Barriers and facilitators to family participation in the care of their hospitalized loved ones

This study’s objective was to better understand family members’ experiences in order to identify how healthcare organizations can facilitate their participation in the care of a hospitalized loved one. Eighteen individuals at the bedside of a hospitalized loved one were interviewed individually. Roles at the bedside and factors that facilitated their participation or represented barriers were examined. A qualitative analysis using a mixed inductive/deductive approach was performed. Reassurance and emotional support, as well as sharing information with the healthcare team emerged as main roles. Quality and timeliness of the information received about the patient’s condition, prognosis and changes in medical condition, as well as information on how to participate in their care, were the factors most frequently evoked as facilitating participation. On the other hand, the need to improve communication channels and access to doctors were highlighted. Most family members having no prior knowledge or exposure to healthcare environments reported feeling overwhelmed in this foreign environment. Among the suggestions on how to improve their experience, having a well-identified contact person who liaises with them and who can instruct them on how to participate in care during hospitalization and back at home was frequently suggested. Furthermore, many mentioned that recognizing the experiential knowledge they have of the patient allows for more holistic care and contributes to improve both patient and family experience. Families need to be adequately recognized and supported and have access to information in a timely manner so that their contribution to their loved one’s care is maximized and the burden associated with this stressful experience alleviated

Cognitive behavioral therapy for insomnia in older adults

Insomnia is associated with significant morbidity and is often a persistent problem, particularly in older adults. It is important to attend to this complaint and not assume that it will remit spontaneously. In many cases, unfortunately, insomnia remains unrecognized and untreated, often because it is presumed that insomnia is an inevitable consequence of aging. Although the sleep structure naturally changes with advancing age, these changes are not necessarily associated with complaints of poor sleep, distress, or daytime consequences, while chronic insomnia clearly is. There is increasing evidence that cognitive behavioral therapy (CBT) is effective for the management of chronic insomnia in the elderly and that it is of significant benefit for insomnia comorbid with medical and psychological conditions, also more prevalent in older age. The aim of this article is to familiarize clinicians working with older adults with the different components of CBT for insomnia and how to adapt the treatment to this population. A clinical case and session-by-session implementation of CBT for insomnia are described to illustrate information and guidelines provided in this article

L’utilisation clinique des benzodiazépines pour le traitement de l’anxiété : Où en sommes-nous?

Cet article vise à faire le point sur l'utilisation clinique des benzodiazépines (BZD) pour le traitement de l'anxiété. Une synthèse de la littérature sur les différents aspects potentiellement problématiques associés à leur utilisation à long terme pour la gestion de l'anxiété ainsi que des solutions alternatives sont présentées. La recherche a été effectuée à l'aide des banques de données Medline et Psychlitt consultées de 1980 à 2001. Des articles pertinents mais antérieurs à ces dates, localisés par l'entremise de la section référence des articles révisés, ont également été consultés. Conclusion : les risques et bénéfices de l'utilisation à long terme des BZD pour le traitement de l'anxiété ne sont toujours pas clairement établis. Néanmoins, malgré des recommandations d'une utilisation à court terme seulement, une proportion importante de patients les utilisent encore sur une base continue. Il serait utile d'évaluer la façon dont certaines ressources alternatives sont présentées aux patients et, s'il y a lieu, comment les rendre plus accessibles et attrayantes pour les patients anxieux.Clinical use of Benzodiazepines for anxiety problems: Where do we stand? This article presents an overview of the clinical use of Benzodiazepines (BZD) for anxiety problems. It presents a synthesis of the literature on potentially problematic aspects associated with long-term use and presents alternatives to BZD use in the management of anxiety. Medline searches from 1980 to 2001 were conducted. Relevant articles anterior to these dates, located through reference sections of more recent articles, were also reviewed. Conclusions: Risks and benefits of these drugs for the long-term management of anxiety problems are still not clearly established. Nevertheless, despite recommendations that BZDs should be used on a short-term basis only, an important proportion of patients continue using them on a long-term basis. It would be useful to assess how alternative anxiety management strategies are presented to patients and, if relevant, how to make them more accessible and appealing to anxious patients.Utilisación clínica de benzodiazepines para el tratamiento de la ansiedad: ¿Donde estamos? Este artículo apunta sobre la utilisación de los benzodiazepines (BZD) para el tratamiento de la ansiedad. Estan presentadas una síntesis de la literatura sobre los varios aspectos potentialmente problemáticos asociados a su utilisación al largo tiempo para la gestión de la ansiedad asi que soluciones alternativas. La investigación ha sido efectuada con la ayuda de los bancos de datos Medline y Psychlitt consultados de 1980 a 2001. Articulos pertinentes pero anteriores a esas fechas, localisados por la sección de referencia de los articulos revisados tambien han sido consultados. Conclusión: los riesgos y beneficios de una utilisación a largo plazo de los BZD para el tratamiento de la ansiedad no son claramente establecidos. Sin embargo, a pesar de recomendaciones de una utilisacón a corto plazo solamente, una proporción importante de patientes les utilisan todavia sobre una base continua. Sería útil evaluar la manera que estan presentados ciertos recursos alternativos a los patientes y, si procede, como hacerlos más accesibles y atractivos para los patientes con ansiedad.A utilização clínica dos benzodiazepínicos para o tratamento da ansiedade: progressos O objetivo deste artigo é situar a utilização clínica dos benzodiazepínicos (BZD) no tratamento da ansiedade. São apresentados resumos de artigos que tratam dos diferentes aspectos duvidosos associados à sua utilização a longo prazo no controle da ansiedade, e soluções alternativas. A pesquisa foi realizada com a ajuda dos bancos de dados Medline e Psychlitt consultados de 1980 a 2001. Também foram consultados artigos pertinentes, anteriores a estas datas, localizados através da seção "referência dos artigos revisados". Conclusão: os riscos e benefícios da utilização a longo prazo dos BZD para o tratamento da ansiedade ainda não foram determinados claramente. Entretanto, apesar das recomendações de uma utilização somente a curto prazo, um grande número de pacientes ainda os utilizam regularmente. Deve-se ressaltar a importância de avaliar a maneira como alguns recursos alternativos são apresentados aos pacientes e, quando for o caso, como torná-los mais acessíveis e atraentes aos pacientes que sofrem de ansiedade

Prevalence of insomnia and its treatment in Canada

Objectives : To estimate the prevalence of insomnia and examine its correlates (for example, demographics and physical and mental health) and treatments. Methods : A sample of 2000 Canadians aged 18 years and older responded to a telephone survey about sleep, health, and the use of sleep-promoting products. Respondents with insomnia were identified using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and the International Classification of Diseases, Tenth Edition, criteria. Results : Among the sample, 40.2% presented at least 1 symptom of insomnia (that is, trouble falling or staying asleep, or early morning awakening) for a minimum of 3 nights per week in the previous month, 19.8% were dissatisfied with their sleep, and 13.4% met all criteria for insomnia (that is, presence of 1 insomnia symptom 3 nights or more per week for at least 1 month, accompanied by distress or daytime impairment). Insomnia was associated with female sex, older age, and poorer self-rated physical and mental health. Thirteen per cent of respondents had consulted a health care provider for sleep difficulties once in their lifetime. Moreover, 10% had used prescribed medications for sleep in the previous year, 9.0% used natural products, 5.7% used over-the-counter products, and 4.6% used alcohol. There were differences between French- and English-speaking adults, with the former group presenting lower rates of insomnia (9.5%, compared with 14.3%) and consultation (8.7%, compared with 14.4%), but higher rates of prescribed medications (12.9%, compared with 9.3%) and the use of natural products (15.6%, compared with 7.4%). Conclusions : Insomnia is a prevalent condition, although few people seek professional consultation for this condition. Despite regional differences in the prevalence and treatments used to manage insomnia, prescribed medications remain the most widely used therapeutic option.Objectifs : Estimer la prévalence de l'insomnie et examiner ses corrélats (par exemple, les données démographiques et la santé physique et mentale) et les traitements. Méthodes : Un échantillon de 2000 Canadiens de 18 ans et plus ont répondu à une enquête téléphonique sur le sommeil, la santé et l'utilisation de produits qui favorisent le sommeil. Les répondants souffrant d'insomnie ont été identifiés à l'aide des critères du Manuel diagnostique et statistique des troubles mentaux, 4e édition révisée, et de la Classification internationale des maladies, 10e édition. Résultats : Dans l'échantillon, 40,2 % présentaient au moins 1 symptôme d'insomnie (c'est-à-dire, difficulté à s'endormir ou à rester endormi, ou réveil tôt le matin) pour un minimum de 3 nuits par semaine durant le mois précédent, 19,8 % étaient insatisfaits de leur sommeil, et 13,4 % satisfaisaient à tous les critères de l'insomnie (c'est-à-dire, la présence d'un symptôme d'insomnie 3 nuits ou plus par semaine pendant au moins 1 mois, accompagnée de détresse ou d'incapacité durant le jour). L'insomnie était associée avec le sexe féminin, l'âge avancé, et une mauvaise santé physique et mentale auto-déclarée. Treize pour cent des répondants avaient consulté un prestataire de soins de santé pour des difficultés de sommeil une fois dans leur vie. En outre, 10 % avaient utilisé des médicaments prescrits pour le sommeil dans l'année précédente, 9,0 % avaient utilisé des produits naturels, 5,7 % avaient utilisé des produits en vente libre, et 4,6 % avaient utilisé de l'alcool. Il y avait des différences entre les adultes francophones et anglophones, le premier groupe présentant des taux plus faibles d'insomnie (9,5 %, comparé à 14,3 %) et de consultations (8,7 %, comparé à 14,4 %), mais des taux plus élevés de médicaments prescrits (12,9 %, comparé à 9,3 %) et d'utilisation de produits naturels (15,6 %, comparé à 7,4 %). Conclusions : L'insomnie est une affection prévalente, bien que peu de gens aient recours à une consultation professionnelle pour ce problème. Malgré des différences régionales de prévalence et des traitements utilisés pour gérer l'insomnie, les médicaments prescrits demeurent l'option thérapeutique la plus utilisée

The use of natural products for sleep: A common practice?

Despite a paucity of data on efficacy and safety of natural (herbal and dietary) products, their use appears to be widespread. This study aimed at examining the frequency of natural products’ use for sleep and their correlates in a population-based sample. Methods A randomly selected sample of adults (n = 997; 59.9% women) from the province of Quebec completed a postal survey on sleep, use of sleep-promoting products (natural products, prescribed medication, over-the-counter medication and alcohol), physical and mental health, lifestyle habits and demographics. Results A total of 18.5% of participants reported having used natural products as sleep aids in the past 12 months, with chamomile being the most popular product. Participants who exclusively used natural products as sleep aids (10.3% of the sample) were predominantly females, younger and had a higher educational level than those using prescribed medications. Natural products users reported engaging in more health-promoting behaviors than the nonusers of sleep aids and, despite the presence of subthreshold insomnia symptoms (mean Insomnia Severity Index score = 9.33), they tended to perceive themselves as healthier when compared with prescribed medication users and nonusers of sleep aids. Conclusions The use of natural products as sleep aids is a common practice. Often associated with a general health-promoting lifestyle, it may reflect the common perception that natural products are necessarily beneficial for sleep and without risk

Monthly fluctuations of insomnia symptoms in a population-based sample

Study Objectives: To document the monthly changes in sleep/insomnia status over a 12-month period; to determine the optimal time intervals to reliably capture new incident cases and recurrent episodes of insomnia and the likelihood of its persistence over time. Design: Participants were 100 adults (mean age = 49.9 years; 66% women) randomly selected from a larger population-based sample enrolled in a longitudinal study of the natural history of insomnia. They completed 12 monthly telephone interviews assessing insomnia, use of sleep aids, stressful life events, and physical and mental health problems in the previous month. A total of 1,125 interviews of a potential 1,200 were completed. Based on data collected at each assessment, participants were classified into one of three subgroups: good sleepers, insomnia symptoms, and insomnia syndrome. Results: At baseline, 42 participants were classified as good sleepers, 34 met criteria for insomnia symptoms, and 24 for an insomnia syndrome. There were significant fluctuations of insomnia over time, with 66% of the participants changing sleep status at least once over the 12 monthly assessments (51.5% for good sleepers, 59.5% for insomnia syndrome, and 93.4% for insomnia symptoms). Changes of status were more frequent among individuals with insomnia symptoms at baseline (mean = 3.46, SD = 2.36) than among those initially classified as good sleepers (mean = 2.12, SD = 2.70). Among the subgroup with insomnia symptoms at baseline, 88.3% reported improved sleep (i.e., became good sleepers) at least once over the 12 monthly assessments compared to 27.7% whose sleep worsened (i.e., met criteria for an insomnia syndrome) during the same period. Among individuals classified as good sleepers at baseline, risks of developing insomnia symptoms and syndrome over the subsequent months were, respectively, 48.6% and 14.5%. Monthly assessment over an interval of 6 months was found most reliable to estimate incidence rates, while an interval of 3 months proved the most reliable for defining chronic insomnia. Conclusions: Monthly assessment of insomnia and sleep patterns revealed significant variability over the course of a 12-month period. These findings highlight the importance for future epidemiological studies of conducting repeated assessment at shorter than the typical yearly interval in order to reliably capture the natural course of insomnia over time

The natural history of insomnia : a population-based 3-year longitudinal study

Background Despite its high prevalence, little information is available about the natural history of insomnia. The extent to which episodes of insomnia will persist or remit over time is difficult to predict. We examined the natural history of insomnia and describe the most common trajectories over 3 years. Methods Three hundred eighty-eight adults (mean [SD] age, 44.8 [13.9] years; 61% women) were selected from a larger population-based sample on the basis of the presence of insomnia at baseline. They completed standardized sleep/insomnia questionnaires at 3 annual follow-up assessments. For each follow-up assessment, participants were classified into 1 of 3 groups (individuals with an insomnia syndrome, individuals with insomnia symptoms, and individuals with good sleep) on the basis of algorithms using standard diagnostic criteria for insomnia. Rates of persistent insomnia, remission, and relapse were computed for each group. Results Of the study sample, 74% reported insomnia for at least 1 year (2 consecutive assessments) and 46% reported insomnia persisting over the entire 3-year study. The course of insomnia was more likely to be persistent in those with more severe insomnia at baseline (ie, insomnia syndrome) and in women and older adults. Remission rate was 54%; however, 27% of those with remission of insomnia eventually experienced relapse. Individuals with subsyndromal insomnia at baseline were 3 times more likely to remit than worsen to syndrome status, although persistence was the most frequent course in that group as well. Conclusion These findings indicate that insomnia is often a persistent condition, in particular when it reaches the diagnostic threshold for an insomnia disorder

Développement d’un instrument évaluant les attentes reliées à l’arrêt des benzodiazépines

L’arrêt de la médication benzodiazépinique peut représenter une tâche ardue pour certaines personnes. Des taux de rechute élevés associés aux tentatives d’arrêt témoignent de cette difficulté. Il demeure toutefois difficile d’expliquer pourquoi certaines personnes échouent dans leurs efforts. Les connaissances actuelles pointent vers l’implication d’une composante psychologique dans la difficulté à cesser les benzodiazépines (BZD). Les attentes qu’entretiennent les individus qui entrevoient l’arrêt de leur traitement médicamenteux ont été évoquées comme explication possible à l’échec du processus de sevrage. Or, aucune étude empirique n’a examiné l’effet des attentes sur l’apparition de symptômes durant la diminution ou l’issue même du sevrage. Cet article présente le développement d’un instrument de mesure visant à évaluer les attentes personnelles face à l’arrêt de la médication benzodiazépinique chez des personnes anxieuses et présente des données préliminaires quant à la validité clinique des items. Des 50 items initiaux, 24 ont été éliminés à la suite d’un premier test auprès des participants. Des 26 items retenus, il a été observé que 8 items (par exemple, nervosité/anxiété, capacités cognitives, humeur) avaient une capacité de discrimination entre les participants ayant réussi et ceux n’ayant pas réussi à cesser leur médication. De façon générale, il a été observé que les participants qui ont réussi à cesser entretenaient des attentes significativement plus positives que ceux n’ayant pas réussi. Ces résultats préliminaires tendent à appuyer l’hypothèse selon laquelle les attentes négatives nuiraient au processus d’arrêt des BZD. Toutefois, ces résultats doivent être répliqués avec un plus grand nombre de participants.Discontinuing the use of benzodiazepine medication can represent a difficult task for some people. High rates of relapses are associated with attempts to stop their use. However, it remains difficult to explain why some people fail in their efforts. The current knowledge suggests the involvement of a psychological component in the difficulty to stop benzodiazepine medication (BZD). Expectations of people who consider stopping their medication has been mentioned as a possible explanation of the failure of the withdrawal process. However, no empirical study has examined the effect of these expectations on the appearance of symptoms during withdrawal or its outcome. This article presents the development of an instrument aiming at assessing personal expectations regarding discontinuation of benzodiazepine medication with individuals who suffer from anxiety. It presents preliminary data related to the clinical validity of items. From 50 initial items, 24 have been eliminated following a first test with some participants. Among 26 chosen items, it has been observed that 8 items (for example, nervousness/anxiety, cognitive capacities, mood) could discriminate between participants having succeeded and those having failed. Generally, it has been observed that participants who have succeeded had expectations that were significantly more positive than people who had failed in their attempt to stop. These preliminary results tend to support the hypothesis according to which negative expectations would harm the BZD withdrawal process. However, these results must be replicated with a greater number of participants.La interrupción de los medicamentos benzodiacepínicos puede representar una tarea ardua para algunas personas. Las elevadas tasas de recaida asociadas a las tentativas de interrupción atestiguan esta dificultad. Sin embargo, sigue siendo difícil explicar por qué ciertas personas fracasan en el intento. Los conocimientos actuales apuntan hacia la implicación de un componente psicológico en la dificultad de suspender las benzodiacepinas (BDZ). Las expectativas que mantienen los individuos que ven la suspensión de su tratamiento medicamentoso ha sido evocada como explicación posible del fracaso en el proceso de abstinencia. Ahora bien, ningún estudio epmírico ha examinado el efecto de las expectativas en la aparición de síntomas durante la disminución o incluso el resultado de la abstinencia. Este artículo presenta el desarrollo de un instumento de medida que busca evaluar las expectativas personales ante la interrupción del medicamento benzodiacepínico en personas ansiosas y presenta los datos preliminares con respecto a la validez clínica de los aspectos. De los 50 aspectos iniciales, 24 fueron eliminados después de la primera prueba. De los 26 aspectos retenidos, se observó que 8 aspectos (por ejemplo, nervios/ansiedad, capacidad cognitiva, humor) tenían una capacidad de discriminación entre los participantes que lograron y los que no lograron suspender su medicamento. En general, se observó que los participantes que lograron suspenderlo tienen expectativas significativamente más positivas que los que no lo lograron. Estos resultados preliminares tienden a apoyar la hipótesis según la cual las expectativas negativas perjudican el proceso de suspensión de las BZD. Sin embargo, estos resultados deben repetirse con un mayor número de participantes.A interrupção no uso de benzodiazepínicos pode ser uma tarefa árdua para algumas pessoas. As taxas elevadas de recaída, associadas às tentativas de interrupção, demonstram esta dificuldade. Entretanto, ainda é difícil explicar porque algumas pessoas não conseguem, apesar de seus esforços. Os conhecimentos atuais demonstram a implicação de um composto psicológico na dificuldade em interromper o uso de benzodiazepinas (BZD). As expectativas dos indivíduos que pretendem parar seu tratamento médico podem possivelmente explicar o fracasso do processo de desabituação. Ora, nenhum estudo empírico examinou o efeito das expectativas criadas sobre a aparição de sintomas durante a diminuição ou mesmo em conseqüência da desabituação. Este artigo apresenta o desenvolvimento de um instrumento de medida que visa avaliar as expectativas pessoais frente à interrupção da medicação benzodiazepínica nas pessoas ansiosas e apresenta dados preliminares quanto à validade clínica destes itens. Dos primeiros 50 itens, 24 foram eliminados após um primeiro teste com os participantes. Dos 26 itens recolhidos, foi observado que 8 itens (por exemplo, o nervosismo e a ansiedade, capacidades cognitivas, humor) tinham uma capacidade de discriminação entre os participantes que já conseguiram e os que não conseguiram interromper sua medicação. De maneira geral, foi observado que os participantes que conseguiram interromper o tratamento tinham expectativas muito mais positivas que os que não conseguiram. Os resultados preliminares tendem a apoiar a hipótese de que as expectativas negativas atrapalhariam o processo de interrupção no uso dos BZD. Entretanto, estes resultados devem ser reaplicados em um número maior de participantes

Insomnie et utilisation accrue de somnifères chez les aînés: Problématique et alternative de traitement

OBJECTIVE: To investigate the problem of insomnia and increased used of sleep medication among seniors and to look at an alternative form of treatment (cognitive-behavioural therapy [CBT]) that has been adapted specifically for this population. QUALITY OF EVIDENCE: MEDLINE and PsycINFO were searched from 1990 to 2005 using the key words insomnia, elderly (older adults), hypnotics (sleep medication), and cognitive behavior therapy. When discussing the efficacy of treatment, sources quoted offer level I evidence. Studies on the deleterious effects of hypnotics primarily offer level II evidence, so their findings must be interpreted with caution (some studies present conflicting results). MAIN MESSAGE: Insomnia in elderly people is associated with marked distress or deterioration in social or physical functioning. Hypnotics can be dangerous for elderly people because they raise the risk of adverse effects on cognitive function and the risk of drug-drug interactions. Treatment should be based on CBT alone or on a combination of CBT and appropriate pharmaceutical therapy. CONCLUSION: Cognitive-behavioural therapy adapted specifically to the problem of insomnia in seniors is one of the recommended options. The gains often include a notable decrease in use of sleep medication and in the emotional distress associated with insomnia