Deprescribing of antidepressants: development of indicators of high-risk and overprescribing using the RAND/UCLA Appropriateness Method.

BACKGROUND: Antidepressants are first-line medications for many psychiatric disorders. However, their widespread long-term use in some indications (e.g., mild depression and insomnia) is concerning. Particularly in older adults with comorbidities and polypharmacy, who are more susceptible to adverse drug reactions, the risks and benefits of treatment should be regularly reviewed. The aim of this consensus process was to identify explicit criteria of potentially inappropriate antidepressant use (indicators) in order to support primary care clinicians in identifying situations, where deprescribing of antidepressants should be considered. METHODS: We used the RAND/UCLA Appropriateness Method to identify the indicators of high-risk and overprescribing of antidepressants. We combined a structured literature review with a 3-round expert panel, with results discussed in moderated meetings in between rounds. Each of the 282 candidate indicators was scored on a 9-point Likert scale representing the necessity of a critical review of antidepressant continuation (1-3 = not necessary; 4-6 = uncertain; 7-9 = clearly necessary). Experts rated the indicators for the necessity of review, since decisions to deprescribe require considerations of patient risk/benefit balance and preferences. Indicators with a median necessity rating of ≥ 7 without disagreement after 3 rating rounds were accepted. RESULTS: The expert panel comprised 2 general practitioners, 2 clinical pharmacologists, 1 gerontopsychiatrist, 2 psychiatrists, and 3 internists/geriatricians (total N = 10). After 3 assessment rounds, there was consensus for 37 indicators of high-risk and 25 indicators of overprescribing, where critical reviews were felt to be necessary. High-risk prescribing indicators included settings posing risks of drug-drug, drug-disease, and drug-age interactions or the occurrence of adverse drug reactions. Indicators with the highest ratings included those suggesting the possibility of cardiovascular risks (QTc prolongation), delirium, gastrointestinal bleeding, and liver injury in specific patient subgroups with additional risk factors. Overprescribing indicators target patients with long treatment durations for depression, anxiety, and insomnia as well as high doses for pain and insomnia. CONCLUSIONS: Explicit indicators of antidepressant high-risk and overprescribing may be used directly by patients and health care providers, and integrated within clinical decision support tools, in order to improve the overall risk/benefit balance of this commonly prescribed class of prescription drugs.

[Tiredness/Fatigue-S3 guideline update]. / Müdigkeit ­ Update der S3-Leitlinie.

Background: Fatigue is one of the most common reasons for seeking medical counseling in the family medicine (FM), often entailing diagnostic uncertainty. Patients use terms describing emotional, cognitive, physical, and behavioral aspects. A number of biological, mental, and social causes may underlie the symptom of fatigue, often in combination. This guideline describes the procedures to be applied for primary undetermined symptomatology. Methods: The experts involved conducted a systematic search using the terms for fatigue in the context of FM in PubMed, Cochrane Library and via manual search. Concerning related guidelines, the National Institute for Health and Care Excellence (NICE) guideline was used for myalgic encephalitis/chronic fatigue syndrome (ME/CFS). In a structured consensus process, broad approval of the core recommendations/background text of the revised guideline was attained. Most important messages: 1) Alongside gathering information concerning the symptom characteristics, the anamnesis aims to collect information about pre-existing health conditions, sleeping behavior, use of drugs and psychosocial factors. 2) Depression and anxiety as two common causes will be identified based on screening questions. The occurrence of post-exertional malaise (PEM) will be inquired. 3) The following basic diagnostics are recommended: physical examination, laboratory tests (blood glucose, full blood count, blood sedimentation/CRP, transaminases/γ-GT, TSH). 4) Further examinations should be conducted only in case of specific indications. 5) A biopsychosocial approach is to be adopted. 6) Behavioral therapy and symptom-oriented activating measures can improve fatigue in underlying diseases and undetermined fatigue. 7) In case of PEM, further ME/CFS criteria should be collected and patients have to be supervised accordingly.

[Examining in General Practice: Licensure Examinations in a General Practice Setting]. / Prüfen in der Allgemeinmedizin ­ Staatsexamina im ambulanten hausärztlichen Setting.

General practitioners play a major role in the health care of the population. Only a small proportion of patients receives care from specialised consultants, in a hospital or in a university hospital. Most of the patients consult a general practitioner. The strengthening of general practice that is called for in the Master Plan for Medical Studies 2020 in new state examination formats, for instance, means that this central position in patient care will be reflected in studies and examinations in the future. The general medical setting is subject to a specific background with unselected patients and a hermeneutic understanding of cases. The format of the new final examination promotes general medical and interdisciplinary competencies in medical interviewing, physical examination, dealing with diseases that can be treated on an outpatient basis, prevention, and the application of general medical guidelines of ethics and law. The standardised oral-practical examination has newly been designed by the Institute for Medical and Pharmaceutical Examination Questions (IMPP). It includes real patients in an outpatient setting. In eight steps, it integrates communicative and technical examination aspects. Two trained examiners will observe and assess the performance of graduates using standardised evaluation forms. The new examination format was developed in 2019 by the IMPP and faculty from various medical schools, was tested in five general medical teaching practices, revised, and then piloted in fourteen examinations. Standardised specifications for the examination process, spatial equipment, and examiner training were developed by IMPP. With approximately 10,000 examinees per year and two students per examination day, a total of 5,000 examination days will be required in general practices. The expertise of the German College of General Practicioners and Family Physicians (DEGAM), the Society of University Teachers of General Medicine (GHA), and the university locations, together with the great potential as the largest specialist group in Germany suggest that the goal of recruiting and motivation of practices appears achievable. With regard to funding, political decisions are necessary. In an increasingly complex care system, the redesign of the oral-practical examination in the outpatient setting contributes to strengthening interdisciplinary and multi-professional cooperation.

Fatigue as the Chief Complaint­Epidemiology, Causes, Diagnosis, and Treatment.

BACKGROUND: Fatigue is a main or secondary reason for 10-20% of all consultations with a primary care physician. METHODS: This review is based on pertinent publications retrieved by a comprehensive, selective literature search on the epidemiology, etiology, and diagnostic evaluation of fatigue as a leading symptom of disease, as well as on the treatment of its common causes. Information was also included from the literature search we conducted for the German clinical practice guideline on fatigue that was issued by the German College of General Practitioners and Family Physicians (Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, DEGAM). RESULTS: Fatigue can be due to any of a broad spectrum of diseases, including decompensation of already known conditions. Sleep disorders and sleep-related disorders of breathing, depression (18.5%), and excessive psychosocial stress are the most common causes of persistent fatigue. Previously undiagnosed cancer is a rare cause, accounting for only 0.6% of cases (95% confidence interval [0.3; 1.3]). Anemia and other organic causes are rare as well (4.3% [2.7; 6.7]). Investigations beyond the history, physical examination, and simple laboratory tests are needed only in the presence of additional symptoms or findings. If the diagnosis remains unclear, watchful waiting and regularly scheduled follow-up help prevent an excessive focus on somatic causes, leading to overdiagnosis. Irrespective of specific causes, psychoeducative and psychotherapeutic approaches should be discussed with the patient, as well as an individually adapted exercise program. CONCLUSION: The work-up of fatigue as a chief complaint should be guided by investigating common and/or potentially dangerous disorders. Since the latter are rare, an exclusively somatic focus should be avoided in order to prevent overdiagnosis.

Perimenopause and Postmenopause - Diagnosis and Interventions. Guideline of the DGGG and OEGGG (S3-Level, AWMF Registry Number 015-062, September 2020).

Aim The aim of the interdisciplinary S3-guideline Perimenopause and Postmenopause - Diagnosis and Interventions is to provide help to physicians as they inform women about the physiological changes which occur at this stage of life and the treatment options. The guideline should serve as a basis for decisions taken during routine medical care. This short version lists the statements and recommendations given in the long version of the guideline together with the evidence levels, the level of recommendation, and the strength of consensus. Methods The statements and recommendations are largely based on methodologically high-quality publications. The literature was evaluated by experts and mandate holders using evidence-based medicine (EbM) criteria. The search for evidence was carried out by the Essen Research Institute for Medical Management (EsFoMed). To some extent, this guideline also draws on an evaluation of the evidence used in the NICE guideline on Menopause and the S3-guidelines of the AWMF and has adapted parts of these guidelines. Recommendations Recommendations are given for the following subjects: diagnosis and therapeutic interventions for perimenopausal and postmenopausal women, urogynecology, cardiovascular disease, osteoporosis, dementia, depression, mood swings, hormone therapy and cancer risk, as well as primary ovarian insufficiency.

Didactic qualification of teaching staff in primary care medicine - a position paper of the Primary Care Committee of the Society for Medical Education.

Having teaching staff with didactic qualifications in university teaching leads to a measurable improvement in academic skills among students. Previous recommendations on the type and scope of medical didactic qualification measures primarily apply to teaching staff at university and in-patient settings. The situation of primary care medicine, which often employs external lecturers and whose teaching takes place to a considerable extent in decentralized training facilities (teaching practices) is not adequately addressed. Taking into account a survey on the status quo at higher education institutions for General Practice in Germany, recommendations for minimum standards are made, based on national and international recommendations on the content and scope of medical didactic qualification measures. These recommendations include preliminary work by the Personnel and Organizational Development in Teaching (POiL) Committee of the Society for Medical Education (GMA), the MedicalTeachingNetwork (MDN), the Society of University Teaching Staff in General Medicine (GHA) as well as the experiences of the committee members, who hail from the field of general medicine, internal medicine and pediatrics amongst others.

Prescription of Benzodiazepines and Related Drugs in Patients with Mild Cognitive Deficits and Alzheimer's Disease.

INTRODUCTION: Benzodiazepines and related drugs (BZDR) should be avoided in patients with cognitive impairment. We evaluated the relationship between a BZDR treatment and the health status of patients with Alzheimer's disease (AD). METHODS: Cross-sectional study in 395 AD patients using bivariate and multiple logistic analyses to assess correlations between the prescription of BZDR and patients' characteristics (cognitive and functional capacity, health-related quality of life (HrQoL), neuropsychiatric symptoms). RESULTS: BZDR were used in 12.4% (n=49) of all participants. In bivariate analyses, the prescription was associated with a lower HrQoL, a higher need of care, and the presence of anxiety. Multivariate models revealed a higher risk of BZDR treatment in patients with depression (OR 3.85, 95% CI: 1.45 - 10.27). Community-dwelling participants and those treated by neurologists/psychiatrists had a lower risk of receiving BZDR (OR 0.33, 95% CI: 0.12 - 0.89 and OR 0.16, 95% CI: 0.07 - 0.36). DISCUSSION: The inappropriate use of BZDR conflicts with national and international guidelines. We suggest evaluating indications and treatment duration and improving the knowledge of alternative therapies in healthcare institutions.

Antidepressant medication in a German cohort of patients with Alzheimer's disease
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OBJECTIVE: The use of antidepressant drugs in dementia patients is associated with the risk of adverse events, and the evidence for relevant effects is scarce. We aimed to determine the associations between the prescription of antidepressants and patients' sociodemographic (e.g., age, gender, living situation) and clinical characteristics (e.g., disease severity, neuropsychiatric symptoms). MATERIALS AND METHODS: We included 395 institutionalized and community-dwelling patients with Alzheimer's disease (AD) across all severity stages of dementia in a cross-sectional study design. The patients' clinical characteristics comprised of cognitive status, daily activities, depressive symptoms, further neuropsychiatric symptoms, and health-related quality of life (HrQoL). We conducted multiple logistic regression analyses for the association between the use of antidepressant drugs and the covariates. RESULTS: Approximately 31% of the participants were treated with antidepressant drugs, with a higher chance of being medicated for institutionalized patients (χ2-test: p = 0.010). In the bivariate analyses, the use of antidepressants was significantly associated with higher levels of care, lower cognitive and daily life capacity, higher extent of neuropsychiatric symptoms, and a lower proxy-reported HrQoL. Finally, multiple logistic regression models showed a significantly higher use of antidepressants in patients treated by psychiatrists and neurologists (OR 2.852, 95% CI: 1.223 - 6.652). CONCLUSION: The use of antidepressant drugs in the study population was high, and the suitability of the treatment with antidepressants remains unclear. Participants with diminished cognitive and functional capacity, higher extent of neuropsychiatric symptoms, and those treated by neuropsychiatric specialists were more likely to be treated with antidepressants. The pharmaceutical treatment of patients with these clinical characteristics should be particularly considered in the daily care for dementia patients. Further longitudinal studies should evaluate the appropriateness of indications for antidepressants and the causative direction of correlations with the patients' clinical characteristics.
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[Differences Between Self- and Proxy-Assessment of Health-Related Quality of Life in Patients with Mild Cognitive Impairment and Alzheimer's Disease]. / Unterschiede in der Selbst- und Fremdbeurteilung gesundheitsbezogener Lebensqualität bei Patienten mit leichter kognitiver Beeinträchtigung und Demenz vom Alzheimer-Typ.

OBJECTIVE: The self-assessment of health-related quality of life (HrQoL) in patients with Alzheimer's disease (AD) and mild cognitive impairment is commonly higher than the proxy-assessment by caregivers. This study aims at evaluating sociodemographic and clinical factors to explain this difference. METHODS: HrQoL of 241 community-dwelling patients was analysed using the dementia-specific Quality of Life-Alzheimer's Disease questionnaire (QoL-AD). Behavioural and psychological symptoms and functional capacity were evaluated using the Geriatric Depression Scale (GDS), the Neuropsychiatric Inventory (NPI) and the Alzheimer's Disease Cooperative Study-Activities of Daily Living scale (ADCS-ADL). RESULTS: The self-assessment of patients' HrQoL was significantly higher than the caregiver-ratings (mean difference: 7.4 ±â€Š5.6, p < 0.001). Considerable influencing factors were the extent of depressive symptoms (GDS), the degree of impairment in functional performance (ADCS-ADL) and the relationship between patients and caregivers. CONCLUSION: Independent variables explained 23 % of the variance in the difference between self- and proxy-assessment of HrQoL. Future studies should include further influencing factors such as caregivers' mental health.

Antipsychotic treatment of community-dwelling and institutionalised patients with dementia in Germany.

OBJECTIVE: A restrictive use of antipsychotic drugs in patients with Alzheimer's disease (AD) is recommended due to an increased risk of cerebrovascular events and mortality. We hypothesise that the prescription of antipsychotics is associated with the patients' socio-demographic and clinical status (e.g., dementia severity). METHODS: The prescription of antipsychotics was cross-sectionally evaluated in 272 community-dwelling and 123 institutionalised patients with AD across all severity stages of dementia. The patients' clinical characteristics covered the cognitive status, neuropsychiatric symptoms, daily activities, and quality of life (HrQoL). To determine associations with the use of antipsychotics bivariate and logistic regression analyses were conducted. RESULTS: Totally, 25% of the patients were treated with antipsychotics. significantly less frequently than nursing home inhabitants (15.1% vs. 45.5%). Severely demented patients (MMSE 0-9) received antipsychotics most often (51.5%). Additionally, multiple regression analyses revealed a higher chance of prescription for participants with depressive symptoms (OR 2.3, 95% CI: 1.019-5.160) and those treated by neuropsychiatric specialists (OR 3.4, 95% CI: 1.408-8.328). CONCLUSIONS: Further longitudinal studies are required to assess the appropriateness of indications for antipsychotics and the reasons for a higher use in nursing home inhabitants and patients with severe dementia and depression.

Use of antidementia drugs in German patients with Alzheimer's disease.

The objective of this study was to evaluate the use of antidementia drugs (ADDs) in patients with Alzheimer's disease (AD) regarding German guideline recommendations and to assess correlations between the use of ADDs and the patients' characteristics. A total of 395 community-dwelling and institutionalized patients with AD across all severity stages of dementia were recruited in this cross-sectional study. Associations between the prescription of ADDs and patients' sociodemographic and clinical parameters (neuropsychiatric symptoms, cognitive capacity, daily activities, and health-related quality of life) were analyzed in multiple logistic regression analyses. ADDs were prescribed in 46.6% of all participants and less often in institutionalized patients (38.2 vs. 50.4%, P=0.025). Patients with mild-to-moderate dementia had a higher chance of receiving ADDs [odds ratio (OR)=3.752, 95% confidence interval (CI): 1.166-12.080 and OR=3.526, 95% CI: 1.431-8.688] as well as those treated by neurologists/psychiatrists (OR=2.467, 95% CI: 1.288-4.726). Overall, 39% of the patients with mild cognitive deficits (Mini-Mental Status Examination 27-30) received ADDs and 21% of the mildly demented patients (Mini-Mental Status Examination 20-26) received memantine. The treatment with ADDs was in part not in line with German guideline recommendations. Particularly, the lower use of ADDs in patients not attending neuropsychiatric specialists should be further evaluated.

Seminar program for postgraduate specialty training in general practice: proposal for a 5-year thematic catalogue.

Introduction: In different German regions, seminar programs have been conducted for General practice residents. In each region, selection and teaching of learning content is conducted in a different manner. So far, no structured, standardized curriculum has been implemented nationwide. We have investigated, if the development of a common 5-year program of learning topics is conceivable between the different university departments of General practice in Germany. Method: The seminar program working group of the DEGAM (German College of General Practitioners and Family Physicians) has conducted an online survey based on information gathered via preliminary telephone conference (n=7; physicians with postgraduate teaching experience) among all German university departments of General Practice and two non-university teaching institutions, identified via the internet. 884 topics were extracted from 14 Seminar programs. The topics were entered in a database, discussed and categorized: Practice management/practice work flow/standardized documentation forms/quality management (n=33 topics), common acute and chronic diseases, including disease management programs (n=29 topics), communication, neurological, psychological and psychiatric consultations (n=24 topics), common medical problems, including eye, ear, nose, throat, skin and pediatric problems (n=99 Topics) family physicians general approach, including epidemiology, shared decision making, test of time (n=42 Topics). These topics have been rated for priority and desirable number of teaching-units. Results: A catalogue of 111 topics was designed, encompassing 160 teaching units. There is a suggestion of wide topics collections plus an add-on catalogue. Conclusion: A proposal for a 5-year-thematic catalogue for postgraduate training of general practice residents in Germany has been developed. This newly developed curriculum has the potential to improve knowledge and skills that have not been covered during in-house and ambulatory general practice residencies.

Psychological risk and protective factors for disability in chronic low back pain - a longitudinal analysis in primary care.

BACKGROUND: Utilizing psychological resources when dealing with chronic low back pain might aid the prevention of disability. The observational study at hand examined the longitudinal impact of resilience and coping resources on disability in addition to established risk factors. METHODS: Four hundred eighty four patients with chronic low back pain (>3 months) were recruited in primary care practices and followed up for one year. Resilience, coping, depression, somatization, pain and demographic variables were measured at baseline. At follow-up (participation rate 89%), data on disability was collected. We first calculated bivariate correlations of all the predictors with each other and with follow-up disability. We then used a multiple regression to evaluate the impact of all the predictors on disability together. RESULTS: More than half of the followed up sample showed a high degree of disability at baseline (53.7%) and had suffered for more than 10 years from pain (50.4%). Besides gender all of the predictors were bivariately associated with follow-up disability. However in the main analysis (multiple regression), disability at follow up was only predicted by baseline disability, age and somatization. There was no relationship between resilience and disability, nor between coping resources and disability. CONCLUSIONS: Although it is known that there are cross-sectional relationships between resilience/coping resources and disability we were not able to replicate it in the multiple regression. This can have several reasons: a) the majority of patients in our sample were much more disabled and suffered for a longer time than in other studies. Therefore our results might be limited to this specific population and resilience and coping resources might still have a protective influence in acute or subacute populations. b) We used a rather broad operationalization of resilience. There is emerging evidence that focusing on more concrete sub facets like (pain) self-efficacy and acceptance might be more beneficial. TRIAL REGISTRATION: German Clinical Trial Register, DRKS00003123 (June 28th 2011).

The differential diagnosis of tiredness: a systematic review.

BACKGROUND: Tiredness is one of the most frequent complaints in primary care. Although often self-limiting and frequently associated with psychosocial stress, patients but also their physicians are often uncertain regarding a serious cause and appropriate diagnostic work-up. We conducted a systematic review and meta-analysis of studies reporting on differential diagnosis of fatigue in primary care. METHODS: MEDLINE, EMBASE and conference abstracts were searched for primary care based studies of patients presenting with tiredness. Twenty-six studies were included. We report on anaemia, malignancy, serious organic disease, depression and the chronic fatigue syndrome (CFS) as causes of tiredness as presenting complaint. RESULTS: We found considerable heterogeneity of estimates which was reduced by limiting our analysis to high quality studies. Prevalences were as follows-anaemia: 2.8 % (CI (confidence interval) 1.6-4.8 %); malignancy: 0.6 % (CI 0.3-1.3 %); serious somatic disease: 4.3 % (CI 2.7-6.7 %); depression 18.5 % (CI 16.2-21.0 %). Pooling was not appropriate for CFS. In studies with control groups of patients without the symptom of tiredness, prevalence of somatic disease was identical to those complaining of tiredness. Depression, however, was more frequent among those with tiredness. CONCLUSIONS: Serious somatic disease is rare in patients complaining of tiredness. Since prevalence is similar in patients without tiredness, the association may not be causal. Extensive investigations are only warranted in case of specific findings from the history or clinical examination. Instead, attention should focus on depression and psychosocial problems.

Feedback promotes learning success! Which kind of feedback for the faculty is given by an interdisciplinary OSCE with focus on decision-making?

Clinical skills such as history taking, diagnostic reasoning, therapy planning, and giving advice are even more complex than practical skills like lung auscultation and have to be applied in complex clinical situations. We judged this competence in an interdisciplinary formative OSCE conducted with students of Marburg University. Results of 218 students passing 643 OSCE stations composed of 37 different scenarios were analyzed. As a competence based examination that reflects the practical skills gained during clinical training, the here presented analysis serves also as a feedback instrument for clinical teachers, their respective disciplines and the medical faculty as a whole.

Influence of thyroid hormone therapy on the fracture rate - A claims data cohort study.

INTRODUCTION: It has been debated for years whether long-term thyroid hormone intake causes fractures. Not only have previous studies suffered from design limitations, they also reached contradictory conclusions. We investigated thyroid hormones (thyroxine) as a possible risk factor for fractures in a cohort of 6.7 million persons based on administrative data. METHODS: The database consists of anonymized settlement data of approximately 70 German statutory health insurances covering a time period of six years. All subjects aged 60 and above were included in the study; subjects with repeated thyroxine prescriptions were assigned to the exposure group; members without thyroxine prescriptions to the control group. Outcome was any incident fracture during a declared time period. In order to calculate fracture risk, we performed multivariate cox regression analyses to adjust for confounders. RESULTS: Of 798 770 subjects fulfilling the inclusion criteria, 11.7% took thyroxine regularly and belong to the exposure group. The final cox regression showed that subjects taking thyroxine have a 6.3% higher risk (HR 1.063; CI 1.046-1.080, p=<.0001) than members of the control group. DISCUSSION: The study supports the assumption that long term thyroxine intake leads to an increase in fracture risk among patients older than 60years. The findings have implications for long term thyroxine treatment.