Philippe Voyer

The Epidemiology of Psychiatric Disorders in Quebec's Older Adult Population

Objective: To document the prevalence of psychiatric disorders in Quebecs older adult population. Method: Data came from the Enquête sur la santé des aînés study conducted in 2005–2006 using a representative sample (n = 2798) of community-dwelling older adults. Results: Our results indicate that 12.7% of the respondents met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for depression, mania, anxiety disorders, or benzodiazepine dependency. The 12-month prevalence rate of major depression was 1.1% and the prevalence of minor depression 5.7%. A total of 5.6% of the respondents reported an anxiety disorder. The most prevalent anxiety disorders were specific phobia (2.0%), obsessive–compulsive disorder (OCD) (1.5%), and generalized anxiety disorder (GAD) (1.2%). Agoraphobia without panic disorder and panic disorder were reported by 0.3% and 0.6% of the respondents, respectively. The prevalence rate of benzodiazepine dependency was 2.3%. The 12-month comorbidity prevalence rate between any psychiatric disorders was 2.2%. Among those with depressive disorder, the most frequent comorbidity was observed between minor depression and specific phobia (4.3%), GAD (4.3%), OCD (3.7%), and mania (1.3%). Further, only 39% of those having at least one active DSM-IV diagnosis reported having used health services for their psychological distress symptoms during the previous 12 months. Among those who consulted health services, 85% visited a general practitioner. Conclusions: Our results indicate that a large proportion of the elderly population in Quebec presents mental health needs. Longitudinal research focusing on the individual and social consequences of mental health problems reported by older adults is needed to avoid misinterpretation of this finding.

Detecting Delirium and Subsyndromal Delirium Using Different Diagnostic Criteria among Demented Long-Term Care Residents

OBJECTIVES To evaluate the impact of using different diagnostic criteria on prevalence rates of delirium and subsyndromal delirium (SSD) among demented long-term care (LTC) residents. DESIGN Descriptive study. SETTING LTC settings in Quebec City, Canada. PARTICIPANTS Participants were 155 individuals aged 65 and older, with dementia. MEASUREMENTS (1) Prevalence rates of delirium according to: (a) the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) and (b) the Confusion Assessment Method (CAM) algorithms for definite and probable delirium; and (2) prevalence rates of SSD employing 2 definitions described in previous studies. RESULTS Prevalence rates of delirium according to each set of criteria were 26.5% for DSM-III; 29% for DSM-IV-TR; 41.3% for DSM-III-R; 45.8% for CAM algorithm for definite delirium; and 70.3% for CAM algorithm for probable delirium. A total of 109 subjects (70.3%) were identified as delirious consistent with at least one classification and 37 (23.9%) met all the sets of criteria considered. Prevalence rates for SSD were 75 (48.4%) and 78 (50.3%) depending on the definition employed. CONCLUSION Prevalence rates for delirium are much affected by the diagnostic formulations used. The use of DSM-IV-TR among this population could result in fewer cases being identified as delirious and thus compromise proper care for those individuals. Considering that SSD was prevalent among this population, a systematic implementation of protocols targeting risk factors of delirium might be beneficial among demented LTC residents.

Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities.

BackgroundVerbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism.MethodsThe goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2 332).ResultsThe same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.ConclusionCognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints.

Prevalence and incidence of delirium in long‐term care

(1) To describe the prevalence and 6‐month incidence of delirium in long‐term care facility (LTCF) residents age 65 and over; (2) To describe differences in these measures by resident baseline characteristics.

Prevalence and Symptoms of Delirium Superimposed on Dementia

Delirium is a frequent syndrome among patients who are elderly. People who are older with cognitive impairment who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. This study goal was to describe the effect of severity of prior cognitive impairment on delirium prevalence and symptom presentation among patients who were older and were newly admitted to an acute care hospital. A total of 104 were included in this descriptive study and screened for delirium. The results showed that the prevalence of delirium increased according to the severity of the patients’ prior cognitive impairment. Except for disorganized thinking, all symptoms of delirium were similar among patients with mild, moderate, and severe prior cognitive impairment. The study concluded that training nurses to recognize subtle changes in mental status among those patients who were older with prior cognitive impairment may prevent the underdetection of delirium.

Assessing Pain in Dementia Patients with Comorbid Delirium and/or Depression

Pain in older adults with severe limitations in ability to communicate is often assessed with observational methods. However, many of the behaviors that are used to assess pain often overlap with behavioral manifestations of delirium and depression. Such overlap can make the assessment of pain in patients with comorbid delirium and/or depression especially challenging. In this study, we assessed pain using the Doloplus-II (one of the most established pain assessment methods for seniors with dementia) and examined the extent to which each of its items were also predictive of delirium, depression, and dementia severity. As expected, several Doloplus-II items were found to be related to dementia severity, depression, and/or delirium. Clinicians assessing pain in dementia patients with comorbid depression or delirium should place less emphasis on items that have reduced specificity in identifying pain problems. Instead, assessment should be informed by items with higher specificity as well as other sources of information (e.g., results of physical examinations and information from caregivers). Although in this investigation we used the Doloplus-II to assess pain, it is likely that our findings generalize to other observational pain assessment measures developed for patients with dementia.

The Prevalence of Benzodiazepine Dependence among Community-Dwelling Older Adult Users in Quebec According to Typical and Atypical Criteria *

Contexte: La consommation de benzodiazépines est reconnue pour pouvoir entraîner un problème de dépendance. Les critères diagnostiques de la dépendance du DSM-IV-TR ne s’appliqueraient pas toujours à la situation d’un médicament prescrit par un médecin. Cette recherche vise à déterminer la prévalence de la dépendance aux benzodiazépines chez les aînés selon les critères classiques et des critères atypiques. Méthode : Étude descriptive basée sur des entrevues réalisées au domicile de 2785 aînés sélectionnés de façon aléatoire dans la province de Québec, Canada. Résultats : Le quart (25,4 %) des participants de l’étude étaient consommateurs de benzodiazépines et 9,5 % d’entre eux étaient dépendants selon le DSM-IV-TR. Toutefois, 43 % des aînés consommateurs se disaient dépendants du médicament et un tiers souhaite arrêter de le consommer. Interprétation : La dépendance aux benzodiazépines se présenteraient chez environ 10 % des aînés consommateurs selon les critères classiques, pourtant plus de 40 % d’entre eux se disent dépendants. Background: Use of benzodiazepines, common among older people, may lead to substance dependence. DSM-IV-TR criteria for this iatrogenic problem may apply poorly to older persons following a physician-prescribed regimen. This study, first of its kind, aimed to determine the prevalence rate of benzodiazepine dependence in older persons according to DSM-IV-TR and other atypical criteria. Methods: Descriptive study based on face-to-face interviews conducted in the homes of 2,785 persons aged 65 years or older who were randomly selected from across the province of Quebec, Canada. Results: Use of benzodiazepines was reported by 25.4 % of respondents. Among them, 9.5 % met DSM-IV-TR criteria for substance dependence. However, 43 % of users reported being dependent, and one third agreed that it would be a good thing to stop taking benzodiazepines. Interpretation: Benzodiazepine substance dependence is established at one tenth of community-dwelling older persons taking these medications, although a much larger proportion self-labels as dependent.

Factors associated with psychotropic drug use among community-dwelling older persons: A review of empirical studies

BackgroundIn the many descriptive studies on prescribed psychotropic drug use by community-dwelling older persons, several sociodemographic and other factors associated with drug use receive inconsistent support.MethodEmpirical reports with data on at least benzodiazepine or antidepressant drug use in samples of older persons published between 1990 and 2001 (n = 32) were identified from major databases and analyzed to determine which factors are most frequently associated with psychotropic drug use in multivariate analyses. Methodological aspects were also examined.ResultsMost reports used probability samples of users and non-users and employed cross-sectional designs. Among variables considered in 5 or more reports, race, proximity to health centers, medical consultations, sleep complaints, and health perception were virtually always associated to drug use. Gender, mental health, and physical health status were associated in about two-thirds of reports. Associations with age, marital status, medication coverage, socioeconomic status, and social support were usually not observed.ConclusionsThe large variety of methods to operationalize drug use, mental health status, and social support probably affected the magnitude of observed relationships. Employing longitudinal designs and distinguishing short-term from long-term use, focusing on samples of drug users exclusively, defining drug use and drug classes more uniformly, and utilizing measures of psychological well-being rather than only of distress, might clarify the nature of observed associations and the direction of causality. Few studies tested specific hypotheses. Most studies focused on individual characteristics of respondents, neglecting the potential contribution of health care professionals to the phenomenon of psychotropic drug use among seniors.

Predisposing Factors Associated With Delirium Among Demented Long-Term Care Residents

This was a cross-sectional study to investigate predisposing factors associated with delirium among demented long-term-care residents and to assess the cumulative effect of these factors on the likelihood of having delirium. Of the 155 participants, 109 (70.3%) were found delirious according to the confusion assessment method. Among these individuals, age (OR = 1.07; 95% CI = 1.05-1.10) and severity of dementia (OR = 1.05; 95% CI = 1.03-1.07) were the most associated factors of delirium. The likelihood of being in delirium increased with the number of associated predisposing factors present (OR = 1.67; 95% CI = 1.11-2.51). Associated factors identified were level of functional autonomy, pain, depression, behavioral disturbances, number of medications, dehydration, fever, and malnutrition. Identification of predisposing factors will help nurses in detecting those residents in long-term care settings who are at high-risk for delirium, as well as in designing preventive intervention strategies for delirium, based on these factors.

Factors associated with benzodiazepine dependence among community-dwelling seniors.

Background: Benzodiazepine (BZD) dependence among seniors is an understudied problem. Objective: Identify the factors associated with BZD dependence. Method: Face-to-face computer-assisted interviews were conducted in the homes of 2,785 persons aged 65 years or older, randomly selected. Results: Nine-and-a-half percent of BZD users met DSM-IV-TR criteria for BZD dependence. Factors associated with BZD dependence are being a woman, and having cognitive impairment, panic disorders, suicidal ideations, and a degree of embarrassment in obtaining help for emotional problem. Discussion: Nurses should be better positioned to identify those elderly users of BZDs who are more likely to be dependent and to address the problem through BZD withdrawal program.