SAMMANFATTNING Bakgrund: Akut förvirringstillstånd är ett vanligt neuropsykiatriskt tillstånd som främst drabbar sköra, äldre människor. När akut förvirringstillstånd väl har uppstått finns det få behandlingar tillgängliga för att minska duration och allvarlighetsgrad. Syftet var att ta reda på hur akut förvirringstillstånd kan förebyggas och hur omvårdnaden kan underlättas för äldre patienter med akut förvirringstillstånd på sjukhus. Metod: För att söka svar till syftet har en beskrivande litteraturstudie valts som metod. Databassökning genomfördes och studiernas kvalitet granskades med hjälp av en granskningsmall. Femton studier inkluderades, både kvantitativa och kvalitativa. Genom analys av inkluderade artiklar kunde betydelsefull data utifrån syftet identifieras och sorteras in i kategorier. Resultat: Resultatet har visat att förebyggande åtgärder har betydelse för att minska risken att drabbas av akut förvirringstillstånd. Flera studier som är multikomponentstudier har visat goda resultat för att undvika insjuknande i akut förvirringstillstånd där interventionerna säkerställer att flera av patientens basala behov tillgodoses, såsom sömn, mat- och vätskeintag, elimination och att kunna kommunicera. Studierna kom fram till att vårdpersonalens kunskap och utbildning har betydelse, att ökad kunskap förbättrar patient omhändertagandet och vårdkvalitén. Underlättande åtgärder beskriver studierna att ha ökad tillsyn, att minska stimuli och att aktivera patienten. Slutsats: Förebyggande åtgärder har betydelse för att minska risken att den äldre patienten drabbas av akut förvirringstillstånd. Ökad kunskap hos vårdpersonalen förbättrar patient omhändertagandet och vårdkvalitén. För att underlätta omhändertagandet om en patient med akut förvirringstillstånd behövs både tid, erfarenhet, lämpliga lokaler och personalresurser. / ABSTRACT Background Delirium is a common neuropsychiatric condition that primarily affects frail, aged people. When it has occured it is few treatments available to reduce duration and severity. The purpose of this study was to find out how delirium can be prevented and how nursing can facilitate the care of aged patients with delirium in hospital. Methods To find answer to our purpose a descriptive litteraturestudy have been chosen as a method. Database searches were implemented and the quality of the studies was scientifically reviewed with a template. Fifteen studies were included, both quantitative and qualitative. Through analysis of included studies, valuable data based on the purpose were identified and sorted into three categories. Results The results show that preventive actions have importance for reducing the risk of being affected of delirium. Some studies formed as multicomponent studies have shown good results for avoiding acute onset of delirium where the interventions secure that several of the patient basic needs are catered, as sleep, nutrition- and fluid intake, elimination and being able to communicate. The studies also came up with the result that the knowledge and education of the health professionals mattered, that increased knowledge facilitates the patient care and the quality of care. When the patient is affected of delirium, there are actions that facilitate the nursing. Facilitating actions is described in the studies as increased supervision, reduction of stimuli, activate the patient etcetera. Conclusion Preventive interventions have importance of reducing the risk of elderly patients being affected of delirium. Increased knowledge of healthcare professionals improves patient care and quality of care. To facilitate the care of the patient with ongoing delirium there is need for time, experience, suitable facilities and enough healthcare personnel.

The Distinctive Function of Trademark Abstract The main aim of this thesis is to define the trademark, the functions it performs, and thoroughly analyse the distinctive function, especially its manifestations in law and decision- making practice. In addition to scientific literature, it is based on decisions of the Industrial Property Office, EUIPO and the Court of Justice of the European Union in particular. The introductory part is devoted to the trademark as a right to a sign, focusing on its history, definition and basic principles. In order to better understand trademark law, it also briefly defines other rights to signs. The second chapter deals with the various functions of the trademark, namely the distinctive, prohibitive, competitive, assuring and promotional functions. The third part is focused on distinctive character, especially its relation to distinctive function and the difference between inherent and acquired distinctive character. It also categorizes signs according to the degree of distinctive character and analyzes the impact of use on the distinctive character of a trademark, namely enhanced distinctiveness, good reputation and general renown, and their demonstration in opposition proceedings. The fourth chapter deals with the legal regulation of refusal to register a trademark due to...

A Quality Improvement project to initiate the Confusion Assessment Method (CAM) delirium screening tool at a Skilled Nursing Facility and Rehabilitation Center in East Tennessee -- by S. Joseph Jadav, Doctor of Nursing Practice Candidate at East Tennessee State University. Purpose/Aims: The aim of this project is to implement a delirium screening protocol in a skilled nursing and rehabilitation facility which will aid in early detection of signs and symptoms of delirium in older adults. This early detection followed by an early intervention can help reduce costs and decrease mortality rates with better outcomes. Processes: A CAM screening is conducted on each patient (male & female) for delirium for a period of four weeks. Data collection will comprise of the number of patients assessed and the total number of positive and negative delirium cases. It was determined that the proposed activity is not research involving human subjects according to United States Department of Health and Human Services (DHHS) regulations by the university’s Institutional Review Board (IRB). Results: The project is currently in the data collection phase. Limitations: Refusal to participate either by the patient or family in the screening. Conclusions: While nearly 80% of delirium cases in an acute care setting go undetected or undiagnosed, this project to implement a delirium screening protocol in a skilled nursing facility is even more imperative in early detection and early intervention.

Bakgrund: Konfusion innebär att patienten drabbas av ett akut förvirringstillstånd som bland annat påverkar kognitionen och medvetandenivån. Detta är en vanlig förekommande komplikation i den postoperativa vården. Tillståndet kan leda till ett ökat lidande och längre vårdtider som påverkar både individen, vården och samhället i stort. Syfte: Syftet var att beskriva den vuxna patientens upplevelser av en konfusion i ett postoperativt skede och hur vårdandet upplevdes i samband med detta. Metod: En allmän litteraturöversikt med kvalitativ ansats, där elva kvalitativa studier söktes i databaserna PubMed och Cinahl. Kvalitetsgranskningen genomfördes med kvalitetsgranskningmall från Statens beredning för social utvärdering. Resultatanalysen utfördes genom Fribergs analysmodell. Resultat: Totalt framkom tre kategorier och dessa var upplevelser av konfusion, upplevelser av omhändertagandet i vården och upplevelser av närståendes involvering i vårdandet. Resultat visade både negativa och positiva upplevelser av konfusion postoperativt, där majoriteten av upplevelserna skildrades som negativa. De negativa upplevelserna beskrevs som ett lidande och overklighetskänslor. Resultatet visade även upplevelser om omhändertagandet i vården vilket innefattade information, kommunikation, närvaro av personal och miljöanpassning. Patienterna beskrev även närståendes involvering i vårdandet, vilket ansågs ha en positiv inverkan på patienten. Slutsats: Postoperativ konfusion kunde leda till stora psykiska påfrestningar för patienten, vilket medförde ett lidande. Lidandet kunde beskrivas i form av ett vårdlidande, sjukdomslidande och ett livslidande. I framtiden bör fler studier genomföras för att få en ökad förståelse och ökade kunskaper kring området. Fortsatt kan detta vara aktuellt för att kunna möta samt möjliggöra en optimal vård för denna patientgrupp. / Background: Confusion means that the patient is affected by an acute confusional state, which affects cognition and the level of consciousness. Confusion is a common complication in postoperative care. The condition can lead to increased suffering and longer hospitalization, which has affects both on the individual, the health care and the society. Aim: The aim was to describe the adult patient’s experiences of confusion in a postoperative stage and how the care was experienced in connection with the hospitalization. Method: A general literature study with a qualitative approach where eleven qualitative studies, found in the databases PubMed and Cinahl, was applied. The quality review was carried out using the quality review template from the Swedish Agency for Health Technology Assesment and Assesment of Social Services. The result analysis was carried out using Friberg’s analysis model. Results: A total of three categories emerged and these were experiences of confusion, experiences about caring performance in healthcare and experiences of relatives' involvement in the care. The results showed both negative and positive experiences of confusion postoperatively, with the majority of experiences described as negative. The negative experiences were explained as suffering and feelings of unreality. The result also showed experiences about caring performance in healthcare, which included information, communication, presence of staff, and environmental adaptation. The patients also described the involvement of relatives in the care, which was considered to have a positive impact on the patient. Conclusion: Postoperative confusion is described as a psychological stress for the patient, which entailed suffering. The suffering could be described in the form of care suffering, disease suffering and life suffering. In the future, more studies are required to gain an increased understanding and increased knowledge of the area. Furthermore, this can be relevant to meet the opportunities and make an optimal health care for this patient group.

No description available.

Introduktion: Akut konfusion är ett tillstånd som karakteriseras av akut kognitiv svikt och drabbar upp till 80% av kritiskt sjuka patienter på intensivvårdsavdelningar.  Tillståndet skapar ett lidande hos patienten och ger även negativa konsekvenser för anhöriga, vården och samhället. Behandlingen består i första hand av omvårdnadsåtgärder vilket ställer höga krav på sjuksköterskans kompetens.  Syfte: Syftet med studien var att beskriva vuxna patienters upplevelser av akut konfusion på intensivvårdsavdelning.  Metod: Allmän litteraturstudie med kvalitativ ansats. Tretton kvalitativa artiklar söktes i databaserna PubMed, CINAHL samt i metaanalysers referenslistor. Kvalitetsgranskningen utfördes med kvalitetsgranskningsmall från SBU. Resultatanalysen genomfördes med Forsberg & Wengströms analysmodell.  Resultat: I resultatet identifierades fem teman: upplevelser av sjuksköterskans och närståendes förhållningssätt och bemötande, upplevelser av perceptionsstörningar, upplevelser av att vara vilsen i tid och rum, upplevelser av skiftande sinnesstämning samt upplevelser av agitation och paranoia.  Slutsats: Patienternas upplevelser av akut konfusion beskrevs som ett lidande. De framkom att patienterna nyttjade olika copingstrategier för att hantera tillståndet. Genom att ha kunskap om detta kan sjuksköterskan vara ett stöd i att lindra patientens lidande. Patienters upplevelser behöver studeras ytterligare så sjukvårdspersonal kan utbildas vidare i ämnet och på så sätt erbjuda en god vård för denna patientgrupp. / Introduction: Acute confusion is a condition characterized by an acute cognitive failure and affects up to 80% of the severely ill patients in intensive care units. The condition contributes to suffering for the patient and also generates negative consequences for relatives, healthcare and society. The treatment is primarily nursing measures which makes high demands on nurses competence.  Aim: The aim of the study was to describe the adult patient's experience of acute confusion in the intensive care unit.  Method: A general literature study with a qualitative approach. Thirteen qualitative studies were found in the databases PubMed, CINAHL and through metaanalyzes references. The quality review was done implementing the quality review template from SBU. The result analysis was carried out using Forsberg and Wengströms analysis model.  Results: The result identified five themes: experiences of the nurse and relatives approach and reception, experiences of perception disorders, experiences of being disoriented in time and space, experiences of mood swings, and also experiences of agitation and paranoia.  Conclusion: Patients' experiences of acute confusion was described as a suffering. Patients used different coping strategies to manage their condition. With knowledge about the condition the nurse can be a support in easing the patients suffering. Patients' experiences need to be studied further so healthcare professionals can be educated about the subject and offer good care för this patient group.

URL parser and normalization processes are common and important operations in different web frameworks and technologies. In recent years, security researchers have targeted these processes and discovered high impact vulnerabilities and exploitation techniques. In a different approach, we will focus on semantic disconnect among different framework-independent web technologies (e.g., browsers, proxies, cache servers, web servers) which results in different URL interpretations. We coined the term “Path Confusion” to represent this disagreement and this thesis will focus on analyzing enabling factors and security impact of this problem.In this thesis, we will show the impact and importance of path confusion in two attack classes including Style Injection by Relative Path Overwrite (RPO) and Web Cache Deception (WCD). We will focus on these attacks as case studies to demonstrate how utilizing path confusion techniques makes targeted sites exploitable. Moreover, we propose novel variations of each attack which would expand the number of vulnerable sites and introduce new attack scenarios. We will present instances which have been secured against these attacks, while being still exploitable with introduced Path Confusion techniques. To further elucidate the seriousness of path confusion, we will also present the large scale analysis results of RPO and WCD attacks on high profile sites. We present repeatable methodologies and automated path confusion crawlers which detect thousands of sites that are still vulnerable to RPO or WCD only with specific types of path confusion techniques. Our results attest the severity of path confusion based class of attacks and how extensively they could hit the clients or systems. We analyze some browser-based mitigation techniques for RPO and discuss that WCD cannot be dealt as a common vulnerability of each component; instead it arises when an ecosystem of individually impeccable components ends up in a faulty situation.

Le biais de confusion est un défi majeur des études observationnelles, surtout s'ils sont induits par des caractéristiques difficiles, voire impossibles, à mesurer dans les banques de données administratives de soins de santé. Un des biais de confusion souvent présents dans les études pharmacoépidémiologiques est la prescription sélective (en anglais « prescription channeling »), qui se manifeste lorsque le choix du traitement dépend de l'état de santé du patient et/ou de son expérience antérieure avec diverses options thérapeutiques. Parmi les méthodes de contrôle de ce biais, on retrouve le score de comorbidité, qui caractérise l'état de santé d'un patient à partir de médicaments délivrés ou de diagnostics médicaux rapportés dans les données de facturations des médecins. La performance des scores de comorbidité fait cependant l'objet de controverses car elle semble varier de façon importante selon la population d'intérêt. Les objectifs de cette thèse étaient de développer, valider, et comparer les performances de deux scores de comorbidité (un qui prédit le décès et l’autre qui prédit l’institutionnalisation), développés à partir des banques de services pharmaceutiques de la Régie de l'assurance-maladie du Québec (RAMQ) pour leur utilisation dans la population âgée. Cette thèse vise également à déterminer si l'inclusion de caractéristiques non rapportées ou peu valides dans les banques de données administratives (caractéristiques socio-démographiques, troubles mentaux ou du sommeil), améliore la performance des scores de comorbidité dans la population âgée. Une étude cas-témoins intra-cohorte fut réalisée. La cohorte source consistait en un échantillon aléatoire de 87 389 personnes âgées vivant à domicile, répartie en une cohorte de développement (n=61 172; 70%) et une cohorte de validation (n=26 217; 30%). Les données ont été obtenues à partir des banques de données de la RAMQ. Pour être inclus dans l’étude, les sujets devaient être âgés de 66 ans et plus, et être membres du régime public d'assurance-médicaments du Québec entre le 1er janvier 2000 et le 31 décembre 2009. Les scores ont été développés à partir de la méthode du Framingham Heart Study, et leur performance évaluée par la c-statistique et l’aire sous les courbes « Receiver Operating Curves ». Pour le dernier objectif qui est de documenter l’impact de l’ajout de variables non-mesurées ou peu valides dans les banques de données au score de comorbidité développé, une étude de cohorte prospective (2005-2008) a été réalisée. La population à l'étude, de même que les données, sont issues de l'Étude sur la Santé des Aînés (n=1 494). Les variables d'intérêt incluaient statut marital, soutien social, présence de troubles de santé mentale ainsi que troubles du sommeil. Tel que décrit dans l'article 1, le Geriatric Comorbidity Score (GCS) basé sur le décès, a été développé et a présenté une bonne performance (c-statistique=0.75; IC95% 0.73-0.78). Cette performance s'est avérée supérieure à celle du Chronic Disease Score (CDS) lorsqu'appliqué dans la population à l'étude (c-statistique du CDS : 0.47; IC 95%: 0.45-0.49). Une revue de littérature exhaustive a montré que les facteurs associés au décès étaient très différents de ceux associés à l’institutionnalisation, justifiant ainsi le développement d'un score spécifique pour prédire le risque d'institutionnalisation. La performance de ce dernier s'est avérée non statistiquement différente de celle du score de décès (c-statistique institutionnalisation : 0.79 IC95% 0.77-0.81). L'inclusion de variables non rapportées dans les banques de données administratives n'a amélioré que de 11% la performance du score de décès; le statut marital et le soutien social ayant le plus contribué à l'amélioration observée. En conclusion, de cette thèse, sont issues trois contributions majeures. D'une part, il a été démontré que la performance des scores de comorbidité basés sur le décès dépend de la population cible, d'où l'intérêt du Geriatric Comorbidity Score, qui fut développé pour la population âgée vivant à domicile. D'autre part, les médicaments associés au risque d'institutionnalisation diffèrent de ceux associés au risque de décès dans la population âgé, justifiant ainsi le développement de deux scores distincts. Cependant, les performances des deux scores sont semblables. Enfin, les résultats indiquent que, dans la population âgée, l'absence de certaines caractéristiques ne compromet pas de façon importante la performance des scores de comorbidité déterminés à partir de banques de données d'ordonnances. Par conséquent, les scores de comorbidité demeurent un outil de recherche important pour les études observationnelles. / Confounding is an important challenge in observational studies given that they are induced by characteristics difficult, if not impossible, to measure in administrative claims databases. Prescription channelling is a frequent source of confounding in pharmacoepidemiologic studies, and occurs when the selection of one treatment over another is influenced by overall health status and patient's experience with other treatment options. Among the methods available to control for this bias, comorbidity scores are frequently used. Most of the comorbidity scores published in the literature assess the patients’ health status through drug dispensing or diagnostic codes included in physicians’ billings. These comorbidity scores, however, are controversial since their performance appears to vary according to the population of interest ( example: elderly vs. adult). The objectives of this thesis were to develop, validate and compare the performance of two comorbidity scores (the Geriatric Comorbidity Score based on death, and a comorbidity score based on institutionalization) derived from dispensing data for use in the community-dwelling elderly population. Furthermore, this thesis aimed to evaluate whether the inclusion of characteristics not usually included in administrative claims databases or with a low validity (such as sociodemographic characteristics, sleep or mental disorders) improves the performance of the Geriatric Comorbidity Score. A nested case-control analysis was conducted within a cohort that consisted of a random sample of 87,389 elderly distributed into a construction cohort (n=61,172; 70%) and a validation cohort (n=26,217; 30%). Sources of data consisted of the databases of the Régie de l’assurance maladie du Québec (RAMQ). To be included in the study, subjects had to be 66 years and older and covered by the public drug insurance program of Quebec between 1st January 2000 and 31st December 2009. Scores were developed using the Framingham Heart Study method, and their performances were assessed using the c-statistics and receiver operating curves (ROC). For the last objective, a prospective cohort study was performed using the participants in the Étude sur la Santé des Aînés (ESA) (n=1,494) which covered the period ranging from 2005 to 2008. Study variables included marital status, social support, mental health as well as sleep disorders. The comprehensive literature review conducted in the thesis and our results revealed that factors associated with death greatly differed from those associated with institutionalization, which supported the need to develop two distinct scores. Performances of the institutionalization score were, however, not statistically different from the death score (institutionalization c-statistic = 0.79; 95% CI: 0.77-0.81; death c-statistic= 0.75; 95% CI: 0.73-0.78). The Geriatric Comorbidity Score (death score) revealed a better performance than the Chronic Disease Score, which has been widely used in the literature (c-statistic= 0.47; 95%CI: 0.45-0.49). The inclusion of variables not recorded in claims databases yielded an improvement of the death score of only 11%, with marital status and social support being mainly responsible for the improvement. In terms of achievement, this thesis made three contributions. First, it was shown that the performance of comorbidity scores based on death vary according to the study population, reinforcing the need for specific scores, such as the Geriatric Comorbidity Score which was developed here. Second, factors associated with the risk of institutionalization were different than those associated with the risk of death in the elderly population, which supported the development of an institutionalization score. Even if the performance of death and institutionalization scores were similar, the latter would be preferred in studies that aim at assessing the effect of drugs on institutionalisation in the elderly. Lastly, the results indicate that the absence of some characteristics in the administrative databases do not appear to have a major impact on the performance of scores based on claims data. Consequently, comorbidity scores based on drug dispensing data remain important research tools for pharmacoepidemiologic studies conducted through health claims databases.

Parmi les réalisateurs, producteurs et acteurs de Bombay, Raj Kapoor (1924-1988) est certainement l’un des plus célèbres et des plus originaux, qu’il s’agisse de son œuvre ou de sa personnalité. Sa vaste filmographie qui rassemble quelques-uns des plus beaux mélodrames du cinéma populaire hindi reste méconnue en France. Proches du peuple, ces mélodrames révèlent un phénomène présent dans différentes situations et sous différents aspects : le sentiment d’incompréhension.Ce travail de recherche, inspiré par la lecture de Peter Brooks et Stanley Cavell sur le mélodrame, se donne pour but de montrer que les mélodrames de Kapoor sont porteurs d’un concept particulier qui les unit et les définit comme un genre cinématographique propre que nous appellerons « mélodrame de l’incompréhension ». Le sentiment de ne pas comprendre ou d’être « mal compris » qui hante ces mélodrames se cristallise non seulement à partir des enjeux esthétiques, historiques, politiques et culturels mais aussi des événements personnels.S’appuyant sur l’esthétique du mélodrame, Kapoor multiplie la présence métaphorique du héros aveugle qui pointe la difficulté ou l’impossibilité de communiquer et fait grief à la société de ne pas le comprendre. Inscrivant sa souffrance dans un contexte plus large, le mélodrame kapoorien dépasse les frontières du drame intimiste pour s’élever au niveau du peuple, voire de la nation, selon certains auteurs. Pour amplifier le phénomène d’incompréhension, le mélodrame utilise le malentendu, la méprise, l’ignorance, la confusion, l’illusion, etc. au point que ces difficultés de communication paraissent très clairement représenter des éléments structurels marqués par la réflexion de Kapoor sur l’incompréhension, teintée de mélancolie et de tristesse. / Among Bombay’s directors, producers and actors, Raj Kapoor (1924-1988) is certainly one of the best known and most original both for his work and for his personality. His vast filmography which constitutes a collection of some of the most beautiful melodramas of Hindi popular cinema remains virtually unknown in France. Close to the people, these melodramas reveal a theme which is universally present, illustrated in a variety of situations and different lights. It is the phenomenon of incomprehension.The present work, inspired by a reading of Peter Brooks and Stanley Cavell on the subject of melodrama, aims to show that Kapoor’s melodramas treat this specific theme which unites them and allows them to be defined as a distinct cinematic genre here termed "melodrama of incomprehension." The feeling of inability to understand or of being misunderstood which haunts these melodramas is gleaned not only from aesthetic, historical, political and cultural subjects but also from personal experience.Drawing on the aesthetics of melodrama, Kapoor multiplies the metaphorical presence of the blind hero illustrating the overwhelming difficulty of communication, and blames society for a lack of understanding. Extending the resulting suffering to a wider context, Kapoor’s melodrama transcends the bounds of individual drama, reaching out to the level of the people as a whole, indeed to the entire nation according to some authors. To amplify the phenomenon of incomprehension, his melodrama uses misunderstanding, scorn, ignorance, confusion, illusion, and more. Kapoor does this to a point at which these difficulties of communication clearly represent identifiable structural elements in his portrayal of incomprehension imbued with melancholy and sadness.

Le biais de confusion est un défi majeur des études observationnelles, surtout s'ils sont induits par des caractéristiques difficiles, voire impossibles, à mesurer dans les banques de données administratives de soins de santé. Un des biais de confusion souvent présents dans les études pharmacoépidémiologiques est la prescription sélective (en anglais « prescription channeling »), qui se manifeste lorsque le choix du traitement dépend de l'état de santé du patient et/ou de son expérience antérieure avec diverses options thérapeutiques. Parmi les méthodes de contrôle de ce biais, on retrouve le score de comorbidité, qui caractérise l'état de santé d'un patient à partir de médicaments délivrés ou de diagnostics médicaux rapportés dans les données de facturations des médecins. La performance des scores de comorbidité fait cependant l'objet de controverses car elle semble varier de façon importante selon la population d'intérêt. Les objectifs de cette thèse étaient de développer, valider, et comparer les performances de deux scores de comorbidité (un qui prédit le décès et l’autre qui prédit l’institutionnalisation), développés à partir des banques de services pharmaceutiques de la Régie de l'assurance-maladie du Québec (RAMQ) pour leur utilisation dans la population âgée. Cette thèse vise également à déterminer si l'inclusion de caractéristiques non rapportées ou peu valides dans les banques de données administratives (caractéristiques socio-démographiques, troubles mentaux ou du sommeil), améliore la performance des scores de comorbidité dans la population âgée. Une étude cas-témoins intra-cohorte fut réalisée. La cohorte source consistait en un échantillon aléatoire de 87 389 personnes âgées vivant à domicile, répartie en une cohorte de développement (n=61 172; 70%) et une cohorte de validation (n=26 217; 30%). Les données ont été obtenues à partir des banques de données de la RAMQ. Pour être inclus dans l’étude, les sujets devaient être âgés de 66 ans et plus, et être membres du régime public d'assurance-médicaments du Québec entre le 1er janvier 2000 et le 31 décembre 2009. Les scores ont été développés à partir de la méthode du Framingham Heart Study, et leur performance évaluée par la c-statistique et l’aire sous les courbes « Receiver Operating Curves ». Pour le dernier objectif qui est de documenter l’impact de l’ajout de variables non-mesurées ou peu valides dans les banques de données au score de comorbidité développé, une étude de cohorte prospective (2005-2008) a été réalisée. La population à l'étude, de même que les données, sont issues de l'Étude sur la Santé des Aînés (n=1 494). Les variables d'intérêt incluaient statut marital, soutien social, présence de troubles de santé mentale ainsi que troubles du sommeil. Tel que décrit dans l'article 1, le Geriatric Comorbidity Score (GCS) basé sur le décès, a été développé et a présenté une bonne performance (c-statistique=0.75; IC95% 0.73-0.78). Cette performance s'est avérée supérieure à celle du Chronic Disease Score (CDS) lorsqu'appliqué dans la population à l'étude (c-statistique du CDS : 0.47; IC 95%: 0.45-0.49). Une revue de littérature exhaustive a montré que les facteurs associés au décès étaient très différents de ceux associés à l’institutionnalisation, justifiant ainsi le développement d'un score spécifique pour prédire le risque d'institutionnalisation. La performance de ce dernier s'est avérée non statistiquement différente de celle du score de décès (c-statistique institutionnalisation : 0.79 IC95% 0.77-0.81). L'inclusion de variables non rapportées dans les banques de données administratives n'a amélioré que de 11% la performance du score de décès; le statut marital et le soutien social ayant le plus contribué à l'amélioration observée. En conclusion, de cette thèse, sont issues trois contributions majeures. D'une part, il a été démontré que la performance des scores de comorbidité basés sur le décès dépend de la population cible, d'où l'intérêt du Geriatric Comorbidity Score, qui fut développé pour la population âgée vivant à domicile. D'autre part, les médicaments associés au risque d'institutionnalisation diffèrent de ceux associés au risque de décès dans la population âgé, justifiant ainsi le développement de deux scores distincts. Cependant, les performances des deux scores sont semblables. Enfin, les résultats indiquent que, dans la population âgée, l'absence de certaines caractéristiques ne compromet pas de façon importante la performance des scores de comorbidité déterminés à partir de banques de données d'ordonnances. Par conséquent, les scores de comorbidité demeurent un outil de recherche important pour les études observationnelles. / Confounding is an important challenge in observational studies given that they are induced by characteristics difficult, if not impossible, to measure in administrative claims databases. Prescription channelling is a frequent source of confounding in pharmacoepidemiologic studies, and occurs when the selection of one treatment over another is influenced by overall health status and patient's experience with other treatment options. Among the methods available to control for this bias, comorbidity scores are frequently used. Most of the comorbidity scores published in the literature assess the patients’ health status through drug dispensing or diagnostic codes included in physicians’ billings. These comorbidity scores, however, are controversial since their performance appears to vary according to the population of interest ( example: elderly vs. adult). The objectives of this thesis were to develop, validate and compare the performance of two comorbidity scores (the Geriatric Comorbidity Score based on death, and a comorbidity score based on institutionalization) derived from dispensing data for use in the community-dwelling elderly population. Furthermore, this thesis aimed to evaluate whether the inclusion of characteristics not usually included in administrative claims databases or with a low validity (such as sociodemographic characteristics, sleep or mental disorders) improves the performance of the Geriatric Comorbidity Score. A nested case-control analysis was conducted within a cohort that consisted of a random sample of 87,389 elderly distributed into a construction cohort (n=61,172; 70%) and a validation cohort (n=26,217; 30%). Sources of data consisted of the databases of the Régie de l’assurance maladie du Québec (RAMQ). To be included in the study, subjects had to be 66 years and older and covered by the public drug insurance program of Quebec between 1st January 2000 and 31st December 2009. Scores were developed using the Framingham Heart Study method, and their performances were assessed using the c-statistics and receiver operating curves (ROC). For the last objective, a prospective cohort study was performed using the participants in the Étude sur la Santé des Aînés (ESA) (n=1,494) which covered the period ranging from 2005 to 2008. Study variables included marital status, social support, mental health as well as sleep disorders. The comprehensive literature review conducted in the thesis and our results revealed that factors associated with death greatly differed from those associated with institutionalization, which supported the need to develop two distinct scores. Performances of the institutionalization score were, however, not statistically different from the death score (institutionalization c-statistic = 0.79; 95% CI: 0.77-0.81; death c-statistic= 0.75; 95% CI: 0.73-0.78). The Geriatric Comorbidity Score (death score) revealed a better performance than the Chronic Disease Score, which has been widely used in the literature (c-statistic= 0.47; 95%CI: 0.45-0.49). The inclusion of variables not recorded in claims databases yielded an improvement of the death score of only 11%, with marital status and social support being mainly responsible for the improvement. In terms of achievement, this thesis made three contributions. First, it was shown that the performance of comorbidity scores based on death vary according to the study population, reinforcing the need for specific scores, such as the Geriatric Comorbidity Score which was developed here. Second, factors associated with the risk of institutionalization were different than those associated with the risk of death in the elderly population, which supported the development of an institutionalization score. Even if the performance of death and institutionalization scores were similar, the latter would be preferred in studies that aim at assessing the effect of drugs on institutionalisation in the elderly. Lastly, the results indicate that the absence of some characteristics in the administrative databases do not appear to have a major impact on the performance of scores based on claims data. Consequently, comorbidity scores based on drug dispensing data remain important research tools for pharmacoepidemiologic studies conducted through health claims databases.