Evidenz-basiertes präventives Assessment für betagte Patienten - Umsetzung der Ergebnisse einer europäischen Studie in eine konkrete hausärztliche Vorsorgeuntersuchung in Deutschland

Dementia diagnostics in general practitioner care : Do general practitioners have reservations? The findings of a qualitative study in Germany

General practitioner (GP) treatment of dementia is often criticized as being ineffective and not implemented consistently enough. The causes and specific standpoints of GPs have not previously been thoroughly investigated. This paper focuses on the reasons and the criticisms levelled at GPs with regard to diagnosing dementia, and identifies approaches to enable optimization. The analysis is based on 41 semi-structured interviews with GPs in Hesse, Germany, in 2018. During the course of a content analysis, the interviewees’ attitudes and behavioral patterns towards dementia diagnostics were to be analyzed. The results of the study show various challenges and problems of primary care in this field. The majority of the sample showed skepticism and reluctance with regard to the diagnosis of dementia. Six key problem areas were extracted from the interviews, which can be seen as root causes for the distance kept by GPs: 1) early delegation of patients due to role understanding, 2) attitude of pessimism towards dementia, 3) differential diagnosis perceived as an obstacle, 4) insufficient remuneration, 5) fear of patient stigmatization, and 6) lack of application. Some GPs demonstrated personal initiative with the aim of optimizing dementia diagnostics. Three approaches can be derived which could be used to improve the GP-based care of dementia: 1) self-efficacy, 2) differential diagnostics and treatment pathways, and 3) physician–patient communication.

[Expectations and attitudes concerning geriatric counseling : Results of a survey among general practitioners and hospital-based providers in two German states]

BACKGROUND

Expertise in geriatrics in the field of ambulatory and hospital-based treatment does not have access to comparable medical specialist structures, such as those in internal medicine and neurology; therefore, it is recommended that geriatric diagnostics by general practitioners can be supported by networking with hospital-based geriatric centers for geriatric counseling. The attitudes and experiences of both faculties in Germany are, however, not well known.

METHODS

Representative samples of general practitioners and hospital-based faculty departments for internal medicine in two regions of Germany (Baden-Württemberg and Hessen) were identified using a systematic selection method. All departments of geriatrics in these regions were also contacted. Participants were asked to give their attitudes and experiences regarding geriatric counseling using a questionnaire.

RESULTS

Responses to the questionnaire were received from 48 general practices (14.9%), 42 internal medicine departments (38.5%) and 25 hospital-based geriatric centers (34.7%). Of the general practices 79.2% reported performing geriatric assessments but only 31.3% had access to geriatric counseling. Of the faculties of internal medicine 71.4% reported providing geriatric counseling of which 16.7% also provided counseling on an outpatient basis. With respect to the spectrum of actual reasons for geriatric counseling, initiation of rehabilitative measures was the main reason in both geriatric and internal medicine departments. There were differences in the estimation of suitable rating topics for geriatric counseling. Geriatric departments more frequently indicated preventive aspects compared to general internal medicine (80% vs 47.6%) and general practices (56.3%). With respect to the domain level, general practitioners rated these in the order of cognition (72.9%), social situation (70.8%), emotion (50%), locomotion (50%) and incontinence (27.1%). Noteworthy was that they also rated much lower compared to hospital-based providers particularly with respect to locomotion and incontinence problems.

CONCLUSION

Geriatric assessment is widely used by general practitioners and there is generally a positive attitude to geriatric counseling and networking with hospital-based geriatric centers. At present, only a minority of general practitioners find local providers of geriatric counseling. Preventive aspects do not reach the same significance as rehabilitation topics and this discloses some potential for improvement. Differences in rating usefulness between the two groups may be explained by competing providers, e. g. specialists in these fields.

Self-Reported Questionnaire of Functional Health of Home-Dwelling Elderly People Living in Austria: Based on the Patient Questionnaire of the Standardized Assessment of Elderly People in Primary Care

Aim: The aim was to review the construct validity and reliability of a functional health assessment questionnaire (Questionnaire on Functional Health 2 [Q-FH2]). Methods: The Q-FH2 was used to assess 344 elderly people in a home setting. A polychoric correlation matrix was applied to conduct a principal axis factor analysis with oblique rotation. The number of factors was determined using various procedures and calculated using theta coefficients to estimate ordinal reliability. Results: The exploratory factor analysis supported a 4-factor solution with an explained total variance of 82%. The internal consistency showed θ coefficients ranging from 0.758 to 0.854. Conclusion: The Q-FH2 appears to be a useful instrument to assess the multidimensionality of functional health as defined by the International Classification of Functioning, Disability and Health to determine the resources and deficits regarding the independent living of older adults and to derive appropriate consulting measures.

[Use and acceptance of a basic geriatric assessment in primary care setting]

BACKGROUND

Aim of this study was to evaluate the acceptance and use of a basic geriatric assessment (BGA), as it is covered by the German pay system, in primary care practices.

METHODS

We conducted qualitative interviews and collected quantitative data by an online questionnaire.

RESULTS

A total of 17 (10 men) general practitioners (GPs) agreed to be interviewed; 161 patients (134 men) completed the online questionnaire. GPs mainly performed BGA to substantiate the suspicion of cognitive impairment. Most of the German general practices accomplished not more than 5-10 BGA per quarter. Although those GPs who conducted BGA were convinced of its usefulness with regard to further patient care, concrete interventions were rarely named. The tests used within the BGA were not always in line with recommendations from the specific guidelines. The main reasons not to conduct BGA were the amount of time required and the lack of therapeutic consequences.

CONCLUSION

Hitherto BGA is not an established tool in German primary care practices. The question, which single instruments are most suitable for older general practice patients, still needs clarification.

Potentially inappropriate medications in the elderly: the PRISCUS list

BACKGROUND

Certain drugs are classified as potentially inappropriate medications (PIM) for the elderly because they carry an increased risk of adverse drug events in this patient group. PIM lists from other countries are of limited usefulness in Germany because different drugs are on the market in each country and prescribing practices vary as well. Thus, a list of potentially inappropriate medications for the elderly was developed specifically for use in Germany.

METHODS

A preliminary PIM list suitable for the German market was created on the basis of a selective literature search and a qualitative analysis of published international PIM lists. The final German PIM list was developed by means of a comprehensive, structured expert survey in two rounds (a so-called Delphi process).

RESULTS

83 drugs in a total of 18 drug classes were rated as potentially inappropriate for elderly patients. For 46 drugs, the experts came to no clear decision after the second Delphi round. For cases in which the administration of a PIM is clinically necessary, the final PRISCUS list contains recommendations for clinical practice, e.g. monitoring of laboratory values and dose adaptation. Therapeutic alternatives are also listed.

CONCLUSION

Potentially inappropriate medications carry the risk of causing adverse drug events in the elderly. A drawback of using a Delphi process to generate a PIM list, as was done for the new German list, is that little scientific evidence is currently available for the evaluation of active substances, potential therapeutic alternatives, and indicated monitoring procedures. Thus, the validity and practicability of the PRISCUS list remain to be demonstrated (and the same holds for PIM lists already published in other countries). It should be used as a component of an overall concept for geriatric pharmacotherapy in which polypharmacy and interacting medications are avoided, and doses are regularly re-evaluated.

Geriatric assessment in general practice using a screening instrument: is it worth the effort? Results of a South Tyrol Study

BACKGROUND

geriatric assessment is a well-established instrument to improve the care of the elderly, but little is known about it in general practice although patients often are known for years.

METHODS

we used STEP-assessment, an instrument developed by European General Practitioners (GPs), which identifies only problems that can be improved; 37 questions had to be answered by the patient and 4 tests had to be done by the GP. Additionally in the study, GP and patient had to indicate separately which of the problems were seen as relevant and what both accepted to do for improvement. A year later, participating GPs were asked by a not-announced questionnaire to report on improvements and reasons for failure.

RESULTS

of the 220 eligible GPs, 45 enrolled a random sample of 894 patients (average age 77 years). In all 7.8 out of 32 possible problems per patient were found. Of those, 1.4 problems were not known to the GP. More than two-thirds of the 'new problems' are perceived as relevant by GP, patient or by both. GPs assessed medical problems and patients assessed social/psychological problems as more relevant. The length and quality of the relationship with the patient was reflected in the number of new problems, with fewer new problems in those well-known. A year later, GPs had offered treatment for 47% of the newly diagnosed problems, with a success-rate of 81%.

CONCLUSION

geriatric screening can detect unidentified problems in general practice. Once detected and dealt with, a high proportion of the undetected problems showed improvement. GPs focussed more on medical, while patients more on psychosocial issues. To increase the outcome of screening, it is necessary to discuss the relevance assessed by the patient.