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Tailored interventions to implement recommendations for elderly patients with depression in primary care: A study protocol for a pragmatic cluster randomised controlled trial
Get PDFBackground The prevalence of depression is high and the elderly have an increased risk of developing chronic course. International data suggest that depression in the elderly is under-recognised, the latency before clinicians provide a treatment plan is longer and elderly patients with depression are not offered psychotherapy to the same degree as younger patients. Although recommendations for the treatment of elderly patients with depression exist, health-care professionals adhere to these recommendations to a limited degree only. We conducted a systematic review to identify recommendations for managing depression in the elderly and prioritised six recommendations. We identified and prioritised the determinants of practice related to the implementation of these recommendations in primary care, and subsequently discussed and prioritised interventions to address the identified determinants. The objective of this study is to evaluate the effectiveness of these tailored interventions for the six recommendations for the management of elderly patients with depression in primary care. Methods/design We will conduct a pragmatic cluster randomised trial comparing the implementation of the six recommendations using tailored interventions with usual care. We will randomise 80 municipalities into one of two groups: an intervention group, to which we will deliver tailored interventions to implement the six recommendations, and a control group, to which we will not deliver any intervention. We will randomise municipalities rather than patients, individual clinicians or practices, because we will deliver the intervention for the first three recommendations at the municipal level and we want to minimise the risk of contamination across GP practices for the other three recommendations. The primary outcome is the proportion of actions taken by GPs that are consistent with the recommendations. Discussion This trial will investigate whether a tailored implementation approach is an effective strategy for improving collaborative care in the municipalities and health-care professionals’ practice towards elderly patients with depression in primary care. The effectiveness evaluation described in this protocol will be accompanied with a process evaluation exploring why and how the interventions were effective or ineffective
Three-year mortality in previously hospitalized older patients from rural areas - the importance of co-morbidity and self-reported poor health
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BACKGROUND:
The risk factors for mortality after hospitalization in older persons are not fully understood. The aim of the present study was to examine the three-year (1,096 days) mortality in previously hospitalized older patients from rural areas, and to explore how objectively and self-reported health indicators at baseline were associated with mortality.
METHODS:
The study included 484 (241 men) medical inpatients with age range 65-101 (mean 80.7, SD 7.4) years. Baseline information included the following health measures: the Charlson Index, the Mini-Mental-State Examination, Lawton and Brody's scales for physical self-maintenance and the instrumental activities of daily living, the Hospital Anxiety and Depression scale, self-reported health (one item), and perceived social functioning (one item) and assistance in living at discharge.
RESULTS:
In all, 172 (35.5%) of those patients included had died within the three years of the follow-up period. Three-year mortality was associated with a high score at baseline on the Charlson Index (HR 1.73, 95%CI 1.09-2.74) and poor self-reported health (HR 1.52, 95%CI 1.03-2.25) in a Cox regression analysis adjusted for age, gender, other objectively measured health indicators, and perceived impaired social functioning.
CONCLUSION:
In a study of older adults admitted to a general hospital for a wide variety of disorders, we found co-morbidity (as measured with the Charlson Index) and poor self-reported health associated with three-year mortality in analysis adjusting for age, gender, and other health-related indicators. The results suggest that self-reported health is a measure that should be included in future studies.publishedVersio
Prevalence and risk factors for postpartum depressive symptoms in Argentina - a cross sectional study
Get PDFIntroduction: Postpartum depression is a prevalent disorder with negative consequences for women, infants, and the family as a whole. Most studies of this disorder have been conducted in Western countries, and studies from developing countries are few. In this paper, we report the first – as far as we are aware – study of the prevalence and risk factors associated with postpartum depressive symptoms in Argentina. Materials and methods: The study participants were 86 women attending 6 week check-ups, (range 4–12 weeks) postpartum at a private health care center in the metropolitan area of Buenos Aires. The women completed the Edinburgh Postnatal Depression Scale (EPDS) and a questionnaire collecting demographic and obstetric data. Data were described as proportions (percentages). Differences between proportions were assessed with chi-squared tests. To control for possible confounders, we fitted bivariate logistic regression models in which the dependent variable was an EPDS sum score of ,10 versus a score of 10, 16 (18.6%) had a score between 10 and 12, and 16 (18.6%) had a score of 10 was significantly associated with multiparity (odds ratio [OR] =3.58; 95% confidence interval [CI]: 1.13–11.30; P=0.030), pregnancy complications (OR =3.40; 95% CI: 1.03–11.26; P=0.045), labor complications (OR =11.43; 95% CI: 1.71–76.61; P=0.012), cesarean section (OR =4.19; 95% CI: 1.10–16.01; P=0.036), and incomplete breast-feeding (OR =5.00; 95% CI: 1.42–17.54; P=0.012). Conclusion: Our results indicate that postpartum depression may be prevalent in Argentina, and may be associated with incomplete breast-feeding, cesarean section, perinatal complications and multiparity. The prevalence and risk factors for postpartum depression has not been described previously and is a considerable health-related problem among women. Argentinian health professionals should be aware of the high prevalence rate and possible risk factors so that these women and families can be identified and receive adequate support and treatment.publishedVersio
Vitamin B6 deficiency and diseases in elderly people - a study in nursing homes
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BACKGROUND:
Vitamin deficiency is a cause of health related problems in elderly people. The aims were to study associations between vitamin B6 (B6) and diseases (primarily functional gastrointestinal disorders) in elderly people in nursing homes, the prevalence of B6 deficiency and factors associated with B6 deficiency.
METHODS:
This cross-sectional study included residents in nursing homes. Demographics, nutritional status (Mini Nutritional Assessment, MNA®), physical activity, activity of daily living (Katz Index), dietary habits, use of drugs, and psychiatric and somatic diseases were recorded. A blood sample was collected for haematological and biochemical screening, including B6 (p-PLP); p-PLP values < 20 nmol/l indicates B6 deficiency. The results are given as mean (SD).
RESULTS:
Sixty-one residents (men/women: 22/39) with an age of 85.3 (6.8) years and BMI 25.7 (4.5) kg/m2 were included. Malnutrition and risk of malnutrition were present in 11.5% and 61% respectively. Dietary intake of B6 (mg/day) in men and women were 1.60 (0.30) and 1.18 (0.31) (recommended 1.6 and 1.2 respectively), and 14 (23%) used B6 supplements. Median p-PLP was 20.7 (range <4.0-175.8), 30 subjects (49%) had B6 deficiency. B6 deficiency was associated with old age, low s-alanine aminotransferase and s-albumin, elevated s-homocysteine and inactivity (p-values 0.01-0.03). There were no clinically significant associations between B6 deficiency and somatic or psychiatric disorders, and B6 deficiency was not observed in subjects given B6 supplements.
CONCLUSIONS:
Half of the residents had vitamin B6 deficiency. Vitamin supplement was effective prophylaxis for deficiency and should be recommended to all elderly people in nursing homes.publishedVersio
Predicting acute side effects of stimulant medication in pediatric attention deficit/hyperactivity disorder: data from quantitative electroencephalography, event-related potentials, and a continuous-performance test
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BACKGROUND:
The aim of this study was to search for predictors of acute side effects of stimulant medication in pediatric attention deficit/hyperactivity disorder (ADHD), emphasizing variables from quantitative electroencephalography (QEEG), event-related potentials (ERPs), and behavior data from a visual continuous-performance test (VCPT).
METHODS:
Seventy medication-naïve ADHD patients aged 7-16 years were tested with QEEG, including a go/no-go task condition (VCPT) from which behavior data and ERPs were extracted, followed by a systematic trial on stimulant medication lasting at least 4 weeks. Based on data from rating scales and interviews, two psychologists who were blind to the QEEG/ERP test results independently rated the patients as having no or small side effects (n = 37) or troublesome side effects (n = 33). We determined if the side effects were related to sex, age, IQ, ADHD subtype, comorbidities, clinical outcome, and variables in QEEG, ERPs, and VCPT.
RESULTS:
There was a moderate negative correlation between clinical outcome and side effects. Three variables were significantly associated with side effects in a multivariate logistic regression analysis. In the ERP independent component - contingent negative variation - which reflected action preparation and time evaluation, patients with high amplitudes (close to normal values) experienced more side effects than patients with lower amplitudes. A faster-than-normal reaction time in VCPT was associated with side effects, as was a high amplitude in an early ERP component (early visual independent component), reported to be influenced by attention, perceptual sensitivity, and anxiety.
CONCLUSION:
The group with troublesome side effects had normal action-preparation electrical brain activity, a faster-than-normal reaction time, and an increased level of anxiety (measured by ERP) compared with the no side-effects group.publishedVersio
Probiotics, Symptoms, and Gut Microbiota: What Are the Relations? A Randomized Controlled Trial in Subjects with Irritable Bowel Syndrome
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INTRODUCTION:
Knowledge of the mechanism of action of probiotics in subjects with irritable bowel syndrome (IBS) is imperfect.
OBJECTIVE:
This trial aimed at discriminating between a direct effect on the gut wall and an indirect effect caused by modulation of the fecal microbiota.
DESIGN:
Randomized, double-blind, crossover trial.
MATERIAL AND METHODS:
Patients with IBS were given one capsule of 10(10) CFU L. plantarum MF 1298 or placebo once daily. Symptoms were registered (score 0-15) and feces collected at the end of each period. The gut microbiota was analyzed with 16S rRNA gene analyses and results reported as proportions of Bacteroides, Faecalibacterium, and Lachnospiraceae and Simpson's D diversity score.
RESULTS:
Sixteen participants (11 women) with a mean age of 50 years (SD 11) were available for the analyses. Intake of L. plantarum MF 1298 was associated with a significant aggravation of symptoms, but neither intake of L. plantarum MF 1298 nor symptoms were associated with the composition of the fecal microbiota (P values >0.10).
CONCLUSIONS:
The trial indicates that the symptomatic aggravation related to intake of L. plantarum MF 1298 was a direct effect of the microbe on the gut wall and not caused by changes in the fecal microbiota.S. C. Ligaarden and P. G. Farup have received funding from Nofima AS (former Matforsk AS) for the clinical trial. K. Rudi has received funding from the Norwegian University of Science and Technology and Østfold Hospital Trust for the analyses of the gut microbiota.publishedVersio
Pregnancy and substance use - the Norwegian § 10-3 solution : ethical and clinical reflections related to incarceration of pregnant women to protect the foetus from harmful substances
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Aims
This article highlights ethical and clinical dilemmas of incarceration of pregnant drug addicts mandated by z 10–3 of the Norwegian Municipal Health and Care Services act.
Material
The material consists of two cases, Siri and Anna, and the ethical dilemmas posed by the use of z 10–3 in these cases.
Methods
Semi-structured in-depth individual interviews were conducted, audio-recorded and transcribed word for word. Transcripts were coded according to converging interests and possible ethical dilemmas and described in a case format. The practical and experiential consequences of the law are discussed in relation to the four main bioethical principles: respect for autonomy, non-maleficence, beneficence and social justice. These are supplemented by the principles of relational ethics.
Results
The application of z 10–3 may lead to situations which distort the psychological preparation for parenthood and strains the helping relationship. The four principles approach seems to be an insufficient tool in grasping the complexity of the situation.
Conclusions
Interventions to protect the foetus from the pregnant woman's use of substances demand elevated professional awareness of ethical and relational challenges and dilemmas. Relational ethics provides a framework to enhance reflexivity and a trusting therapeutic alliance. The potential for psychological change during pregnancy should be invested in. Hence, we suggest that during incarceration according to z 10–3, foetal protection and the promotion of parental competences should be given equal priority.publishedVersio
IgG and IgG4 antibodies in subjects with irritable bowel syndrome: a case control study in the general population
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BACKGROUND:
Patients with Irritable Bowel Syndrome (IBS) often relate their symptoms to the intake of food and modify their diet. IgE-mediated food allergy is uncommon in IBS, but the role of IgG-mediated food hypersensitivity remains inconclusive. The primary aim of this study was to compare food- and yeast-specific IgG and IgG4 antibodies in subjects with and without IBS.
METHODS:
This was a case control study in the general population for which subjects completed questionnaires about abdominal complaints and their intake of common food items. Blood samples were collected, and food- and yeast-specific IgG and IgG4 antibodies were measured. Antibodies were measured in mg/L.
RESULTS:
We included 269 subjects with IBS and 277 control subjects. After correction for subject characteristics and diet, there were no significant differences with regard to food- and yeast-specific IgG and IgG4 antibodies between subjects with IBS and controls. Lower values of IgG antibodies against egg (OR 0.99 (0.98 to 1.00), p = 0.002) and beef (OR 0.75 (0.60 to 0.94), p = 0.012) and higher values of IgG antibodies against chicken (OR 1.14 (1.03 to 1.27), p = 0.009) were associated with more severe symptoms.
CONCLUSIONS:
Our findings suggest that IgG-and IgG4-mediated food and yeast hypersensitivity in IBS is unlikely. IgG antibodies against food and yeast may reflect the diet.publishedVersio
Drugs and Constipation in Elderly in Nursing Homes: What Is the Relation?
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INTRODUCTION:
Constipation is a common adverse drug reaction.
OBJECTIVE:
Study associations between drugs and constipation in nursing home residents.
DESIGN:
Cross-sectional study.
MATERIAL AND METHODS:
Nursing home residents above 60 years of age were included. Demographics, diet, physical activity, activity of daily living, nutritional status, use of drugs, and diseases were recorded. Constipation was defined as functional constipation or constipation-predominant IBS according to the Rome III criteria and/or regular use of laxatives. Drugs were classified according to the Anatomical-Therapeutic-Chemical Classification System (ATC), and anticholinergic effect was noted.
RESULTS:
In all, 79 men and 188 women with a mean age of 85.4 (SD 7.1) years were included. The prevalence of constipation was 71.5%. Use of drugs in general, including polypharmacy, was not associated with constipation. Reduced activity of daily living (OR = 0.71, 95% CI : 0.60-0.84, P < 0.001), other antidepressants (N06AX) (OR 3.08, 95% CI : 1.09-8.68, P = 0.03), and benzodiazepine derivatives (N05BA) (OR = 2.80, 95% CI : 1.12-7.04, P = 0.03) were significantly associated with constipation; drugs with markedly anticholinergic effect (OR = 3.7, 95% CI : 0.78-17.53, P = 0.10), natural opium alkaloid (N02AA) (OR = 5.01, 95% CI : 0.95-25.94, P = 0.06), and propionic acid derivatives (M01AE) (OR = 7.00, 95% CI : 0.75-65.08, P = 0.09) showed a trend.
CONCLUSION:
In elderly with constipation, focus should be on specific groups of drugs and nonpharmacological factors, not on drugs in general.publishedVersio