Clinical variables influencing treatment decisions for agitated dementia patients: survey of physician judgments

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review

OBJECTIVES

To synthesise the existing published literature on general practitioners (GP)'s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions.

METHODS

We conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs' experiences of managing BPSD (PROSPERO protocol registration CRD42017054916). Seven electronic databases were searched from inception to October 2017. Each stage of the review process involved at least 2 authors working independently. The meta-ethnographic approach was used to synthesise the findings of the included studies while preserving the context of the primary data. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to assess the confidence in our individual review findings.

RESULTS

Of the 1638 articles identified, 76 full texts were reviewed and 11 were included. Three main concepts specific to GPs' experiences of managing BPSD emerged: unmet primary care resource needs, justification of antipsychotic prescribing, and the pivotal role of families. A "line of argument" was drawn, which described how in the context of resource limitations a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached.

CONCLUSION

This systematic review offers new insights into GPs' perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.

Cognitive Citizenship: Access to Hip Surgery for People with Dementia

Dementia and chronic hip disease are both more prevalent with advancing age. Given this, the number of people with both dementia and hip disease is likely to increase in an ageing population such as the UK. This article raises questions about how people with dementia and chronic hip disease are conceptualized in the context of evidence-based medicine, and whether this conceptualization may limit unfairly their access to surgical services. The published clinical research discourse at the interface of hip disease and dementia is taken as an ‘evidence-base’, and is evaluated in terms of its suitability for informing professional decisions about viability for surgery. The analysis suggests that the outcomes criteria used to determine patient viability serve to discriminate unfairly against people with dementia. If such discrimination exists, it necessarily militates against the promotion of health-related citizenship rights of the cognitively impaired, creating an evidence-based culture that encourages a problematic model of cognitive citizenship.

Identifying the components of clinical vignettes describing Alzheimer's disease or other dementias: a scoping review

Background

Clinical vignettes are often used to elicit information about health conditions in research studies. This review summarizes the components of clinical vignettes describing Alzheimer’s disease (AD) or other dementias. The purpose is to provide recommendations for the development of standardized vignettes that may be used in future studies.

Methods

MEDLINE, EMBASE, PsycINFO, ASSIA, CINAHL were searched from their inception to June 2014. Primary English-language studies employing vignettes to describe AD or similar disorders (including other dementias and Parkinson’s disease) were included in the review. Included studies had to describe the content of the vignettes in the published manuscripts. The characteristics of the included studies and the vignettes were extracted in tabular form and summarized qualitatively.

Results

Forty-two studies were included in the review. Twenty-four of the studies contained at least one AD vignette, 11 had vignettes focusing on non-AD dementias, and seven contained vignettes describing conditions other than dementia. In total, 58 vignettes were obtained from the 42 included studies.

Conclusions

Key aspects to consider when constructing vignettes for AD or other dementias include writing the vignettes from a third-person perspective and presenting hypothetical patients as being at least 65 years of age. Researchers should develop standardized vignettes for use across studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0179-x) contains supplementary material, which is available to authorized users.

Factors influencing veterinarian referral to oncology specialists for treatment of dogs with lymphoma and osteosarcoma in Ontario, Canada

OBJECTIVE

To elucidate factors influencing practitioner decisions to refer dogs with cancer to veterinary oncology specialists.

DESIGN

Cross-sectional study.

SAMPLE

2,724 Ontario primary care companion animal veterinarians.

PROCEDURES

Practitioners were invited to participate in a survey involving clinical scenarios of canine cancer patients, offered online and in paper format from October 2010 through January 2011. Analyses identified factors associated with the decision to refer patients to veterinary oncology specialists.

RESULTS

1,071 (39.3%) veterinarians responded, of which 603 (56.3%) recommended referral for dogs with multicentric lymphoma and appendicular osteosarcoma. Most (893/1,059 [84.3%]) practiced within < 2 hours' drive of a specialty referral center, and most (981/1,047 [93.7%]) were completely confident in the oncology service. Few (230/1,056 [21.8%] to 349/1,056 [33.0%]) were experienced with use of chemotherapeutics, whereas more (627/1,051 [59.7%]) were experienced with amputation. Referral was associated with practitioner perception of patient health status (OR, 1.54; 95% confidence interval [CI], 1.15 to 2.07), the interaction between the client's bond with the dog and the client's financial status, practitioner experience with treating cancer (OR, 2.79; 95% CI, 1.63 to 4.77), how worthwhile practitioners considered treatment to be (OR, 1.66 to 3.09; 95% CI, 1.08 to 4.72), and confidence in the referral center (OR, 2.20; 95% CI, 1. 11 to 4.34).

CONCLUSIONS AND CLINICAL RELEVANCE

Several factors influenced practitioner decisions to refer dogs with lymphoma or osteosarcoma for specialty care. Understanding factors that influence these decisions may enable practitioners to appraise their referral decisions and ensure they act in the best interests of patients, clients, and the veterinary profession.

Physicians' practice and familiarity with treatment for agitation associated with dementia in Israeli nursing homes

BACKGROUND

To clarify physicians' actual practice in treating agitation in the nursing home and to elucidate the relationship between background factors, familiarity with interventions, and practice.

METHODS

A survey of actual practice for agitation in persons with dementia was administered to 67 physicians aged 31-70+ working in nursing homes in Israel. Questionnaires were administered by personal interview, self-completed, or a combination of the two.

RESULTS

Psychotropic medications are prescribed by 92.5% of physicians for treating agitation, most notably, Haloperidol (39%). Non-pharmacological treatment was also reported to be common, though to a lesser extent, with environmental change being the most prevalent non-pharmacological intervention. Generally, physicians showed low familiarity levels with non-pharmacological interventions, with higher levels noted for physicians with a specialty in geriatrics compared to those who were non-specialized. Physicians who were non-Israeli and younger also reported higher familiarity levels compared to their respective counterparts (i.e. Israeli and older) but this difference did not reach significance.

CONCLUSION

The findings indicate that, despite current guidelines, psychotropic medications are the treatment of choice among nursing home physicians in Israel. While rates of use of non-pharmacological interventions are substantial, their in-practice application may be hindered by lack of familiarity as well as system barriers. The results have implications for system and education changes.

Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment

AIM

To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries.

METHOD

158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland.

FINDINGS

Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases.

CONCLUSIONS

The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care.

How to use clinical vignettes in hematology--a pilot survey in the context of chronic lymphocytic leukemia

RATIONALE

Case vignettes have been validated as an efficient tool for assessing the quality of clinical practices, and have been used in a variety of medical settings. However, their use in the field of hematology has not been tested.

OBJECTIVES

We undertook a study to pre-test seven case vignettes, and thereby to assess practice patterns and, when possible, guideline adherence in the treatment of chronic lymphocytic leukemia (CLL) by French hematologists.

FINDINGS

Of the 64 hematologists who agreed to participate, 26 (41%) completed the vignettes. We found significant differences in the physicians' patterns of ordering further investigations among young and old patients in the same clinical context. This is not consistent with published guidelines. Moreover, the most striking differences concerned the physicians' interpretations of prognostic factors and the use of radiological testing before treatment. Modalities of treatment were variable across clinical situations, especially with regard to second-line treatments. Clinicians understood the vignettes well, except for those that dealt with stem cell transplantation.

CONCLUSIONS

This pilot study showed the feasibility of the use of case vignettes to assess the quality of clinical practice in CLL. The initial results identified deviations from the published guidelines. A large-scale European survey will commence in a few months.

Memory impairment among primary care veterans

Memory impairment is the most frequent cognitive dysfunction for older patients. Though studies have shown that dementia is often overlooked in primary care settings, there has been minimal focus specifically on memory impairment, on patients' concerns about memory, or their desire to address these concerns. The objectives of this study were to (1) investigate the prevalence of memory impairment among patients without dementia diagnoses, (2) determine the degree of patients' concern about memory impairment and (3) identify other patient characteristics associated with memory impairment among older primary care patients. Using telephone versions of a four-item memory test and proxy-reported cognitive decline for patients unable to complete interviews, we performed memory assessment of randomly selected patients, 75 years and older, without dementia diagnoses who see primary care physicians at least twice every six months. Among 260 patients and 20 proxies, 19.8% had memory impairment at a level indicative of probable dementia. Adjusting for age, ethnicity, and education, subjects who were more concerned about memory impairment were more likely to be impaired. (Adjusted odds ratio [AOR]: 1.4 (for each additional level of concern); 95% confidence interval [CI]: (1.0-2.0)). Similarly, subjects wanting their physician to discuss with them their memory concerns were more likely to be impaired (AOR: 1.4; 95% CI: 1.0-1.9). Memory impairment is common among older primary care patients without diagnosed dementia. Knowing patients' concerns about memory impairment and their desire to discuss these concerns may facilitate cognitive screening in this setting.

Développement et application d’une vignette clinique pour apprécier la qualité des soins en oncology

BACKGROUND

In conjunction with a study focusing on the implementation and effect of an integrated care network for cancer patients in the Monteregie region in Quebec, the vignette research strategy was adopted to assess the quality of care provided by the interdisciplinary teams working with this clientele. This research strategy has only recently been used to assess professional practices. This article adopts a resolutely methodological angle in order to describe a rigorous, innovative, transferable experience from the standpoint of the elaboration of a vignette.

METHODS

We adopted a six-step approach to elaborate the vignette. This vignette includes the description of collaboration with clinicians. The approach assured us of attaining high content validity from the standpoint of facets of its relevance, completeness and intelligibility to respondents. Our clinical vignette describes a sequence of events stemming from the care coordination of a 58-year-old man suffering from rectal cancer. Data were collected through group interviews with the interdisciplinary teams (n=5) under study. The professionals present were asked to describe their usual practices with respect to the events described in the vignette. We adopted two data analysis strategies: (i) a comparison of practices revealed through the interviews with anticipated responses in light of the guidelines of the "Programme québécois de lutte contre le cancer"; and (ii) an analysis according to facets of the quality of care.

RESULTS

Team professional practices seem to evolve towards the care package valued by the "Programme québécois de lutte contre le cancer". Differences were also observed between the teams from the standpoint of the continuity of care.

CONCLUSION

Our study shows that it is possible to develop a vignette that enables us to understand professional practices in an interdisciplinary context provided that a rigorous approach is adopted. This approach, which can be transferred to the study of similar phenomena, makes it possible to document the care offered and contribute to the renewal of professional practices.

Anesthesiologists' practice patterns for treatment of postoperative nausea and vomiting in the ambulatory Post Anesthesia Care Unit

Background

When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV). Only until recently have there been any published recommendations, mostly derived from expert opinion, as to which regimens to use once a patient develops PONV. The goal of this study was to assess the responses to a written survey to address the following questions: 1) If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment of PONV in the ambulatory Post-Anesthesia Care Unit (PACU)?; 2) Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3) If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment?

Methods

A questionnaire with five short hypothetical clinical vignettes was mailed to 300 randomly selected USA anesthesiologists. The types of pharmacological and nonpharmacological interventions for PONV treatment were analyzed.

Results

The questionnaire was completed by 106 anesthesiologists (38% response rate), who reported that on average 52% of their practice was ambulatory. If a patient develops PONV and received no prophylaxis, 67% (95% CI, 62% – 79%) of anesthesiologists reported they would administer a 5-HT3-antagonist as first choice for treatment, with metoclopramide and dexamethasone being the next two most common choices. 65% (95% CI, 55% – 74%) of anesthesiologists reported they would also use non-pharmacologic interventions to treat PONV in the PACU, with an IV fluid bolus or nasal cannula oxygen being the most common. When PONV prophylaxis was given during the anesthetic, the preferred PONV treatment choice changed. Whereas 3%–7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% (95% confidence intervals, 18% – 36%) of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.

Conclusion

5-HT3-antagonists are the most common choice for treatment of established PONV for outpatients when no prophylaxis is used, and also following prophylactic regimens that include a 5HT3 antagonist, regardless of the number of prophylactic antiemetics given. Whereas 3% – 7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.

Wisdom From the Front Lines: Clinicians’ Descriptions of Treating Agitation in the Nursing Home, A Pilot Study

The management of behavior problems is one of the most difficult challenges a clinician must face when treating patients with dementia. This article presents a qualitative analysis of the responses of 7 nursing home physicians and 1 nurse practitioner to open-ended questions regarding their experiences in treating behavior problems in dementia with an emphasis on nonpharmalogical methods. This study serves to highlight both the issues encountered by those commonly asked to treat behavior problems in the nursing home, and the thoughtfulness and insight developed by some clinicians to address the problems. Several themes emerged from clinicians' responses. Some of the clinicians developed algorithms for treating behavior problems. Some of the clinicians were frustrated with the expectation that behavior problems would be effectively treated pharmacologically. The treatment of behavior problems was described as complex and requiring more time than is allocated by reimbursement systems. They also expressed the need for multiple systemic changes in order to improve treatment, and provided many examples of inadequate resources, including reimbursement, staff, activities, staff training, and management issues needed to improve treatment of behavior problems in nursing home residents. On the positive side, they reported a high level of satisfaction when treating behavior nonpharmacologically. The clinicians felt that with appropriate systemic change many behavior problems can be either prevented or treated effectively by nonpharmacological means.

Medical decision making: a selective review for child psychiatrists and psychologists

Physicians, including child and adolescent psychiatrists, show variability and inaccuracies in diagnosis and treatment of their patients and do not routinely implement evidenced-based medical and psychiatric treatments in the community. We believe that it is necessary to characterize the decision-making processes of child and adolescent psychiatrists using theories and methods from cognitive and social sciences in order to design effective interventions to improve practice and education. This paper selectively reviews the decision-making literature, including recent studies on naturalistic decision making, novice-expert differences, and the role of technology on decision making and cognition. We also provide examples from other areas of medicine and discuss their implications for child psychiatry.

The impact of medical issues in inpatient geriatric psychiatry

At an advanced age, serious medical and psychiatric illnesses frequently coalesce. Often, the need for admission to inpatient geriatric psychiatric care arises from coexisting medical problems. While cognitive and behavioral interventions are important, the complexity of physical comorbidities usually becomes the focus of hospitalization and requires intensive medical treatments. This paper describes adaptations made in one metropolitan geriatric psychiatry unit in order to better treat complex patients who experience both medical and psychiatric illness. The need for all members of the interdisciplinary team to expand their practice and the importance of complementary approaches of psychiatry and medicine are emphasized.

How do NPs make clinical decisions?

The authors conducted a study to explore the process primary care NPs use in making clinical decisions and the factors that influence the process. By delineating the process used by primary care NPs in therapeutic decision making, we can enhance clinical decision making in students and practicing NPs.

Variation in practice patterns of anesthesiologists in California for prophylaxis of postoperative nausea and vomiting

STUDY OBJECTIVE

To assess the responses to a survey asking anesthesiologists to report their clinical practice patterns for postoperative nausea and vomiting (PONV) prophylaxis. These practice patterns data may be useful for understanding how to optimize the decision to provide PONV prophylaxis.

DESIGN

A written questionnaire with three detailed clinical scenarios with differing levels of a priori risk of PONV (a low-risk patient, a medium-risk patient, and a high-risk patient) was mailed to 454 anesthesiologists.

SETTING

Survey was completed by anesthesiologists (n = 240) in 3 university and 3 community practices in California.

MEASUREMENTS

Type and number of pharmacological and nonpharmacological interventions for PONV prophylaxis were recorded. To assess the variability in the responses (by the a priori risk of patient), we counted the number of different regimens that would be necessary to account for 80% of the responses.

MAIN RESULTS

For the 240 respondents, we found that 1, 9, and 11 different pharmacological prophylaxis regimens were required to account for 80% of the variability in practice patterns for the low-, medium-, and high-risk patients, respectively. For the low-risk patient, 19% of practitioners would use pharmacological prophylaxis, and 37% would use nonpharmacological prophylaxis. For the medium-risk patient, 61% would use nonpharmacological prophylaxis and 67% of practitioners would use multidrug prophylaxis: 45% of patients would receive a 5HT(3) antagonist, 35% would receive metoclopramide, and 16% would receive droperidol. For the high-risk patient, 94% of practitioners would administer a 5HT(3) antagonist, whereas 84% would use multi-drug prophylaxis.

CONCLUSIONS

We found a wide range of PONV prophylaxis management patterns. This variation in clinical practice may reflect uncertainty about the efficacy of available interventions, or differences in practitioners' clinical judgment and beliefs about how to treat PONV. Some therapies with proven benefit for PONV may be underused. Our results may be useful for designing studies aimed at determining the impact on PONV rates when physicians develop and implement guidelines for PONV prophylaxis.

Neuroleptic drug use in long‐term care: An inappropriate panacea?

Despite the increasing evidence about the inappropriate use of medications by older people, there is very little published evidence about the control and monitoring of neuroleptic drugs used in nursing homes. As others have indicated, this is all the more worrying when set in the context of the paucity of research on nursing home care and the trend to replace registered nurses with untrained care assistants. In the United States, legislation in the form of the Nursing Home Reform Act (OBRA 1987) was introduced, in part, to regulate the prescribing and administration of neuroleptic (antipsychotic) drugs. No such legislation exists in Canada or the United Kingdom. In the case of the latter jurisdiction, the recent Royal Commission on Long‐Term Care for older people (The Stationery Office, 1999) has recommended a national care commission to monitor care, and set assessment and quality benchmarks. In Canada this debate has not even begun, and the purpose of this paper is not to ignite controversy, but to raise questions about the use of these drugs with nursing home residents. Voluntary guidelines and education of physicians, nurses and care attendants would be infinitely better than legislation. In the meantime, we need research to address the following questions: For what reasons should these drugs be given to older people? Are these drugs being used appropriately? Is the risk of side‐effects too great with these drugs? Are the numbers and type of staff employed in nursing homes adequate/qualified to detect and report side‐effects? How well do these drugs manage the behaviours they are given to control? Are they being used as chemical restraints or to make the older person compliant? Are the so‐called ‘atypical’ neuroleptic drugs any better? What we offer in this article is background information that might encourage others to not only review their practice but also to address these questions.

Impact of medical and nonmedical factors on physician decision making for HIV/AIDS antiretroviral treatment

To examine influences of medical factors (e.g., viral load) and nonmedical factors (e.g., patient characteristics) on treatment decisions for highly active antiretroviral therapy (HAART), we sent a survey to a random sample of 995 infectious disease physicians who treat patients with HIV/AIDS in the United States in August, 1998. The response rate was 53%. Respondents were asked to report their current practices with respect to antiretroviral treatment and the extent to which each of three medical and 17 nonmedical factors would influence them for or against prescribing HAART to a hypothetical HIV-positive patient. Most reported initiating HAART with findings of low CD4+ cell counts and high viral loads, and weighing CD4+ cell counts, viral load, and opportunistic infection heavily in their decisions to prescribe HAART. Patients' prior history of poor adherence was weighed very much against initiating HAART. Patient homelessness, heavy alcohol use, injection drug use, and prior psychiatric hospitalization were cited by most physicians as weighing against HAART initiation. Thus, most physicians in this sample follow guidelines for the use of HAART, and nonmedical factors related to patients' life situations are weighed as heavily as disease severity in treatment decisions. As HIV increasingly becomes a disease associated with economic disadvantage and other social health problems, it will be essential to develop interventions and care support systems to enable patients experiencing these problems to benefit from HIV treatment advances.

Primary care physician responses to a panic disorder vignette: diagnostic suspicion and clinical management

Objective:

To study current patterns of panic disorder (PD) recognition and management by primary care physicians (PCPs).

Method:

We administered a vignette describing a female PD patient to 189 PCPs.

Results:

Three-quarters of respondents believed that PD was at least 50 percent probable, and the mean PD likelihood rating was 63 percent. Diagnostic suspicion was significantly higher for PD than for other anxiety disorders, major depressive disorder, and cardiac disorders. Medication was rated as significantly more necessary than medical testing and mental health referral. A benzodiazepine was suggested by 78 percent of respondents, while 35 percent suggested a serotonin reuptake inhibitor (SRI). Under half rated the patient as requiring medical testing, mostly for hyperthyroidism (70%) and/or cardiovascular disorder (62%), and half felt that the patient required mental health referral.

Conclusions:

The data suggest that most PCPs are able to recognize PD. However, they may be excessively inclined to prescribe benzodiazepines rather than more appropriate medications.

Clinical predictors of aggressive behaviour in Alzheimer's disease

OBJECTIVES

To examine the level and clinical correlates of aggressive behaviour in Alzheimer's disease (AD).

METHOD

Seventy patients with probable AD were rated using validated assessment instruments including the Rating Scale for Aggressive Behaviour in the Elderly (RAGE).

RESULTS

Thirty-one subjects were rated as at least mildly aggressive during the 3-day period prior to assessment. RAGE scores correlated significantly with delusions and activity disturbance scores. Aggressive behaviour was not associated with age, sex, dementia severity, hallucinations or depression.

CONCLUSIONS

Aggressive behaviour occurs frequently in patients with AD. Our results confirm the findings of previous studies that the presence of delusions increases the risk of aggression in this population.