitive reserve (CR) or brain reserve capacity explains why individuals with higher IQ, education, or occupational attainment have lower risks of developing dementia, Alzheimer’s disease (AD) or vascular dementia (VaD). The CR hypothesis postulates that CR reduces the prevalence and incidence of AD or VaD. It also hypothesizes that among those who have greater initial cognitive reserve (in contrast to those with less reserve) greater brain pathology occurs before the clinical symptoms of disease becomes manifest. Thus clinical disease onset triggers a faster decline in cognition and function, and increased mortality among those with initial greater cognitive reserve. Disease progression follows distinctly separate pathological and clinical paths. With education as a proxy we use meta-analyses and qualitative analyses to review the evidence for the CR hypothesis. Methodology/Principal Findings We searched PubMed, PsycoINFO, EMBASE, HealthStar, and Scopus databases from January 1980 to June 2011 for observational studies with clear criteria for dementia, AD or VaD and education. One hundred and thirty-three articles with a variety of study designs met the inclusion criteria. Prevalence and incidence studies with odds ratios (ORs), relative risks or original data were included in the meta-analyses. Other studies were reviewed qualitatively. The studies covered 437,477 subjects. Prevalence and incidence studies with pooled ORs of 2.61 (95%CI 2.21–3.07) and 1.88 (95%CI 1.51–2.34) respectively, showed low education increased the risk of dementia. Heterogeneity and sensitivity tests confirmed the evidence. Generally, study characteristics had no effect on conclusions. Qualitative analyses also showed the protective effects of higher education on developing dementia and with clinical disease onset hastening a decline in cognition and function, and greater brain pathology. Conclusion/Significance This systematic review and meta-analyses covering a wide range of observational studies and diverse settings provides robust support for the CR hypothesis. The CR hypothesis suggests several avenues for dementia prevention.

Isotretinoin Use and Subsequent Depression and Suicide Presenting the Evidence

AbstractThe growing number of reported cases of depression and suicide associated with isotretinoin (a retinoid receptor agonist) use in patients with acne has prompted concern among dermatologists, patients, and their relatives and has triggered new warnings from regulators including depression-related, patient-informed consent forms. In establishing a cause-effect relationship, it is useful to judiciously consider whether there is an association, what is the nature of that association, if there is a plausible biological mechanism of action, the validity and reliability of measures used and the strength of study designs. Hoffmann-La Roche estimates that by April 2001 approximately 12 million patients worldwide have used isotretinoin, with 5 million patients in the US.A MEDLINE search between January 1966 and May 14 2003 of the published medical literature found 24 documented cases of isotretinoin-associated depression, with 3 suicides. One additional patient committed suicide during the fourth month of isotretinoin treatment and 3 further patients attempted suicide by taking an overdose of isotretinoin. The US FDA’s Adverse Event Reporting System (AERS) contains almost 23 000 reports for isotretinoin from its approval in 1982 to December 2002. As of November 30, 2002, AERS contained 3104 reports (US and foreign) with at least one reported psychiatric event. The FDA is aware of 173 reports of suicide (both US and foreign) in association with isotretinoin. Reports of positive dechallenge and rechallenge present a strong signal pointing to an association between isotretinoin and depression. A Hoffmann-La Roche sponsored epidemiological study failed to find any evidence of an association between isotretinoin and depression or suicide. However, the design of the study was flawed and the evidence was deemed inconclusive. Further studies using strong study designs, reliable and valid measures, and adequate sample sizes may bring us closer to the answer.The evidence suggesting a relationship between isotretinoin and depression needs to be weighed against the increasing prevalence of depression among adolescents and young adults and the psychological impact of acne. The literature contains credible evidence that isotretinoin treatment may reduce the psychosocial impact of acne in some patients. At the present time, there is no known pharmacological mechanism that would account for psychiatric symptomatology as a result of isotretinoin treatment; however, retinoid receptors are widely distributed in the brain and more research is needed to ascertain whether they have a role in depression.In the meantime, for the practitioner, the obvious benefit of isotretinoin in treating acne should encourage continued use. However, patients and their relatives must be informed and depressive symptoms should be actively assessed at each visit and, if necessary, referral to a psychiatrist, antidepressant therapy or discontinuation of isotretinoin should be considered.

Improving access to dementia care: Development and evaluation of a rural and remote memory clinic

The availability, accessibility and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.

Moving on? Predictors of intent to leave among rural and remote RNs in Canada

CONTEXT Examination of factors related to the retention or voluntary turnover of Registered Nurses (RNs) has mainly focused on urban, acute care settings. PURPOSE This paper explored predictors of intent to leave (ITL) a nursing position in all rural and remote practice settings in Canada. Based on the conceptual framework developed for this project, potential predictors of ITL were related to the individual RN worker, the workplace, the community context, and satisfaction related to both the workplace and the community(s) within which the RN lived and worked. METHODS A national cross-sectional mail survey of RNs in rural and remote Canada provided the data (n = 3,051) for the logistic regression analysis of predictors of ITL. FINDINGS We found that RNs were more likely to plan to leave their nursing position within the next 12 months if they: were male, reported higher perceived stress, did not have dependent children or relatives, had higher education, were employed by their primary agency for a shorter time, had lower community satisfaction, had greater dissatisfaction with job scheduling, had lower satisfaction with their autonomy in the workplace, were required to be on call, performed advanced decisions or practice, and worked in a remote setting. CONCLUSIONS The statistical evidence for predictors of ITL supported our framework with determinants related to the individual, the workplace, the community, and satisfaction levels. The importance of community makes this framework uniquely relevant to the rural health context. Our findings should guide policy makers and employers in developing retention strategies.

Evaluation of Telehealth for Preclinic Assessment and Follow-Up in an Interprofessional Rural and Remote Memory Clinic.

Using data from a sample of 169 patients, this study evaluates the acceptability and feasibility of telehealth videoconferencing for preclinic assessment and follow-up in an interprofessional memory clinic for rural and remote seniors. Patients and caregivers are seen via telehealth prior to the in-person clinic and followed up at 6 weeks, 12 weeks, 6 months, 1 year, and yearly. Patients are randomly assigned to in-person (standard care) or telehealth for the first follow-up, then alternating between the two modes of treatment, prior to 1-year follow-up. On average, telehealth appointments reduce participants’ travel by 426 km per round trip. Findings show that telehealth coordinators rated 85% of patients and 92% of caregivers as comfortable or very comfortable during telehealth. Satisfaction scales completed by patient–caregiver dyads show high satisfaction with telehealth. Follow-up questionnaires reveal similar satisfaction with telehealth and in-person appointments, but telehealth is rated as significantly more convenient. Predictors of discontinuing follow-up are greater distance to telehealth, old-age patient, lower telehealth satisfaction, and lower caregiver burden.

Rural–Urban Differences in the Prevalence of Chronic Disease in Northeast China

Rural–urban differences in the prevalence of chronic diseases in the adult population of northeast China are examined. The Jilin Provincial Chronic Disease Survey used personal interviews and physical measures to research the presence of a range of chronic diseases among a large sample of rural and urban provincial residents aged 18 to 79 years (N = 21 435). Logistic regression analyses were used. After adjusting for age and gender, rural residents had higher prevalence of hypertension, chronic ischemic heart disease, cerebrovascular disease, chronic low back pain, arthritis, chronic gastroenteritis/peptic ulcer, chronic cholecystitis/gallstones, and chronic lower respiratory disease. Low education, low income, and smoking increased the risk of chronic diseases in rural areas. Reducing rural–urban differences in chronic disease presents a formidable public health challenge for China. The solution requires focusing attention on issues endemic to rural areas such as poverty, lack of chronic disease knowledge, and the inequality in access to primary care.

The Prevalence of Anxiety Disorders Among Patients With Mitral Valve Prolapse Syndrome and Chest Pain

Nineteen patients from a cardiology practice with complaints of chest pain and with mitral valve prolapse syndrome were compared with 26 patients with chest pain but no discernible cardiac disorder. Instruments included a truncated form of the Diagnostic Interview Schedule, the symptom checklist 90 revised (SCL-90-R), the McGill Pain Questionnaire, and life events, physical activity, and family history questionnaires. Neither panic disorder nor self-rated anxiety were more common in the mitral valve prolapse group. This study failed to confirm the reported high association between mitral valve prolapse syndrome and panic disorder.

Mitral valve prolapse and psychiatric disorders

Abstract The authors report the prevalence of anxiety and depressive disorders in three groups of cardiac outpatients. The first group had mitral valve prolapse syndrome; the second group had been referred with chest complaints but were proven to have no cardiac disease; and the third group had been referred with innocent murmurs and were found to have no chest complaints and no cardiac disease. There was a somewhat higher prevalence of symptoms and diagnoses of depression in the chest complaint group. The findings did not support the often reported association between mitral valve prolapse syndrome and anxiety disorders.

The projected effect of risk factor reduction on major depression incidence: a 16-year longitudinal Canadian cohort of the National Population Health Survey.

BACKGROUND Few studies have examined the effect of risk factor modification on depression incidence. This study estimated the effect of risk factor modification on depression incidence. METHODS Data analyzed were from the Canadian National Population Health Survey (NPHS) - a longitudinal population-based cohort study. The study followed-up a national cohort sample over a 16-year period from 1994 to 2010. Multivariate modified Poisson regression was used to estimate relative risk. RESULTS The cumulative incidence rate of depression during the 16-year follow-up was 12.07%. Being younger adult, female, Caucasian, poor, occasional/abstainer/former drinker, regular smoker, and having chronic disease were significantly associated with an increased risk of developing depression. About 40% of depression incidence (850,000 cases) was potentially attributable to modifiable risk factors (poor income, smoking, and having a chronic disease). A 10% reduction in the prevalence of these modifiable risk factors could potentially prevent about 165,000 cases of depression. LIMITATIONS The calculation of PAFs assumes that there is a causal relationship between a risk factor and depression. However, major depression has multiple causes. The potential effect of risk factor modification on depression incidence may vary by the profile of risk factors assessed in a particular study. Several potentially important risk factors were not included in this study. CONCLUSION Public health campaigns targeted at significant modifiable risk factors could have a profound effect on future depression incidence. Prevention trials are needed to directly evaluate the effect of single and/or multiple risk factors modification on depression incidence.

Associations between adult attachment style and mental health care utilization: Findings from a large-scale national survey

This study investigated the association between attachment style and the use of a range of mental health services controlling socio-demographic, physical and psychological risk factors. Using a large nationally representative sample from the US National Comorbidity Survey Replication (NCS-R), a total of 5645 participants (18+) were included. The majority of participants reported their attachment as secure (63.5%), followed by avoidant (22.2%), unclassified (8.8%), and anxious (5.5%). The percentages using different health services studied varied widely (1.1-31.1%). People with insecure (anxious and avoidant) attachment were more likely to report accessing a hotline, having had a session of psychological counselling or therapy, getting a prescription or medicine for mental and behavioural problems. Individuals with anxious attachment only were also more likely to report the use of internet support groups or chat rooms. This is a first analysis to explore relationships between self-reported adult attachment style and a wide range of health care services. Insecurely attached individuals were more likely to use a wide range of health care services even after controlling for socio-demographic factors, psychiatric disorders and chronic health conditions. These findings suggest that adult attachment plays an important role in the use of mental health care services.