An assessment of quality of sleep and the use of drugs with sedating properties in hospitalized adult patients

Background  

Hospitalization can significantly disrupt sleeping patterns. In consideration of the previous reports of insomnia and apparent widespread use of benzodiazepines and other hypnotics in hospitalized patients, we conducted a study to assess quality of sleep and hypnotic drug use in our acute care adult patient population. The primary objectives of this study were to assess sleep disturbance and its determinants including the use of drugs with sedating properties.     

精神专科医院门诊失眠症患者用药分析

目的:分析精神专科医院门诊失眠症患者的药物治疗等状况,促进合理用药。方法:对2010年1月1日至2010年12月31日门诊诊断为"失眠症"的5 571张处方进行调查和分析。结果:单一用药占总人次的40.54%,联合用药占59.46%。药物类别方面,使用苯二氮卓类药物者占总人次的83.13%,抗抑郁药者占34.77%,抗精神病药物者占14.40%,其它药物者占30.45%。药物的用药频度(DDDs),苯二氮卓类药物排在前三的依次为阿普唑仑、氯硝西泮、劳拉西泮;抗抑郁药排在前三的为帕罗西汀、米氮平、西酞普兰;抗精神病药物排在前三的为喹硫平、奥氮平、氯氮平。结论:失眠症患者的门诊药物治疗以苯二氮卓类药物为主,同时有新型抗抑郁药、新型非苯二氮卓类镇静催眠药、中成药、新型非典型抗精神病药物等药物单用或联用的方案。     

福建省急诊医师压力管理情况调查及其对策

目的：了解福建省急诊医师工作及其压力管理情况。方法：采用＂一般调查问卷＂和＂成人心理压力量表＂等测量工具,通过简单随机抽样方法对福建省各级医院的230名急诊医师进行问卷调查。结果：福建省急诊医师最主要的压力来源为当前的职业环境（91.7%）;福建省急诊医师的压力管理平均得分为（46.33±10.7）,不同性别间、不同医院所在地间的急诊医师在压力管理方面的比较差异有统计学意义。结论：福建省急诊医师的工作负荷和强度较大,在压力管理方面总体情况不容乐观。实际工作中,亟需采取相应的缓解措施,构建有效的工作机制和安排合理的工作量,帮助急诊医师疏导心理压力。     

失眠与催眠药使用的调查

对1289名成年人作了有关睡眠习惯、睡眠紊乱、催眠药使用等15项内容的调查,并对睡眠素乱的发生与年龄、性别、职业及居住环境的关系进行了统计学比较。所得结果表明,经常失眠和有时失眠的人分别占所调查人数的5.4%和52.9%。失眠的发生率中老年组大于青年组,但中老年组之间无明显差异。失眠率无明显的性别差异。居住农村的人经常失眠和有时失眠的发生率明显低于城市。长期服用催眠药的人数占所调查人数的1.1%,有时服药者占10.6%。我国部分地区失眠的发生率和催眠药的使用率远低于美国及欧洲的一些国家。     

Sedatives and hypnotics in Stockholm: social factors and kinds of use.

OBJECTIVES. The aims of the study were (1) to estimate prevalence rates of current, regular, and long-term use of sedatives and hypnotics and the incidence of regular use in an urban population and (2) to study the association between such use of drugs and sociodemographic factors, symptoms of disease, and alcohol consumption. METHODS. Data on drug use in a random sample of 6217 adults in Stockholm County were analyzed with logistic regression. RESULTS. The prevalence rate for current use of sedatives or hypnotics was 12.8% among men and 18.6% among women; the rate for regular use was 3.7% among males and 4.7% among females. The odds ratio for current use increased with age and was higher among unemployed persons and disability pensioners, high consumers of alcohol, persons with an increased level of symptoms, and widows. More than 25% of the persons who had used sedatives or hypnotics during the previous 2 weeks were regular users 6 months later. For persons aged 25 through 64 years, the annual incidence rate was 1.8% among men and 2.7% among women. CONCLUSIONS. The comparatively low incidence and high prevalence of regular use implies that long-term use of sedatives and hypnotics is common.     

Symptom burden among cancer survivors: impact of age and comorbidity.

BACKGROUND: Previous research among specific cancer populations has shown high but variable symptom burden; however, very little is known about its extent and pattern among the entire population of US cancer survivors, which is more clinically relevant to primary care physicians. METHODS: To determine the prevalence of ongoing symptom burden among cancer survivors and compare it with the general population without cancer, we analyzed data from the 2002 National Health Interview Survey, which included 1,904 cancer survivors and 29,092 controls. Main outcome measures included self-reported ongoing pain, psychological distress, and insomnia. Multivariate logistic regression models were used to adjust for confounders and test for interactions. RESULTS: The rates of ongoing pain, psychological distress, and insomnia among cancer survivors were 34%, 26%, and 30%, respectively, and were significantly higher (all P<.001) than controls without a history of cancer (18%, 16%, and 17%). Compared with controls in the same age groups, younger survivors (younger than 50) were much more likely to report ongoing symptoms than older survivors (older than 64); adjusted odds ratios were 2.96 and 1.36 for pain in the respective age groups (P<.001). Comorbidities also interact with cancer status and contribute to a marked increase in reports of ongoing symptom burden among cancer survivors, with a greater number of comorbidities leading to greater degree of symptom burden in a dose-dependent manner (P<.001). CONCLUSIONS: The symptom burden among cancer survivors on a population level is substantial and can be impacted by other comorbidities. Thus, engaging primary care physicians in the design, testing, and implementation of effective interventions is important to reduce the symptom burden among cancer survivors.     

Characteristics of falls producing hip fractures in nonagenarians

Objectives: To evaluate the characteristics associated with falls causing hip fracture in patients 90 years of age or older (nonagenarians). A second objective was to compare these characteristics with those present in younger patients (65–79 year-olds).Design: Prospective, observational study.Setting: Six hospitals in Barcelona (Spain) and its surrounding area.Participants: 105 nonagenarians diagnosed with hip fracture after a fall. Most patients were women (78; 74%), with a mean age of 92.2±2 years. All of them were living in the community, except for eight institutionalized patients. 221 patients aged 65 to 79 composed the younger patient’s comparison group.Measurements: Characteristics of falls causing hip fracture were analyzed: location, time and the risk factor for the fall, classified as intrinsic, extrinsic or combined.Results: The mean number of falls in the previous year was 1.5–22% of the patients reported having fallen two or more times. Falls usually happened while at home (70%) and during the day (64%). An intrinsic risk factor was considered the most likely cause in 37% of the cases, an extrinsic risk factor in 35%, and a combination in 28%. Multiple stepwise logistic regression analysis showed that nonagenarians were characterized by lower BI scores, more falls happening during night time, a higher use of, benzodiazepines and diuretics, and a lower use of non-benzodiazepinic hypnotics.Conclusions: Most falls causing hip fracture in nonagenarians happen during the day and at home. Falls in nonagenarians happening more frequently during nighttime, and these oldest subjects had lower BI scores, and a higher use of benzodiazepines and diuretics and less use of non-benzodiazepines hypnotics compared with the younger patients.     

Health care resources and mortality as assessed by the "empirical Bayes estimate of standardized mortality ratio": results for Fukuoka Prefecture

BACKGROUND AND OBJECTIVE: The standardized mortality ratio (SMR) is frequently used to compare health status among different populations. However, it may be biased when based upon communities with small population sizes such as towns, cities, and wards. Thus, comparison of SMRs among such small communities is not appropriate. But the "empirical Bayes estimate of standardized mortality ratio" (EBSMR) is, in contrast, a useful index. The objective of the present study was to use the EBSMR to clarify the relationships between health care resources and mortalities in 109 communities in Fukuoka Prefecture. MATERIALS AND METHODS: Data for health care resources (number of physicians, number of general clinics, number of general sickbeds in hospitals, number of emergency hospitals, and proportion of elderly outpatients within their resident' community) and socioeconomic factors (birth rate, inflow or outflow population, aged households, marital status, taxable income per individual under taxes duty, unemployment, primary, secondary, tertiary industrial employment and criminal offense records) were obtained from officially published reports. EBSMRs for all causes, cerebrovascular disease, heart disease, malignant neoplasms, and acute myocardial infarction were calculated from the 1993-1997 vital statistic records. Multiple regression analysis with stepwise variable selection was used to examine the relationships between EBSMRs and the five variables representing health care resources, considering the eleven socioeconomic factors as covariates. Some of the variables were log-transformed to normalize the distribution. RESULTS: Some of the EBSMRs were inversely related to the numbers of physicians per person (acute myocardial infarction in males (P=0.047) and females (P=0.012)), emergency hospitals per person (acute myocardial infarction in females: P=0.001), and general sickbeds per person (all causes in females: P<0.001, cerebrovascular disease in females: P=0.007, heart disease in females: P<0.001, malignant neoplasms in females: P=0.049). In contrast, when the higher the number of clinics per person, the higher the EBSMR in females for all causes (P=0.025), as well as acute myocardial infarction (P=0.006). CONCLUSION: The results suggest that an appropriate distribution of hospital care resources such as physicians, general sickbeds, and emergency hospitals is an important factor related to mortality in a community.     

Factors influencing the practice of vaginal birth after cesarean section.

OBJECTIVES. Vaginal birth after cesarean has been recommended for most women with previous cesarean sections for the past 10 years. This practice, however, has not yet been generalized because high variations can still be observed among countries, hospitals, and physicians. METHODS. A case-control study involving 635 case patients and 2593 control patients was carried out to determine which characteristics of the physician, the patient, or the hospital were important in the adoption of this practice. RESULTS. The results of the multiple stepwise logistic regression analysis indicate a higher likelihood that women will experience vaginal birth after cesarean if their physicians had cesarean rates under 20%, had less than 5% of their patients considered at risk, and were younger than 54 years old. Vaginal birth after cesarean was also favored by hospitals characterized by a high degree of neonatal and obstetrical specialization, and a patient population with a low level of education. CONCLUSIONS. This policy is still in the developmental stage, as evidenced by the great variability between hospitals and physicians in rates of vaginal birth after cesarean. Further efforts are required for this policy to become the norm.     

The number of admissions to Dutch hospitals for barbiturate poisoning from 1981-1989 and those for poisoning with sedatives and hypnotics,and benzodiazepines]

Over the period 1981 to 1989, the number of admissions to Dutch general hospitals for barbiturate poisoning has dropped sharply and steadily, due to a more restrictive policy in prescribing regarding these sedatives. This trend is also present concerning poisoning with sedatives and hypnotics in general (ICD-code 967), but not concerning those with benzodiazepines (ICD-code 969.4). The female-male ratio was nearly 2:1. This difference is possibly due to the fact that females take more medication than males.     

A cross-sectional study of self-reported work conditions and psychiatric health in native Swedes and immigrants

Several studies have demonstrated that immigrants in Scandinaviancountries are more affected by psychosocial disabilities thanthe native-born population. The aim of the study was to evaluatethe possible impact of work-related stressors on psychiatrichealth in immigrants compared to native Swedes. The study includeda cluster selected cohort of 1,040 men born in 1944 (participationratio=79.9%), living in Gothenburg, Sweden. Of these, 182 (18.0%)were immigrants, defined as being born outside Sweden. Informationon work conditions and psychiatric health were obtained by self-administeredquestionnaires. Employment in native Swedes showed inverse associationsto frequent use of anxiolytics [relative risk (RR)=0.2; 95%confidence interval (Cl)=0.067ndash;0.4], frequent use of hypnotics(RR=0.1; Cl=0.02–0.2) and use of antidepressants (RR=0.3;Cl=0.2–0.5). None of the employed immigrants used anxiolyticsor hypnotics frequently. Swedes seemed to display a number ofpsychiatric ill-health factors related to working conditions.These factors included frequent use of hypnotics, frequent insomnia,use of antidepressants, a high degree of melancholy, and wererelated to shift work, dissatisfaction with current work andmanagement and a low degree of influence on work situation,often related to a high degree of stress at work and a frequentdesire to change type of work. These associations were not seenin immigrants, apart from the risk of frequent insomnia (RR=4.7;Cl=1.2–18.3) and dissatisfaction with colleagues (RR=10.4;Cl=2.27ndash;48.8) when working in shift. With a few exceptions,non-optimal working environment was associated with a low degreeof life satisfaction in both groups. It was hypothesized thatoptimal working conditions are important for maintaining psychiatrichealth, and that immigrants, when employed, seem less affectedby impaired working conditions than native Swedes.     

Zolpidem Use and Risk of Fracture in Elderly Insomnia Patients

Objectives

To evaluate the risk of fractures related with zolpidem in elderly insomnia patients.

Methods

Health claims data on the entire South Korean elderly population from January 2005 to June 2006 were extracted from the Health Insurance Review and Assessment Service database. We applied a case-crossover design. Cases were defined as insomnia patients who had a fracture diagnosis. We set the hazard period of 1 day length prior to the fracture date and four control periods of the same length at 5, 10, 15, and 20 weeks prior to the fracture date. Time independent confounding factors such as age, gender, lifestyle, cognitive function level, mobility, socioeconomic status, residential environment, and comorbidity could be controlled using the casecrossover design. Time dependent confounding factors, especially co-medication of patients during the study period, were adjusted by conditional logistic regression analysis. The odds ratios and their 95% confidence intervals (CIs) were estimated for the risk of fracture related to zolpidem.

Results

One thousand five hundred and eight cases of fracture were detected in insomnia patients during the study period. In our data, the use of zolpidem increased the risk of fracture significantly (adjusted odds ratio [aOR], 1.72; 95% CI, 1.37 to 2.16). However, the association between benzodiazepine hypnotics and the risk of fracture was not statistically significant (aOR, 1.00; 95% CI, 0.83 to 1.21). Likewise, the results were not statistically significant in stratified analysis with each benzodiazepine generic subgroup.

Conclusions

Zolpidem could increase the risk of fracture in elderly insomnia patients. Therefore zolpidem should be prescribed carefully and the elderly should be provided with sufficient patient education.     

Prevalence and determinants of tuberculin reactivity among physicians in Edmonton, Canada: 1996-1997.

BACKGROUND: Health care workers (HCW) have historically borne a heavy burden of tuberculosis (TB) infection and disease. Unfortunately, physicians are rarely included in HCW surveys of tuberculin exposure and infection. METHODS: The prevalence and risk factors for tuberculin reactivity were determined for a sample of the 1732 licensed physicians in Edmonton. Stratified random sampling was used to select 554 specialists and 219 general practitioners. These physicians were contacted by means of an introductory letter and a follow-up telephone call to solicit participation. All eligible physicians were asked to complete a questionnaire and those with either no recorded positive tuberculin test or a previously negative result were two-step tuberculin skin tested. RESULTS: In total, 560 physicians (72.4 %) participated in the study. The overall tuberculin reactivity for this population was 45.9%. Using logistic regression analysis, we determined that risk factors for reactivity were aged over 45 years, of foreign-birth, previous Bacillus Calmette-Guérin (BCG) vaccination, foreign practice experience, and being a respiratory medicine specialist. CONCLUSION: The prevalence of tuberculin reactivity among physicians is considerably higher than estimates for the general Canadian population. This observed excess risk may be associated with factors linked to their medical practice. The high participation rate suggests physician willingness to participate in this type of research, and emphasizes the need to include them in routine HCW surveillance.     

北京市综合医院医师神经症知识知晓情况调查

目的了解北京市综合医院医师对神经症相关知识的知晓情况。方法采用分层随机整群抽样方法,对北京市4所不同级别综合医院的191位医师进行《神经症知识》问卷调查。结果84．3％的医师听说过神经症,67．0％的医师能够列举神经症的主要表现,74．3％医师的神经症知识来自专业书籍,仅35．9％和12．6％的医师能够诊断和治疗神经症。获取途径中,“同事、同学或朋友”二级医院比例（53．5％）高于三级医院;三级医院医师从“宣传资料”（25．9％）、“专业书籍”（81．7％）获得知识的比例高于二级医院（P〈0．01）。结论北京市综合医院医师的神经症知识知晓情况较为基础,专业诊治能力不足,应加强综合医师的神经症知识教育。     

Do Spanish patients drink alcohol while undergoing treatment with benzodiazepines?

In this study, we analyzed patterns of combined benzodiazepines and alcohol use among the Spanish general population over the age of 16 years. The study was based on information from the 1997 Spanish National Household Health Survey. A total of 6,396 persons over 16 years of age, a representative sample of noninstitutionalized Spaniards, were surveyed. One percent of the population are consumers of benzodiazepines and daily drinkers of alcohol; fundamentally, these consumers are men, of whom 15.4% drink alcohol at a high level (>50 units/week). Findings show the frequency of concurrent use of benzodiazepines and alcohol by the Spanish population.     

Prevalencia de consumo de hipnosedantes en población ocupada y factores de estrés laboral asociados

Objective

To explore the prevalence of the use of hypnotics and sedatives in a sample of the Spanish working population and to examine its association with certain work-related stress factors.

Methods

Using data from the 2007 Spanish Household Survey on Alcohol and Drugs (Encuesta Domiciliaria sobre Alcohol y Drogas en España [EDADES]), we analyzed the distribution of the use of hypnotics and sedatives in the previous month in the working population aged 16 to 64 years old (n = 13,005). Associations with exposure to certain work-related stress factors (noxious working environment, precariousness, workload, and social support) were examined using logistic regression modelling.

Results

The prevalence of the use of hypnotics and sedatives among women in the previous month doubled that of men (6.5% and 3.3%, respectively), while use among the oldest age group was twice that of the youngest group in both sexes (10.2% in women and 5.5% in men older than 45 years), and was four times higher among those reporting poor health (18.9% in women and 11% in men). Concerning work-related stress, exposure to moderate (OR: 1.96; 95%CI: 1.31-2.92) and high (OR: 1.95; 95%CI: 1.14-3.34) levels of precariousness in men and moderate levels in women (OR: 1.43; 95%CI: 1.03-1.99) was associated with the use of hypnotics and sedatives.

Conclusions

The prevalence of the use of hypnotics and sedatives was high in women and in workers older than 45 years. Further research is needed on the relationship between the use of hypnotics and sedatives and workers’ health, and on the role that work-related stress factors play in this association.     

Use of psychoactive drugs and related falls among older people living in a community in Brazil

INTRODUCTION: Population aging in Brazil has increased the prevalence of neurodegenerative diseases (Parkinson's and Alzheimer's disease) and affective disorders (anxiety, depression), all common in old age. A retrospective study was carried out with the purpose of ascertaining if there is an association between falls and psychoactive medication use among older residents of a community in Brazil. METHODS: All residents aged 65+ (n=161) of one neighborhood of Campo Belo, Brazil (population of 48,000) were evaluated regarding the use of psychoactive drugs and the occurrence of falls in the 12 months preceding the study. Vision and hearing screenings were also performed. RESULTS: From the study population, 9.3% were taking prolonged half-life benzodiazepines, 4.4% anticonvulsants (mostly barbiturates), 2.5% antidepressants (all cyclics) and 8.1% alpha-methyldopa. No subject reported use of hypnotics, neuroleptics or drugs to treat Alzheimer's or Parkinson's diseases (except biperiden). As a whole, drugs that increase the risk of falls were used by 1/5 of this population. In the 12-month period preceding the study, 27 residents (16.8%) experienced falls and, of those, 4 (14.8%) had fracture(s). There was an independent association between psychoactive drug use and falls when variables such as age, gender, vision and hearing were controlled (p=0.02). CONCLUSIONS: Although the population of this neighborhood must be considered young (only 4% are 65 years old or more), there are already problems related to the use of psychoactive drugs among people. Prescribed anxiolytics, anticonvulsants, antidepressants and antihypertensives are not appropriate for this age group and their use is associated with falls.     

Impact of physician training level on emergency readmission within internal medicine

OBJECTIVES: The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine. METHODS: This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan-suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression. RESULTS: A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13-1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38-0.73). CONCLUSION: The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.