The present study was conducted to determine whether anxiety among community-dwelling elders is associated with cognitive decline over a period of one year as well as to verify whether there are sex differences in the association between anxiety and cognitive decline. Participants (n=1942) were community-dwelling adults aged 65–96 years assessed at study entry (T0) and one year later (T1). Anxiety was identified with a semi-structured interview and cognitive functioning was assessed using the Mini-Mental State Examination. Results revealed that the presence of a clinically significant anxiety disorder did not predict cognitive decline in men and women. Subclinical anxiety symptoms predicted cognitive decline in women only. Moreover, for men, the presence of symptoms from at least two anxiety disorders predicted cognitive decline. For women, cognitive decline was predicted by the presence of symptoms from one anxiety disorder only. Overall, the results illustrate the role of anxiety in cognitive decline in community-dwelling older adults.

Several measuring devices are available to assess specific behavioural problems of dementia patients residing in nursing homes but only a few have been translated and validated in French. This study’s main objective was to determine the factorial structure of the French version of the Nursing Home Behavior Problem Scale (NHBPS) with people suffering from dementia. A secondary objective was to document the variables associated with the global score of the NHBPS and the underlying dimensions of the instrument. Participants (n = 155) were diagnosed with dementia and resided in three nursing homes and a hospital’s long-term care unit. The presence of behavioural problems and other characteristics were assessed by two nurses. A factor analysis revealed five key dimensions in the francophone version of the questionnaire. Several variables were associated with the total score of the NHBPS and its five underlying dimensions. Although the factorial solution of the French version of the NHBPS is similar to the English versions, our results also show differences that may depend on methodological characteristics.

Background: Detection of long-term care (LTC) residents at risk of delirium may lead to prevention of this disorder. The primary objective of this study was to determine if the presence of one or more Confusion Assessment Method (CAM) core symptoms of delirium at baseline assessment predicts incident delirium. Secondary objectives were to determine if the number or the type of symptoms predict incident delirium.

Methods: The study was a secondary analysis of data collected for a prospective study of delirium among older residents of seven LTC facilities in Montreal and Quebec City, Canada. The Mini-Mental State Exam (MMSE), CAM, Delirium Index (DI), Hierarchic Dementia Scale, Barthel Index, and Cornell Scale for Depression were completed at baseline. The MMSE, CAM, and DI were repeated weekly for six months. Multivariate Cox regression models were used to determine if baseline symptoms predict incident delirium.

Results: Of 273 residents, 40 (14.7%) developed incident delirium. Mean (SD) time to onset of delirium was 10.8 (7.4) weeks. When one or more CAM core symptoms were present at baseline, the Hazard Ratio (HR) for incident delirium was 3.5 (95% CI = 1.4, 8.9). The HRs for number of symptoms present ranged from 2.9 (95% CI = 1.0, 8.3) for one symptom to 3.8 (95% CI = 1.3, 11.0) for three symptoms. The HR for one type of symptom, fluctuation, was 2.2 (95% CI = 1.2, 4.2).

Conclusion: The presence of CAM core symptoms at baseline assessment predicts incident delirium in older LTC residents. These findings have potentially important implications for clinical practice and research in LTC settings.

Contexte : La consommation de benzodiazépines est une pratique courante chez les personnes aînées. Cette consommation peut entraîner un problème de dépendance dont les critères du Manuel diagnostic et statistique des troubles mentaux, 4e édition révisée (DSM-IV-TR) ne s’appliqueraient pas toujours à la situation de l’aîné. Cette recherche vise à examiner l’association entre le sentiment de dépendance aux benzodiazépines et l’utilisation des services de santé par les aînés. Un objectif secondaire consiste à décrire l’utilisation des benzodiazépines chez les aînés vivant dans la communauté.

Méthode : Les données proviennent d’une enquête menée au Québec en 2005-2006 auprès d’un échantillon représentatif de 707 francophones âgés de 65 ans et plus vivant dans la communauté. Le sentiment de dépendance aux benzodiazépines a été évalué par une variable composite intégrant deux questions inspirées du DSM-IV-TR. L’utilisation des services de santé a été mesurée par l’incidence cumulée des consultations auprès des professionnels de la santé au cours d’une période de 12 mois.

Résultats : Les aînés ont consommé au total 745 benzodiazépines parmi lesquelles 117 (16,5 %) avaient une longue demi-vie d’élimination. La proportion d’aînés qui ont rapporté un sentiment de dépendance aux benzodiazépines a été estimée à 35,1 %. Ces aînés n’ont pas significativement davantage utilisé les services de santé pour leurs problèmes de dépendance aux benzodiazépines.

Conclusion : Les résultats de cette étude suggèrent que l’utilisation des benzodiazépines chez les aînés au Québec est loin d’être optimale. Par ailleurs, le besoin ressenti de dépendance ne constitue pas un facteur suffisant pour amener les aînés à utiliser les services de santé pour la prise en charge d’un problème de dépendance. Il existe donc un besoin de recherche afin de mieux cerner les barrières associées à l’utilisation des services de santé par les aînés dépendants aux benzodiazépines.

Background: Persons with dementia frequently present behavioral and psychological symptoms as well as delirium. However, the association between these has received little attention from researchers and current knowledge in this area is limited. The purpose of this study was to examine the relation between delirium and behavioral symptoms of dementia (BSD).

Methods: Participants were 155 persons with a diagnosis of dementia, 109 (70.3%) of whom were found delirious according to the Confusion Assessment Method. BSD were assessed using the Nursing Home Behavior Problem Scale.

Results: Participants with delirium presented significantly more BSD than participants without delirium. More specifically, they presented more wandering/trying to leave, sleep problems, and irrational behavior after controlling for cognitive problems and use of antipsychotics and benzodiazepines. Most relationships between participant characteristics and BSD did not differ according to the presence or absence of delirium, but some variables, notably sleep problems, were more strongly associated to BSD in persons with delirium.

Conclusions: Although correlates of BSD in persons with delirium superimposed on dementia are generally similar to those in persons with dementia alone, delirium is associated with a higher level of BSD. Results of this study have practical implications for the detection of delirium superimposed on dementia, the management of behavioral disturbances in patients with delirium, and caregiver burden.

ESA study data were paired with Quebec medical and pharmaceutical services records to document potentially inappropriate benzodiazepines (Bzs) prescriptions among community-dwelling adults aged 65 and older. Results indicate that 32 per cent of respondents took a mean daily dose of 6.1 mg of equivalent diazepam for, on average, 205 days per year. Almost half (48%) of Bzs users received a potentially inappropriate benzodiazepine prescription at least once during the year preceding the survey. About 23 per cent received at least one concomitant prescription of a Bz and another drug that could result in serious interaction. In addition, individuals aged 75 and older were more likely to receive Bzs for a longer period of time than those aged 65–74. Number of pharmacies used was associated with inappropriate Bzs prescriptions. Our results argue in favour of a more integrated health services system, including a regular review of older adults’ drug regimens.

Background: Delirium among long-term care (LTC) residents is frequent and is associated with increased morbidity and mortality. Identification of clinical changes during the prodromal phase of delirium could lead to prevention of a full-blown episode and perhaps limit the deleterious consequences of this syndrome. The aim of the present study was to identify clinical changes observable in the 2-week period prior to the onset of full-blown delirium.

Methods: Long-term care (LTC) residents aged 65 years and over, with or without dementia were eligible for this nested case-control study. Delirium was assessed weekly over a 6-month period using the Confusion Assessment Method. Cases with incident delirium were matched by time since enrolment to one or more controls without delirium.

Results: When compared to the controls, LTC residents who developed delirium (cases = 85) were more likely to have new-onset perceptual disturbances (OR = 4.75; 95% CI 1.65–13.66) and disorganized thinking (OR = 3.09; 95% CI 1.33–7.19) and a worsening of the Mini-Mental State Examination (MMSE) item measuring registration (OR = 2.59; 95% CI 1.24–5.41) during the preceding 2 weeks. However, the frequency of these changes was low. Residents with at least 3 clinical changes were more likely to develop delirium than those without any clinical change (OR = 2.52; 95% CI 1.08–5.87).

Conclusions: This study provides evidence of clinical changes during the prodromal phase of delirium among LTC residents. More studies are needed to further explore the role and relevance of these clinical changes as warning signs of imminent delirium.

Background: Previous studies have reported that nurse detection of delirium has low sensitivity compared to a research diagnosis. As yet, no study has examined the use of nurse-observed delirium symptoms combined with research-observed delirium symptoms to diagnose delirium. Our specific aims were: (1) to describe the effect of using nurse-observed symptoms on the prevalence of delirium symptoms and diagnoses in long-term care (LTC) facilities, and (2) to compare the predictive validity of delirium diagnoses based on the use of research-observed symptoms alone with those based on research-observed and nurse-observed symptoms.

Methods: Residents aged 65 years and over of seven LTC facilities were recruited into a prospective study. Using the Confusion Assessment Method (CAM), research assistants (RAs) interviewed residents and nurses to assess delirium symptoms. Delirium symptoms were also abstracted independently from nursing notes. Outcomes measured at five month follow-up were: death, the Hierarchic Dementia Scale (HDS), the Barthel ADL scale, and a composite outcome measure (death, or a 10-point decline in either the HDS or the ADL score).

Results: The prevalence of delirium among 235 LTC residents increased from 14.0% (using research-observed symptoms only) to 24.7% (using research- and nurse-observed symptoms). The relative risks (and 95% confidence intervals) for prediction of the composite outcome, after adjustment for covariates, were: 1.43 (0.88, 1.96) for delirium using research-observed symptoms only; 1.77 (1.13, 2.28) for delirium using research- and nurse-observed symptoms, in comparison with no delirium.

Conclusions: The inclusion of delirium symptoms observed by nurses not only increases the detection of delirium in LTC facilities but improves the prediction of outcomes.

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.

Background: Aggressive behavior (AB) is common in institutional settings. It is an important issue because of its consequences on both the person manifesting such behaviors and their caregivers. Although there are numerous studies assessing non-pharmacologic strategies to manage AB in older adults, no extensive review of the literature is available. This review synthesizes the current knowledge on the effectiveness of non-pharmacological interventions in institutional settings.

Method: Papers describing the assessment of a non-pharmacological intervention to manage AB in which participants were at least 60 years old and living in a long-term care facility were selected mainly by searching various databases.

Results: A total of 41 studies were identified and included in the review. These studies mainly use quasi-experimental designs and include less than 30 participants. Sixty-six percent (27/41) of the studies report either a statistically or behaviorally significant reduction of AB as a result of a non-pharmacological intervention. Staff training programs and environmental modifications appear to be the most effective strategies.

Conclusion: Non-pharmacological interventions seem effective for managing AB. Future studies on the effectiveness of these interventions need to be more rigorous. Development in this field needs to be based on knowledge regarding the determinants of AB in older adults.

Activation of a depressogenic schema by a negative life event is said to be more likely when the life event corresponds to the same domain of vulnerability (congruency hypothesis). Specifically, this refers to a negative interpersonal event for the sociotropy/dependency schema, and an obstacle or a failure in achieving a goal for the autonomy/accomplishment or self-criticism schema. This study examines the congruency hypothesis for the prediction of relapse. Older patients were followed for 6 months after remission from major depression. Life events were rated as interpersonal or autonomous in nature. Their subjective impact on social relations and on autonomous functioning was also assessed. Congruency between dependency schema and interpersonal events, but only when the subjective impact of event was taken into consideration, predicted relapse. Non-congruency between an autonomous schema and an event rated as impacting the social domain also predicted relapse. However, in both analyses of dependency and autonomy schemas, impact of event on social relations on its own predicted relapse. These findings support the cognitive vulnerability theory of depressive relapse, underlining the importance of considering how the person views the influence of life events and the determining impact of stressful life events on social relations.