Insomnia and its relationship to health-care utilization, work absenteeism, productivity and accidents

Background and purpose To document and provide a micro analysis of the relationship between insomnia and health problems, health-care use, absenteeism, productivity and accidents. Participants and methods A population-based sample of 953 French-speaking adults from Québec, Canada. Participants were categorized as having insomnia syndrome (SYND) or insomnia symptoms (SYMPT) or as good sleepers (GS). They completed questionnaires on sleep, health, use of health-care services and products, accidents, work absences and reduced work productivity. Data were also obtained from the Québec-government-administered health insurance board on selected variables (e.g., consultations with health-care professionals, diagnoses). Results There were significantly more individuals in the SYND group relative to the GS group reporting at least one chronic health problem (83% vs. 53%; OR: 2.78) and who had consulted a health-care professional in the past year (81% vs. 60%; OR: 2.8). There were also higher proportions of individuals in the SYND group than in the GS group who had used prescription medications (57% vs. 30.7%; OR: 2.8), most notably to treat insomnia, mood and anxiety disorders, or who had used over-the-counter products (75.6% vs. 62.0%; OR: 1.8) and alcohol as a sleep aid (17.8% vs. 3.9%; OR: 4.6). In terms of daytime function, 25.0% of the SYND had been absent from work relative to 17.1% of GS (OR: 1.7), 40.6% reported having experienced reduced productivity compared to 12.3% of GS (OR: 4.8) and non-motor-vehicle accidents occurred at higher rates in the SYND group (12.5% vs. 6.4% for GS; OR: 2.4). No differences were found for hospitalisations or motor-vehicle accidents. Most of the associations remained significant even after controlling for psychiatric comorbidity. Rates for the SYMPT group were situated between SYND and GS on all major dependent variables. Furthermore, insomnia and fatigue were perceived as contributing significantly to accidents, absences and decreased work productivity, regardless of insomnia status. Conclusions This study indicates that insomnia is associated with significant morbidity in terms of health problems and health-care utilization, work absenteeism and reduced productivity, and risk of non-motor-vehicle accidents. Future studies should evaluate whether treating insomnia can reverse this morbidity

Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia : a randomized controlled trial

Context: Cognitive behavioral therapy (CBT) and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. It is unclear whether combined or maintenance therapies would enhance outcome. Objectives: To evaluate the added value of medication over CBT alone for acute treatment of insomnia and the effects of maintenance therapies on long-term outcome. Design, Setting, and Patients: Prospective, randomized controlled trial involving 2-stage therapy for 160 adults with persistent insomnia treated at a university hospital sleep center in Canada between January 2002 and April 2005. Interventions: Participants received CBT alone or CBT plus 10 mg/d (taken at bedtime) ofzolpidemforaninitial6-weektherapy,followedbyextended6-monththerapy.Patients initially treated with CBT attended monthly maintenance CBT for 6 months or received no additional treatment and those initially treated with combined therapy (CBT plus 10 mg/d of zolpidem) continued with CBT plus intermittent use of zolpidem or CBT only. Main Outcome Measures: Sleep onset latency, time awake after sleep onset, total sleep time, and sleep efficiency derived from daily diaries (primary outcomes); treatment response and remission rates derived from the Insomnia Severity Index (secondary outcomes). Results: Cognitive behavioral therapy used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy (all P .001); a larger increase of sleep time was obtained with the combined approach (P=.04). Both CBT alone and CBT plus zolpidem produced similar rates of treatment responders (60% [45/75] vs 61% [45/74], respectively; P=.84) and treatment remissions (39% [29/75] vs 44% [33/74], respectively; P=.52) with the 6-week acute treatment, but combined therapy produced a higher remission rate compared with CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% [43/74 and 32/59] vs 43% [34/75 and 28/68]; P=.05). The best long-term outcome was obtained with patients treated with combined therapy initially, followed by CBT alone, as evidenced by higher remission rates at the 6-month follow-up compared with patients who continued to take zolpidem during extended therapy (68% [20/30] vs 42% [12/29]; P=.04). Conclusion: In patients with persistent insomnia, the addition of medication to CBT produced added benefits during acute therapy, but long-term outcome was optimized when medication is discontinued during maintenance CBT

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

Mémento 2 : Résidences 1999-2000

This richly illustrated catalogue documents the work of 35 artists who took part in six residencies (including two events - La Cueillette and La Ruche) that took place in 1999 and 2000 at Centre Est-Nord-Est. The centre’s director, F. Michel, describes the nature and purpose of the residencies as well as that of the catalogue : to reflect each participant’s experience. Includes brief comments by the artist on their work and on their stay. Text in French and English. Biographical notes

Potentially inappropriate prescriptions for older patients in long-term care

BACKGROUND: Inappropriate medication use is a major healthcare issue for the elderly population. This study explored the prevalence of potentially inappropriate prescriptions (PIPs) in long-term care in metropolitan Quebec. METHODS: A cross sectional chart review of 2,633 long-term care older patients of the Quebec City area was performed. An explicit criteria list for PIPs was developed based on the literature and validated by a modified Delphi method. Medication orders were reviewed to describe prescribing patterns and to determine the prevalence of PIPs. A multivariate analysis was performed to identify predictors of PIPs. RESULTS: Almost all residents (94.0%) were receiving one or more prescribed medication; on average patients had 4.8 prescribed medications. A majority (54.7%) of treated patients had a potentially inappropriate prescription (PIP). Most common PIPs were drug interactions (33.9% of treated patients), followed by potentially inappropriate duration (23.6%), potentially inappropriate medication (14.7%) and potentially inappropriate dosage (9.6%). PIPs were most frequent for medications of the central nervous system (10.8% of prescribed medication). The likelihood of PIP increased significantly as the number of drugs prescribed increased (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 1.33 – 1.43) and with the length of stay (OR: 1.78, CI: 1.43 – 2.20). On the other hand, the risk of receiving a PIP decreased with age. CONCLUSION: Potentially inappropriate prescribing is a serious problem in the highly medicated long-term care population in metropolitan Quebec. Use of explicit criteria lists may help identify the most critical issues and prioritize interventions to improve quality of care and patient safety

Survie des patients atteints de tumeur intracranienne primaire

Le but principal de cette étude est de décrire la survie des patients atteints de tumeur intracrânienne primaire admis pour la première fois à l'Hôpital de l'Enfant-Jésus de Québec entre le 1er janvier 1970 et le 30 juin 1981. Les lésions étudiées comprennent les tumeurs originant de toutes structures intracrâniennes incluant l'hypophyse et les vaisseaux sanguins. Les patients ont été retenus pour l'analyse lorsqu'ils ont présenté une tumeur intracrânienne unique, confirmée par l'histologie et qu'ils ont reçu leur traitement initial à l'Hôpital de l'Enfant-Jésus. Les dossiers médicaux de ces patients ont été revus. Ces malades ont été suivis jusqu'à leur décès ou jusqu'à la date de fin d'étude qui a été fixée au 30 juin 1982. Aucun patient n'a été perdu de vue. Les enregistrements de décès ont été consultés afin de confirmer la date du décès et d'en préciser la cause. La survie est estimée par la méthode de Kaplan-Meier. Les décès par toutes causes sont compris dans l'analyse. Cinq cent vingt-deux (322) patients sont inclus dans cette étude. Le principal type de tumeur est le glioblastome multiforme et 30,5% des patients en sont atteints. Le méningiome bénin, l'adénome hypophysaire, l'astrocytome, le schwannome et le médulloblastome sont responsables respectivement de 15,3%, 14,0%, 11,7%, 4,8% et 3,4% des cas de tumeurs intracrâniennes. Ces six principaux types de tumeurs regroupent 79,7% des malades. Le pronostic des patients atteints de glioblastome multiforme est très mauvais. Leur survie médiane est de 86 jours et leur taux de survie à cinq ans est de 0%. Les patients atteints d'astrocytome cérébelleux et hémisphérique ont une évolution très différente. L'astrocytome cérébelleux, habituellement diagnostiqué chez l'enfant ou l'adolescent, est une tumeur dont le pronostic est bon. Dans cette étude, le taux de survie à cinq ans est de 90,9%. Au contraire, l'astrocytome hémisphérique est diagnostiqué le plus souvent chez l'adulte et il évolue moins favorablement. Dans cette étude, le taux de survie à cinq ans est de 33,0%. Parmi les patients atteints d'astrocytome hémisphérique, la survie semble meilleure chez les femmes et chez les malades âgés de moins de 30 ans à l'entrée dans l'étude. Chez les patients atteints de méningiome bénin, le taux de survie à cinq ans est de 76,3%. Il semble que les patients ayant des tumeurs de la région sagittale et de la convexité évoluent plus favorablement que les autres patients. La survie des patients âgés de 55 ans et plus à l'entrée dans l'étude est inférieure à celle des patients plus jeunes. Ce pronostic défavorable ne semble pas lié à la tumeur intracrânienne mais plutôt aux autres causes de décès qui sont plus fréquentes chez les patients âgés. Les patients atteints d'adénome hypophysaire et de schwannome ont une évolution favorable et leurs taux de survie à cinq ans sont respectivement de 96,5% et 92,0%. Enfin, les patients atteints de médulloblastome ont un mauvais pronostic et leur taux de survie à cinq ans est de 22,9%. La survie des patients atteints de glioblastome multiforme, d'astrocytome et de méningiome bénin est comparable au cours des deux périodes d'entrée dans l'étude (1970-1977, 1978-1981). La stabilité de la survie suggère qu'il y a eu peu de changement dans l'efficacité des traitements offerts à ces patients au cours de ces deux périodes.Montréal Trigonix inc. 201