"Let's talk about sleep health": Patient perspectives on willingness to engage in psychological interventions for insomnia

BACKGROUND

Cognitive behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment yet remains underutilised in general practice. Understanding patient motivations and barriers to engaging in psychological interventions for insomnia is critical. Theoretical frameworks, such as the Theory of Planned Behaviour, are needed to identify variables related to intentions and behaviour change.

AIM

To explore key influences that motivate individuals' intention to engage with psychological interventions for insomnia.

DESIGN AND SETTING

An online survey and interviews with 20 community-dwelling participants with insomnia, aged 26-75 years.

METHOD

Guided by the Theory of Planned Behaviour, reflexive thematic analysis was used to identify factors influencing participants' intention to engage with psychological interventions for insomnia.

RESULTS

Participants reported positive attitudes towards psychological interventions for insomnia, stemming from negative beliefs about pharmacological sleep aids and the perceived benefits of a structured and evidence-based intervention. Important others positively influenced participants' intention to engage, however the GP influence was less consistent and often indirect. Participants believed in the efficacy of psychological interventions, but several barriers hampered their ability to benefit from them. Accessibility was identified as a key facilitator, whilst lack of knowledge and clear referral pathways were the main barriers impacting uptake.

CONCLUSION

This study highlights key factors influencing patients' intention to engage in psychological interventions for insomnia as well as opportunities for GPs to support uptake and engagement. Routine conversations about sleep health are essential to reduce the burden of untreated insomnia in the community, and active promotion of evidence-based psychological interventions are needed.

Treatment of urge incontinence in postmenopausal women: A systematic review

BACKGROUND

Urinary incontinence and other urinary symptoms tend to be frequent at menopause because of hormonal modifications and aging. Urinary symptoms are associated with the genitourinary syndrome of menopause which is characterized by physical changes of the vulva, vagina and lower urinary tract. The treatment strategies for postmenopausal urinary incontinence are various and may include estrogens, anticholinergics, and pelvic floor muscle training. A comparison of these treatments is difficult due to the heterogeneity of adopted protocols. We systematically reviewed the evidence from randomized controlled trials (RCTs) focusing on treatment of postmenopausal women with urge incontinence.

METHODS

We conducted a systematic review and meta-analysis by searching PubMed and EMBASE databases for randomized controlled trials (RCTs) reporting results of treatments for postmenopausal urinary urge incontinence. Odds ratios for improvement of urinary incontinence were calculated using random effect Mantel-Haenszel statistics.

RESULTS

Out of 248 records retrieved, 35 eligible RCTs were assessed for risk of bias and included in the meta-analysis. Compared with placebo, systemic estrogens were associated with decreased odds of improving urinary incontinence in postmenopausal women (OR = 0.74, 95% CI: 0.61-0.91, 7 series, 17132 participants, Z = 2.89, P = 0.004, I2 = 72%). In most studies, no significant improvement in urinary symptoms was observed in patients treated with local estrogens, although they showed to be helpful in improving vaginal symptoms. Vitamin D, phytoestrogens and estrogen modulators were not effective in improving symptoms of incontinence and other symptoms of genitourinary menopause syndrome or yielded contradictory results. A randomized controlled trial demonstrated that oxybutynin was significantly better than placebo at improving postmenopausal urgency and urge incontinence. The combination of anticholinergics with local estrogens has not been shown to be more effective than anticholinergics alone in improving urinary incontinence symptoms in postmenopausal women. Physical therapy showed an overall positive outcome on postmenopausal urinary incontinence symptoms, although such evidence should be further validated in the frame of quality RCTs.

CONCLUSIONS

The evidence for effective treatment of postmenopausal urinary incontinence is still lacking. Welldesigned large studies having subjective and objective improvement primary endpoints in postmenopausal urinary incontinence are needed. At present, a combination of different treatments tailored to the characteristics of the individual patient can be suggested.

Migraine in multiple sclerosis patients: potential links and treatment approach

INTRODUCTION

Migraine has been reported to be twice as prevalent in patients with multiple sclerosis (MS) compared to the non-MS population. However, prospective, controlled studies that could lead to robust conclusions are still lacking.

AREAS COVERED

Treatment of migraine in patients with MS can be challenging. Comorbidities need to be assessed and managed early, and preventive treatment should be initiated when indicated. Caution is warranted regarding the selection of the preventive medication since certain agents can magnify MS symptoms and particularly cognitive symptoms. This paper aims to discuss the association of MS and migraine, shed light on distinguishing points and red flags, as well as offer practical advice on the selection of treatment according to patients' characteristics.

EXPERT OPINION

A holistic approach including pharmacological and non-pharmacological modifications is required to treat migraine in patients with MS effectively. Anti-CGRP monoclonal antibodies are a promising option due to limited drug-to-drug interactions; however, larger prospective studies are required to draw robust conclusions on the concomitant use of anti-CGRPs with MS disease modifying treatments. Early migraine preventive treatment might be needed to reduce the burden of disease in patients with MS.

Acute Efficacy and Safety of Escitalopram Versus Desvenlafaxine and Vortioxetine in the Treatment of Depression With Cognitive Complaint: A Rater-Blinded Randomized Comparative Study

OBJECTIVE

This study aimed to compare the efficacy and safety of escitalopram, vortioxetine, and desvenlafaxine for acute treatment of major depressive disorder (MDD) with cognitive complaint (CC).

METHODS

A total of 129 patients with MDD who also complained of CC were randomized evenly to either escitalopram, vortioxetine, or desvenlafaxine group and underwent a multi-center, six-week, rater-blinded, and head-to-head comparative trial. Differences in depressive symptoms following treatment were measured using the Hamilton Depression Rating Scale (HAMD) and the Montgomery-Åsberg Depression Rating Scale (MADRS). Subjective cognitive function and the presence of adverse events were assessed.

RESULTS

The three antidepressant treatment groups did not show significant differences in the improvement of depressive symptoms as measured by HAMD and MADRS. Desvenlafaxine treatment was associated with a superior treatment response rate in depressive symptoms compared to vortioxetine or escitalopram treatment. However, no significant differences were found in the remission rate of depressive symptoms. The three antidepressant treatment groups did not show significant differences in the improvement of CC. Adverse profiles of each treatment group were tolerable, with no significant differences.

CONCLUSION

In acute antidepressant treatment for MDD with CC, escitalopram, vortioxetine, and desvenlafaxine presented similar efficacy in relief of depressive symptoms; however, desvenlafaxine was associated with a superior treatment. Further studies are needed to confirm these results by investigating the therapeutic efficacy and safety profile of long-term antidepressant treatment of MDD with CC (Clinical Trial Registry, http://cris.nih.go.kr/cris/en/: KCT0002173).

Understanding differences in prescription drug misuse between two Texas border communities

Objectives: The misuse of prescription drugs in the U.S. is an alarming public health crisis. Prior research at the U.S.-Mexico border has found high rates of prescription drug misuse, but with rates varying significantly across border communities. We aimed to examine a model of permissive climate measures and stress exposures as potential mediators of community differences in prescription drug misuse at the U.S.-Mexico border.Design: We analyzed data from the U.S.-Mexico Study of Alcohol and Related Conditions (UMSARC). Household, in-person interviews were conducted with Mexican-origin residents of the Texas border cities Laredo (n = 751) and Brownsville/McAllen (n = 814). Interviews assessed past-year misuse of any and pain-reliever prescription drugs. Drug availability, neighborhood safety, exposure to violence/crime, and social support were examined as potential mediators. Analyses were stratified by gender and employed regressions and mediation analysis with Mplus.Results: The past-year prevalence of any prescription drug misuse in Laredo was 26.3% among women and 24.4% among men, and in Brownsville/McAllen was 12.4% among men, and 6.7% among women. Mediation analysis revealed site effects via some of the hypothesized risk factors for men, but not for women. Specifically, for men, site effects on any and pain reliever prescription drug misuse were partially mediated via high drug availability and low family support.Conclusions: Past-year prescription drug misuse was over 3 times the 2015 national prevalence among both men and women in Laredo and calls for immediate attention. Findings regarding the model suggest drug availability and social support may be relevant to understanding community differences in prescription drug misuse among men living at the border, and that additional factors should be investigated to understand misuse among women living at the border.

Non-benzodiazepine hypnotic use for sleep disturbance in people aged over 55 years living with dementia: a series of cohort studies

BACKGROUND

Sleep disturbance affects around 60% of people living with dementia and can negatively affect their quality of life and that of their carers. Hypnotic Z-drugs (zolpidem, zopiclone and zaleplon) are commonly used to treat insomnia, but their safety and efficacy have not been evaluated for people living with dementia.

OBJECTIVES

To estimate the benefits and harms of Z-drugs in people living with dementia with sleep disturbance.

DESIGN

A series of observational cohort studies using existing data from (1) primary care linked to hospital admission data and (2) clinical cohort studies of people living with dementia.

DATA SOURCES

Primary care study - Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data. Clinical cohort studies - the Resource Use and Disease Course in Dementia - Nursing Homes (REDIC) study, National Alzheimer's Coordinating Centre (NACC) clinical data set and the Improving Well-being and Health for People with Dementia (WHELD) in nursing homes randomised controlled trial.

SETTING

Primary care study - 371 primary care practices in England. Clinical cohort studies - 47 nursing homes in Norway, 34 Alzheimer's disease centres in the USA and 69 care homes in England.

PARTICIPANTS

Primary care study - NHS England primary care patients diagnosed with dementia and aged > 55 years, with sleep disturbance or prescribed Z-drugs or low-dose tricyclic antidepressants, followed over 2 years. Clinical cohort studies - people living with dementia consenting to participate, followed over 3 years, 12 years and 9 months, for REDIC, NACC and WHELD, respectively.

INTERVENTIONS

The primary exposure was prescription or use of Z-drugs. Secondary exposures included prescription or use of benzodiazepines, low-dose tricyclic antidepressants and antipsychotics.

MAIN OUTCOME MEASURES

Falls, fractures, infection, stroke, venous thromboembolism, mortality, cognitive function and quality of life. There were insufficient data to investigate sleep disturbance.

RESULTS

The primary care study and combined clinical cohort studies included 6809 and 18,659 people living with dementia, with 3089 and 914 taking Z-drugs, respectively. New Z-drug use was associated with a greater risk of fractures (hazard ratio 1.40, 95% confidence interval 1.01 to 1.94), with risk increasing with greater cumulative dose (p = 0.002). The hazard ratio for Z-drug use and hip fracture was 1.59 (95% confidence interval 1.00 to 2.53) and for mortality was 1.34 (95% confidence interval 1.10 to 1.64). No excess risks of falls, infections, stroke or venous thromboembolism were detected. Z-drug use also did not have an impact on cognition, neuropsychiatric symptoms, disability or quality of life.

LIMITATIONS

Primary care study - possible residual confounding because of difficulties in identifying patients with sleep disturbance and by dementia severity. Clinical cohort studies - the small numbers of people living with dementia taking Z-drugs and outcomes not necessarily being measured before Z-drug initiation restricted analyses.

CONCLUSIONS

We observed a dose-dependent increase in fracture risk, but no other harms, with Z-drug use in dementia. However, multiple outcomes were examined, increasing the risk of false-positive findings. The mortality association was unlikely to be causal. Further research is needed to confirm the increased fracture risk. Decisions to prescribe Z-drugs may need to consider the risk of fractures, balanced against the impact of improved sleep for people living with dementia and that of their carers. Our findings suggest that when Z-drugs are prescribed, falls prevention strategies may be needed, and that the prescription should be regularly reviewed.

FUTURE WORK

More research is needed on safe and effective management strategies for sleep disturbance in people living with dementia.

STUDY REGISTRATION

This study is registered as European Union electronic Register of Post-Authorisation Studies (EU PAS) 18006.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 1. See the NIHR Journals Library website for further project information.

Are Anticholinergic Medications Associated With Increased Risk of Dementia and Behavioral and Psychological Symptoms of Dementia? A Nationwide 15-Year Follow-Up Cohort Study in Taiwan

BACKGROUND/OBJECTIVE

In previous reports, the usage of anticholinergic medications has been associated with an increased risk of dementia with prolonged usage or with a high Anticholinergic Cognitive Burden (ACB). This study aimed to investigate the association between anticholinergic medications and the risk of dementia using data from Taiwan's National Health Research Database (NHIRD).

METHODS

A total of 790,240 patients, with 197,560 patients receiving anticholinergic medications and 592,680 control patients (1:3) matched for sex, age, and index-year, were enrolled from the two million Longitudinal Health Insurance Dataset, a subdataset of the NHIRD, between 2000 and 2015. The time-dependent Cox regression analysis was used to explore the hazard ratio (HR) with a 95% confidence interval for the association between anticholinergics and the risk of dementia during the 15-year follow-up. The behavioral and psychological symptoms of dementia (BPSD) were recognized by the usage of psychotropics. The ACB ranged from zero to three, divided as score <1, 1-1.9, 2-2.9, 3-4.9,and ≧5. The sensitivity analysis was done by excluding the diagnoses of dementia in the first 2 or 4 years after anticholinergic usage.

RESULTS

In the anticholinergic usage cohort, the HR was 1.043 (95% CI = 0.958-1.212, p = 0.139) without a significant difference. The sensitivity analysis revealed no association between the usage of anticholinergics and the risk of dementia. Anticholinergic usage was not associated with BPSD. Male sex, patients of ages of 60-64 and ≧80, usage of antiparkinsonian medications, a history of Parkinson's disease, epilepsy, urinary incontinence, depression, bipolar disorder, and psychotic disorder were independent risk factors of dementia. Increased HRs for dementia were associated with an ACB ≥ 5 and an anticholinergic usage period ≥ 1,460 days.

CONCLUSION

In this study, the usage of anticholinergics was not associated with the risk of dementia or BPSD in a 15-year follow-up study. However, patients with the male sex, patients with ages of 65-79 and ≧80, patients with some comorbidities, high ACB scores, and long anticholinergic treatment duration were associated with the risk of dementia.

Effects of Antiepileptic Drug Tapering on Episodic Memory as Measured by Virtual Reality Tests

Antiepileptic drugs impair episodic memory in patients with epilepsy, but this effect has so far only been examined with tests that do not provide first-person experience-an aspect that is crucial for episodic memory. Virtual reality techniques facilitate the development of ecologically valid tests. In the present study, we measure the effect of antiepileptic drug changes in a within-subject design using a virtual reality test in order to provide direct evidence for effects of antiepileptic drugs on episodic memory. Among 106 recruited patients, 97 participated in a virtual reality test up to six times during a 4-day hospitalization, and 78 patients underwent changes in drug load during this period. There were six parallel versions of a virtual town test, with immediate recall and delayed recall after about 12 h. The test requires recall of elements, details, sequence of experience, and egocentric and allocentric spatial memory. We determined drug load by defined daily dose, and compared test performance at lowest antiepileptic drug load to highest antiepileptic drug load. Across the six towns, performance was lower in delayed compared to immediate recall. There was an overall effect of medication when comparing patients taking vs. not taking antiepileptic drugs and/or psychoactive drugs (p = 0.005). Furthermore, there was a within-subject effect of antiepileptic drug load (p = 0.01), indicating lower test performance at higher drug load. There was no effect of gender, daytime, circadian type, depression, seizures, lesions, and epilepsy. For patients with temporal lobe epilepsy, there was no effect of lateralization. The present study provides direct evidence for episodic memory impairment due to antiepileptic drugs, suggesting that a small change in drug load can matter. This study can serve as a proof of principle for the methodology, but a larger sample is needed to examine the differential effects of individual antiepileptic drugs.

Effectiveness of a direct-to-consumer written health education program in the reduction of benzodiazepine and sedative-hypnotic use in an elderly population at a single Veterans Affairs medical center

Introduction

The use of benzodiazepines and sedative-hypnotics in the elderly is associated with a significant risk of delirium, falls, fractures, cognitive impairment, and motor vehicle accidents. This quality improvement project applies a direct-to-consumer intervention to an elderly veteran population to reduce the use of these medications.

Methods

Patients aged 75 and older currently taking a benzodiazepine and/or a sedative-hypnotic were included in the project. Direct-to-consumer education intervention letters were mailed to patients within 30 days of their next appointment. Their providers were emailed a questionnaire after the patient's appointment. Providers were asked if the letter prompted a conversation regarding medication use, whether the provider initiated discussion regarding a taper, and whether a specific taper plan was developed. Medical records were reviewed to determine if a reduction in dose or discontinuation occurred.

Results

Fifty-nine direct-to-consumer education letters were mailed to the patients. Follow-up questionnaires were e-mailed to 44 providers, and 27 providers responded. Twenty-two percent of patients had their benzodiazepine and/or sedative hypnotic dose reduced or discontinued after their follow-up appointment. Sixty-seven percent of veterans initiated a conversation with their provider regarding their medication with 74% of providers discussing dose reduction. Fifty-six percent of recipients developed a specific taper plan with their provider.

Discussion

The data from this project suggests that direct-to-consumer patient education can reduce the exposure to benzodiazepines and sedative-hypnotics in an elderly veteran population. More data is needed on larger populations to further explore the benefit of direct-to-consumer interventions.

Drug Burden Index and change in cognition over time in community-dwelling older men: the CHAMP study

OBJECTIVE

Anticholinergic and sedative medications are associated with acute cognitive impairment, but the long-term impact on change in cognition is unclear. This study investigated the effect of anticholinergic and sedative medications, quantified using the Drug Burden Index (DBI), on change in cognition over time in community-dwelling older men.

METHODS

This was a prospective cohort study of men aged ≥70 years in Sydney, Australia. DBI was assessed at baseline, 2, and 5 years. Cognitive performance was assessed using the Mini-Mental State Exam (MMSE) at each wave. Logistic quantile mixed-effects modelling was used to assess the adjusted effect of DBI on the median MMSE-time profile. Analyses were restricted to men with English-speaking backgrounds (n = 1059, 862, and 611 at baseline, 2, and 5 years).

RESULTS

Overall, 292 (27.7%), 258 (29.9%), and 189 (31.3%) men used anticholinergic or sedative medications at baseline, 2, and 5 years. There was a concave relationship between MMSE and time, where higher DBI corresponded to lower MMSE scores (coefficient: -0.161; 95% CI: -0.250 to -0.071) but not acceleration of declining MMSE over time.

CONCLUSIONS

Exposure to anticholinergic and sedative medications is associated with a small impairment in cognitive performance but not decline in cognition over time. KEY MESSAGES Exposure to anticholinergic and sedative medications, quantified using the Drug Burden Index, is associated with small cross-sectional impairments in cognitive performance. There was no evidence that exposure to anticholinergic and sedative medications is associated with accelerating decline in cognitive performance over a 5-year follow-up. Older people taking anticholinergic and sedative medications may derive immediate but small benefits in cognitive performance from clinical medication reviews to minimize or cease prescribing of these medications.

An interdisciplinary memory clinic: a novel practice setting for pharmacists in primary care

Pharmacists have developed innovative practices in various settings as singular providers or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure, hypertension, or hyperlipidemia clinics. There is a paucity of literature describing pharmacists in interdisciplinary memory clinics and specifically pharmacists practicing in interdisciplinary, primary care-based memory clinics. New practice models should be disseminated to guide others in the development of similar models given the complexity of this population. Patients with dementia are more difficult to manage because of cognitive impairment, behavioral and psychological symptoms, the common presence of multiple comorbidities, and related polypharmacy and caregiver issues. These challenges require expertise in neurodegenerative disorders and geriatrics. The purpose of this article is to describe the role of clinical pharmacists providing care to patients with cognitive complaints in a primary care-based, interdisciplinary memory clinic, with a focus on how the pharmacist practices and is integrated in this collaborative care setting. Patients are assessed using an interdisciplinary approach, with team consensus for assessment and planning of care. Pharmacists' activities include assessment of (1) appropriateness of medications based on frailty, (2) medications that can impair cognition and/or function, (3) medication adherence and management skills, and (4) vascular risk factor control. Pharmacists provide education regarding medications and diseases, ensure appropriate transitions in care, and conduct home visits. Pharmacist participation in this clinic represents a novel opportunity to advance pharmacy practice in primary care, interdisciplinary models. Work is ongoing to describe outcomes attributable to pharmacist participation in this clinic.

Drug cessation in complex older adults: time for action

BACKGROUND

general opinion is growing that drug cessation in complex older patients is warranted in certain situations. From a clinical viewpoint, drug cessation seems most warranted in four situations, i.e., falls, delirium, cognitive impairment and end-of-life situations. To date, little information about the effects of drug cessation in these four situations is available.

OBJECTIVES

to identify the effects and effectiveness of drug cessation on falls, delirium and cognitive impairment. For end-of-life situations, we reviewed cessation of inappropriate drug use.

METHODS

electronic databases were searched using MeSH terms and relevant keywords. Studies published in English were included if they evaluated the effects of drug cessation in older persons, aged ≥65 years, with falls, delirium or cognitive impairment; or cessation of inappropriate drug use in end-of-life situations.

RESULTS

we selected seven articles for falls, none for delirium, two for cognition and two for end-of-life situations. Withdrawal of psychotropics reduced fall rate; a prescribing modification programme for primary care physicians reduced fall risk. Withdrawal of psychotropics and a systematic reduction of polypharmacy resulted in an improvement of cognition. Very little rigorous research has been conducted on reducing inappropriate medications in patients approaching end of life.

CONCLUSION

little research has focussed on drug cessation. Available studies showed a beneficial impact of cessation of psychotropic drugs on falls and cognitive status. More research in this field is needed. The issue of systematic drug withdrawal in end-of-life cases is controversial, but is increasingly relevant in the face of rising numbers of older people of this clinical status.

Dissociative seizures: a challenge for neurologists and psychotherapists

BACKGROUND

The prevalence of dissociative seizures is between 2 and 33 sufferers per 100,000 persons. 70% of sufferers are women. Dissociative seizures markedly impair quality of life. Their close superficial resemblance to epileptic seizures makes them hard to diagnose.

METHODS

Selective literature search in PubMed and PsycINFO.

RESULTS

Persons with dissociative seizures constitute a mixed group with a wide variety of predisposing, precipitating, and maintaining factors. Some 90% have comorbid psychiatric disorders such as depression, anxiety, somatoform disorders, personality disorders, or post-traumatic stress disorder. Video-EEG monitoring enables highly reliable diagnosis. Psychotherapy is considered the treatment of first choice; in prospective studies, it has been found to lower the frequency of dissociative seizures by at least 50%, or to eliminate them completely, in 50% to 80% of patients. An individually tailored combination of behavioral therapeutic, imagery-based, and psychodynamic approaches seems reasonable. For the treatment of psychiatric comorbidities, psychotherapy is indicated, in combination with psychoactive drugs if necessary. Before any treatment is provided, the diagnosis should be communicated to the patient in an appropriate way, ideally by both the neurologist and the psychotherapist, so that the patient can develop an alternative disease model.

CONCLUSION

When the diagnosis of dissociative seizures has been made, psychotherapy is indicated, possibly in combination with psychoactive medication, in the setting of long-term treatment provided in collaboration by the neurologist, psychiatrist, psychotherapist, and family physician. Further randomized trials are needed to determine which treatments are best for which subgroups of patients.