Colleen J. Maxwell

Measurement, Correlates, and Health Outcomes of Medication Adherence Among Seniors

OBJECTIVE To provide a comprehensive review of the literature on the measurement, correlates, and health outcomes of medication adherence among community-dwelling older adults. DATA SOURCES Searches of MEDLINE, PubMed, and International Pharmaceutical Abstracts databases for English-language literature (1966–December 2002) were conducted using one or more of the following terms: elderly, adherence/nonadherence, compliance/noncompliance, medication/drug, methodology/measurement, and hospitalization. STUDY SELECTION AND DATA EXTRACTION From the above search, studies of medication adherence in community-dwelling seniors were selected for review along with relevant publications from the reference lists of articles identified in the initial database search. DATA SYNTHESIS Although several methods are available for the assessment of adherence, accurate measurement continues to be difficult. The available evidence suggests that polypharmacy and poor patient–healthcare provider relationships (including the use of multiple providers) may be major determinants of nonadherence among older persons, with the impact of most sociodemographic factors being negligible. There is little consensus regarding other determinants of nonadherence. Relatively few high-quality investigations have examined the associations between nonadherence and subsequent health outcomes. Available data provide some support for increased health risks with nonadherence. However, interventions to improve adherence have seldom demonstrated positive effects on health outcomes. CONCLUSIONS There are few empirical data to support a simple systematic descriptor of the nonadherent patient. The inconsistencies across studies may be attributable, in part, to the inherent difficulties involved in the measurement of a behavioral risk factor such as nonadherence. Future research in this area would be strengthened by incorporation of detailed assessments of patient-reported reasons for nonadherence, the appropriateness of drug regimens, and the effect of nonadherence on health outcomes.

Descriptive Epidemiology of Major Depression in Canada

Objective: The Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) is the first national study to use a full version of the Composite International Diagnostic Interview. For this reason, and because of its large sample size, the CCHS 1.2 is capable of providing the best currently available description of major depression epidemiology in Canada. Using the CCHS 1.2 data, our study aimed to describe the epidemiology of major depression in Canada. Method: All estimates used appropriate sampling weights and bootstrap variance estimation procedures. The analysis consisted of estimating proportions supplemented by logistic regression modelling. Results: The lifetime prevalence of major depressive episode was 12.2%. Past-year episodes were reported by 4.8% of the sample; 1.8% reported an episode in the past 30 days. As expected, major depression was more common in women than in men, but the difference became smaller with advancing age. The peak annual prevalence occurred in the group aged 15 to 25 years. The prevalence of major depression was not related to level of education but was related to having a chronic medical condition, to unemployment, and to income. Married people had the lowest prevalence, but the effect of marital status changed with age. Logistic regression analysis suggested that the annual prevalence may increase with age in men who never married. Conclusions: The prevalence of major depression in the CCHS 1.2 was slightly lower than that reported in the US and comparable to pan-European estimates. The pattern of association with demographic and clinical variables, however, is broadly similar. An increasing prevalence with age in single (never-married) men was an unexpected finding.

Depression in epilepsy: A systematic review and meta-analysis

Objective: To estimate the prevalence of depression in persons with epilepsy (PWE) and the strength of association between these 2 conditions. Methods: The MEDLINE (1948–2012), EMBASE (1980–2012), and PsycINFO (1806–2012) databases, reference lists of retrieved articles, and conference abstracts were searched. Content experts were also consulted. Two independent reviewers screened abstracts and extracted data. For inclusion, studies were population-based, original research, and reported on epilepsy and depression. Estimates of depression prevalence among PWE and of the association between epilepsy and depression (estimated with reported odds ratios [ORs]) are provided. Results: Of 7,106 abstracts screened, 23 articles reported on 14 unique data sources. Nine studies reported on 29,891 PWE who had an overall prevalence of active (current or past-year) depression of 23.1% (95% confidence interval [CI] 20.6%–28.31%). Five of the 14 studies reported on 1,217,024 participants with an overall OR of active depression of 2.77 (95% CI 2.09–3.67) in PWE. For lifetime depression, 4 studies reported on 5,454 PWE, with an overall prevalence of 13.0% (95% CI 5.1–33.1), and 3 studies reported on 4,195 participants with an overall OR of 2.20 (95% CI 1.07–4.51) for PWE. Conclusions: Epilepsy was significantly associated with depression and depression was observed to be highly prevalent in PWE. These findings highlight the importance of proper identification and management of depression in PWE.

Supplemental Use of Antioxidant Vitamins and Subsequent Risk of Cognitive Decline and Dementia

There are conflicting reports about the potential role of vitamin antioxidants in preventing and/or slowing the progression of various forms of cognitive impairment including Alzheimer’s disease (AD). We examined longitudinal data from the Canadian Study of Health and Aging, a population-based, prospective 5-year investigation of the epidemiology of dementia among Canadians aged 65+ years. Our primary objective was to examine the association between supplemental use of antioxidant vitamins and subsequent risk of significant cognitive decline (decrease in 3MS score of 10 points or more) among subjects with no evidence of dementia at baseline (n = 894). We also explored the relationship between vitamin supplement use and incident vascular cognitive impairment (VCI; including a diagnosis of vascular dementia, possible AD with vascular components and VCI but not dementia), dementia (all cases) and AD. After adjusting for potential confounding factors assessed at baseline, subjects reporting a combined use of vitamin E and C supplements and/or multivitamin consumption at baseline were significantly less likely (adjusted OR 0.51; 95% CI 0.29–0.90) to experience significant cognitive decline during a 5-year follow-up period. Subjects reporting any antioxidant vitamin use at baseline also showed a significantly lower risk for incident VCI (adjusted OR 0.34, 95% CI 0.13–0.89). A reduced risk for incident dementia or AD was not observed. Our findings suggest a possible protective effect for antioxidant vitamins in relation to cognitive decline but randomized controlled trials are required for confirmation.

Large Increases in Hypertension Diagnosis and Treatment in Canada After a Healthcare Professional Education Program

This study was conducted to compare the self-reported prevalence and treatment of hypertension in adult Canadians before and subsequent to the implementation of the Canadian Hypertension Education Program in 1999. Data were obtained from 5 cycles of the Canadian Health Surveys between 1994 and 2003 on respondents aged ≥20 years. Piecewise linear regression was used to calculate the average annual increase in rates, before and after 1999. Between 1994 and 2003, the percentage of adult Canadians aware of being diagnosed with hypertension increased by 51% (from 12.37% to 18.74%; P<0.001), and the percentage prescribed antihypertensive drugs increased by 66% (from 9.57% to 15.86%; P<0.001). After 1999, there was approximately a doubling of the annual rate of increase in the diagnosis of hypertension (from 0.52% of the population per year before 1999 to 1.03% per year after 1999; P<0.001) and the percentage prescribed antihypertensive drugs (from 0.54% of the population per year before 1999 versus 0.98% per year after 1999; P<0.001). The proportion of those aware of the diagnosis of hypertension but not being treated with drugs was reduced by half between 1994 and 2003 (from 31.47% untreated to 15.34% untreated; P<0.001). There was a greater increase in awareness of hypertension and use of antihypertensive drugs among men compared with women after 1999. The large increase in the diagnosis and treatment of hypertension in Canada between 1994 and 2003 is consistent with an overall beneficial effect of the Canadian Hypertension Education Program, including a reduced gender gap in hypertension care.

The prevalence and management of current daily pain among older home care clients

&NA; The aim of this cross‐sectional study was to examine the prevalence and correlates of pharmacotherapy for current daily pain in older home care clients, focusing on analgesic type and potential contraindications to treatment. The sample included 2779 clients aged 65 + years receiving services from Community Care Access Centres in Ontario during 1999–2001. Clients were assessed with the Resident Assessment Instrument‐Home Care (RAI‐HC). Prescription and over‐the‐counter (OTC) medications listed on the RAI‐HC were used to categorize analgesic treatment into two groups (relative to no analgesic use): use of non‐opioids (acetaminophen or non‐steroidal anti‐inflammatory drugs only); and, use of opioids alone or in combination with non‐opioids. Associations between client characteristics and analgesic treatment among those in current daily pain were examined using multivariable multinomial logistic regression. Approximately 48% (n = 1,329) of clients had daily pain and one‐fifth (21.6%) of this group received no analgesic. In multivariable analyses, clients aged 75 + years and those with congestive heart failure, diabetes, other disease‐related contraindications, cognitive impairment and/or requiring an interpreter were significantly less likely to receive an opioid alone or in combination with a non‐opioid. Clients with congestive heart failure and without a diagnosis of arthritis were significantly less likely to receive a non‐opioid alone. A diagnosis of arthritis or cancer and use of nine or more medications were significantly associated with opioid use. The findings provide evidence of both rational prescribing practices and potential treatment bias in the pharmacotherapeutic management of daily pain in older home care clients.

Antidepressant utilization in Canada

ObjectiveAntidepressant utilization can be used as an indicator of appropriate treatment for major depression. The objective of this study was to characterize antidepressant utilization in Canada, including the relationships of antidepressant use with sociodemographic variables, past-year and lifetime depression, number of past depressive episodes, and other possible indications for antidepressants.MethodWe examined data from the Canadian Community Health Survey (CCHS) Cycle 1.2. The CCHS was a nationally representative mental health survey (N=36,984) conducted in 2002 that included a diagnostic instrument for past-year and lifetime major depressive episodes and other psychiatric disorders and a record of past-year antidepressant use.ResultsOverall, 5.8% of Canadians were taking antidepressants, higher than the annual prevalence of major depressive episode (4.8%) in the survey. Among persons with a past-year major depressive episode, the frequency of antidepressant use was 40.4%. After application of adjustments for probable successful outcomes of treatment, the estimated frequency of antidepressant use for major depression was more than 50%. Frequency of antidepressant treatment among those with a history of depression but without a past-year episode increased with the number of previous episodes. Among those taking antidepressants over the past year, only 33.1% had had a past-year episode of major depression. Migraine, fibromyalgia, anxiety disorder, or past depression was present in more than 60% of those taking antidepressants without a past-year episode of depression.ConclusionsThe CCHS results suggest that antidepressant use has increased substantially since the early 1990s, and also that these medications are employed extensively for indications other than depression.

Comorbidity of major depression with substance use disorders.

Objectives: In the Canadian adult population, we aimed to 1) estimate the 12-month prevalence of major depressive disorder (MDD) in persons with a diagnosis of harmful alcohol use, alcohol dependence, and drug dependence; 2) estimate the 12-month prevalence of harmful alcohol use, alcohol dependence, and drug dependence in persons with a 12-month and lifetime diagnosis of MDD; 3) identify socioeconomic correlates of substance use disorder–major depression comorbidity; 4) determine how comorbidity impacts the prevalence of suicidal thoughts; and 5) determine how comorbidity affects mental health care used. Methods: We examined data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Results: The 12-month prevalences of MDD in persons with a substance use disorder (SUD) were 6.9% for harmful alcohol use (95% confidence interval [CI], 5.2 to 8.5), 8.8% for alcohol dependence (95%CI, 6.6 to 11.0), and 16.1% for drug dependence (95%CI, 10.3 to 21.9). Conversely, the 12-month prevalences of harmful alcohol use, alcohol dependence, and drug dependence in persons with a 12-month diagnosis of MDD were 12.3% (95%CI, 9.4 to 15.2), 5.8% (95%CI, 4.3 to 7.3), and 3.2% (95%CI, 2.0 to 4.4), respectively. Regression modelling did not identify any socioeconomic predictors of SUD–MDD comorbidity. Substance dependence and MDD independently predicted higher prevalence of suicidal thoughts and mental health treatment use. Conclusions: SUDs cooccur with a high frequency in cases of MDD. Clinicians and mental health services should consider routine assessment of SUDs in depression patients.

Psychotropic Medication Use in Canada

Background: Psychotropic medication use can be employed as an indicator of appropriate treatment for mental disorders. The Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) offers the first opportunity to characterize Canadian psychotropic medication use on a national level within diagnostic groups as assessed by a full version of the Composite International Diagnostic Interview (CIDI). Method: We assessed the prevalence of antidepressant, sedative-hypnotic, mood stabilizer, psychostimulant, and antipsychotic use over 2 days overall and in subgroups defined by CIDI-diagnosed disorders and demographics. We employed sampling weights and bootstrap methods. Results: Overall psychotropic drug utilization was 7.2%. Utilization was higher for women and with increasing age. With any lifetime CIDI-diagnosed disorder assessed in the CCHS 1.2, utilization was 19.3%, whereas without such disorders, it was 4.1%. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly used antidepressants for those with a past-year major depressive episode (17.8%), followed by venlafaxine (7.4%). Among people aged 15 to 19 years, antidepressant use was 1.8% overall and 11.7% among those with past-year depression; SSRIs made up the majority of use. Sedative-hypnotics were used by 3.1% overall, increasing with age to 11.1% over 75 years. Conclusions: International comparison is difficult because of different evaluation methods, but antidepressant use may be higher and antipsychotic use lower in Canada than in recent European and American reports. In light of the relative lack of contemporary evidence for antidepressant efficacy in adolescents, it is likely that antidepressant use among those aged 15 to 19 years will continue to decline. The increased use of sedative-hypnotics with age is of concern, given the associated risk of adverse effects among seniors.

Medication Nonadherence and Subsequent Risk of Hospitalisation and Mortality among Older Adults

BackgroundDespite a higher risk for medication nonadherence among older adults residing in the community, few prospective studies have investigated the health outcomes associated with nonadherence in this population or the possible variations in risk in urban versus rural residents.ObjectivesThe primary objective of this study was to examine, in a prospective manner, the risk for hospitalisation (including an emergency department visit) and/or mortality associated with medication nonadherence in older, at-risk adults residing in the community. A secondary objective was to examine differences in the prevalence, determinants and consequences of medication nonadherence between rural and urban home care clients.MethodsData were derived from a 1-year prospective study of home care clients aged ≥65 years (n = 319) randomly selected from urban and rural settings in southern Alberta, Canada. Trained nurses conducted in-home assessments including a comprehensive medication review, self-report measures of adherence and the Minimum Data Set for Home Care (MDS-HC) tool. Hospitalisation and mortality data during 12-month follow-up were obtained via linkages with regional administrative and vital statistics databases.ResultsNonadherent clients showed an increased but nonsignificant risk for an adverse health outcome (hospitalisation, emergency department visit or death) during follow-up (hazard ratio [adjusted for relevant covariates] = 1.24, 95% CI 0.93, 1.65). Subgroup analyses suggested this risk may be higher for unintentional nonadherence (unadjusted hazard ratio = 1.55, 95% CI 0.97, 2.48). The prevalence of nonadherence was similar among rural (38.2%) and urban (38.9%) clients and was associated with the presence of vision problems, a history of smoking, depressive symptoms, a high drug regimen complexity score, residence in a private home (vs assisted-living setting) and absence of assistance with medication administration. In both settings, approximately 20% of clients received one or more inappropriate medications.ConclusionsAlthough not associated with rural/urban residence, medication nonadherence was common in our study population, particularly among those with depressive symptoms and complex medication regimens. The absence of a significant association between overall medication nonadherence and health outcomes may reflect study limitations and/or the need to differentiate among types of nonadherent behaviours.