Learning from complex elderly care: a qualitative study on motivating residents in family medicine.

BACKGROUND: More and more patients need complex care, especially the elderly. For various reasons, this is becoming increasingly difficult. The onus is essentially on family physicians to provide this care and family medicine residency programs should therefore prepare their residents for this task. We know from self-determination theory (SDT) that motivation plays a key role in learning and that in order to boost motivation, fulfillment of 3 basic psychological needs - for autonomy, competence, and relatedness - is crucial. As residents often lack motivation, residency programs face the important challenge to motivate them to learn about and engage in complex elderly care. How to do so, however, is not yet sufficiently understood. METHODS: We conducted a qualitative multi-institutional case study across four universities in Belgium and the Netherlands. In the period between June, 2015, and May, 2019, we triangulated information from semi-structured interviews, document analysis, and observations of educational moments. Guided by SDT concepts, the analysis was performed iteratively by a multidisciplinary team, using ATLAS.ti, version 8. In this process, we gained more insights into residents' motivation to learn complex elderly care. RESULTS: We scrutinized 1,369 document pages and 4 films, observed 34 educational moments, and held 41 semi-structured interviews. Although we found all the 3 basic psychological needs postulated by SDT, each seemed to have its own challenges. First, a tension between the need to guide residents and to encourage their independent learning complicated fulfillment of the need for autonomy. Second, the unpredictability of complex care led to reduced feelings of competence. Yet, guidelines and models could help residents to capture and apprehend its complexity. And third, family medicine practice, patients, and educational practice, by either satisfying or thwarting the need for relatedness, were identified as key mediators of motivation. By setting the right example and encouraging residents to discuss authentic dilemmas and switch their health care approach from cure to care, educators can boost their motivation. CONCLUSION: Our study has demonstrated that the degree of perceived autonomy, guidance by the education program, use of authentic dilemmas, as well as involvement of group facilitators can aid the process of motivation. TRIAL REGISTRATION: NVMO, ERB number 482.

[Somatic care in psychiatry : barriers perceived by patients and health professionals]. / Soins de santé somatiques en psychiatrie : barrières perçues par les patients et les professionnels de la santé.

Disparities in access to, use of and delivery of somatic health care contribute to widening gaps in morbidity and mortality between psychiatric patients and the general population. We conducted a qualitative semi-structured interview study with psychiatric patients and health professionals from different psychiatric care settings to understand these poor physical health outcomes. Optimal somatic follow-up of patients with severe mental illness seems to be hampered by (1) provider-related elements (attitude, training, experiences); (2) organisational aspects (equipment, infrastructure, staff, pharmacy, communication networks); (3) psychiatric patient-related elements and (4) financial barriers.There is an urgent need for integrated somatic and psychiatric health care systems and for cultural change. Psychiatrists and somatic health care providers continue to view the mental and physical health of their patients as mutually exclusive responsibilities. A range of system changes will improve the quality of somatic health care for these vulnerable patients.

Les disparités dans l'accès, l'utilisation et la prestation des soins de santé somatiques contribuent à creuser les écarts de morbidité et mortalité entre patients psychiatriques et la population générale. Nous avons mené une étude qualitative par entretiens semi-structurés auprès de patients psychiatriques et de professionnels de santé de différents lieux de soins psychiatriques afin de comprendre ces mauvais résultats en matière de santé physique. Le suivi somatique optimal des patients atteints d'une maladie mentale sévère semble entravé par des éléments : (1) liés aux prestataires de soins (attitude, formation, expériences); (2) en relation avec des aspects organisationnels (équipement, infrastructure, personnel, pharmacie, réseaux de communication); (3) inhérents aux caractéristiques des patients psychiatriques et (4) représentés par des obstacles financiers. Il est urgent de mettre en place des systèmes de soins de santé somatiques et psychiatriques intégrés et d'entamer un changement culturel. Les psychiatres et les prestataires de soins somatiques continuent de considérer la santé mentale et la santé physique de leurs patients comme des responsabilités mutuellement exclusives. Un changement de paradigme tendant vers une meilleure intégration permettra d'améliorer la qualité des soins de santé somatiques pour ces patients vulnérables.

[Euthanasia: opinions and experiences of Flemish psychiatrists working at a university]. / Euthanasie: opvattingen en ervaringen van universitair werkzame Vlaamse psychiaters.

BACKGROUND: Little is known about the attitude of Belgian psychiatrists and psychiatrists in training towards euthanasia for psychiatric reasons. AIM: To analyse opinions about and experiences with euthanasia in physicians from a university psychiatric hospital. METHOD: A mail with a questionnaire was sent to the 111 psychiatrists and psychiatrists in training from University Psychiatric Centre KU Leuven to assess their profile, opinions towards euthanasia in different cases and own experiences with requests for euthanasia in the last five years. RESULTS: The response rate was 45%. The majority of psychiatrists were accepting towards euthanasia, also in the case of psychiatric disorders (64%) or a combination of non-terminal somatic and psychosocial illness (60%). Religious psychiatrists were less accepting towards euthanasia than non-religious colleagues. Older psychiatrists (more than 20 years of working experience) were more open towards euthanasia than their younger colleagues, but less so than psychiatrists in training. Encounters with euthanasia were limited. CONCLUSION: The common attitude towards euthanasia in doctors from a tertiary psychiatric centre is accepting. More research in a broader population is recommended.

[The reform of the Flemish mental health care reviewed: the road is long and bumpy]. / De hervorming van de Vlaamse ggz doorgelicht: de weg is lang en hobbelig.

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Studying the impact of a medication use evaluation for polymedicated older patients by the community pharmacist (SIMENON): study protocol.

BACKGROUND: Aged polymedicated patients are particularly vulnerable for drug-related problems. A medication review aims to optimize the medication use of patients and improve health outcomes. In this study, the effect of a pharmacist-led medication use review is investigated for polymedicated ambulatory older patients with the aim of implementing this pharmaceutical care intervention across Belgium. METHODS: This article describes the study protocol of the SIMENON study and reports the results of the feasibility study, which aimed to test and optimize this study protocol. In the SIMENON intervention study, 75 Belgian community pharmacies each recruit 12 patients for a medication use review. For each patient, the identified drug-related problems and subsequent interventions are registered using the PharmDISC classification. In a subset of Dutch speaking patients, a pretest-posttest single group design is used to measure the impact of this review on patient related outcomes using questionnaires. The main outcome of the study is the type and number of drug-related problems and related interventions. A second outcome is the impact of the medication use review on adherence, objectively measured with dispensing data. Evolution in medication related quality of life is another outcome, measured with the Living with Medicines Questionnaire version 3. Other patient reported outcomes include adherence, self-management, patient satisfaction, fall incidents and use of emergency healthcare services. DISCUSSION: The findings of this study can provide data on the effectiveness of a medication use review in the Belgian primary care setting. Furthermore, it will provide insights in which patients benefit most of this intervention and therefore facilitate the implementation of medication review in Belgium. TRIAL REGISTRATION: ClinicalTrials.gov NCT03179722 . Retrospectively registered 7 June 2017.

[Detection and prevention in later life: risk profiles for physical, psychological, social and environmental frailty.] / Detectie en preventie van kwetsbaarheid: Op zoek naar risicoprofielen voor fysieke, psychische, sociale en omgevingskwetsbaarheid.

In order to provide proactive care and support for older people attention is needed for the prevention of frailty among older adults. Subsequently, accurate case finding of those who are more at risk of becoming frail is crucial to undertake specific preventive actions. This study investigates frailty and risk profiles of frailty among older people in order to support proactive detection. Hereby, frailty is conceived not only as a physical problem, but also refers to emotional, social, and environmental hazards. Using data generated from the Belgian Ageing Studies (N = 21,664 home-dwelling older people), a multinomial logistic regression model was tested which included socio-demographic and socio-economic indicators as well as the four dimensions of frailty (physical, social, psychological and environmental). Findings indicate that for both men and women having moved in the previous 10 years and having a lower household income are risk factors of becoming multidimensional frail. However, studying the different frailty domains, several risk profiles arise (e. g. marital status is important for psychological frailty), and gender-specific risk groups are detected (e. g. non-married men). This paper elaborates on practical implications and formulates a number of future research recommendations to tackle frailty in an ageing society.

[Tiredness of life in older adults]. / Vieillesse et fatigue de vivre. La lassitude chez la personne âgée.

Tiredness of life in older adults can lead to a request for the wish to die. This article provides a practical approach for physicians of this problem on the basis of a flow chart. The main causes of tiredness of life should be identified and evaluated for their reversibility and treatment options. The first group are the physical factors which, besides organ pathology, should also take frailty into account as a possible cause. A second important group are the psychological risk factors such as psychiatric disorders, loneliness, dignity, subjective well-being, coping and spiritual power. These factors also determine the complaint and needs of the patient. Here is a multidisciplinary assessment and approach desirable. This multidisciplinary approach also applies to the socioeconomic risk factors. In addition, the caregiver should examine if the weariness of life indeed gives rise to the suffering of the older person and to what extent this is hopeless and unbearable suffering. Hopelessness is a professional judgment about the remaining treatment and care perspective and is often objectified; unbearable is a matter of the patient and therefore always subjective and personal. The current legislation on euthanasia, the reversibility of the underlying causes and the unbearable suffering will determine whether the request of the patient with tiredness of life can be considered. Some questions will not fit within the proposed framework. For those a multidisciplinary advice of an ethics committee may be desirable.

La fatigue de vie chez la personne âgée peut susciter le désir de mourir. Ce document, destiné aux médecins, est un manuel pratique sur cette problématique. Il faut rechercher les facteurs de risque physiques, psychiques et socioéconomiques de la lassitude pour évaluer dans quelle mesure ils sont réversibles et peuvent être traités. L'étiologie de la lassitude étant souvent multifactorielle, il est souhaitable que son évaluation soit multidisciplinaire, tout comme son approche. Le prestataire de soins doit chercher à savoir si la lassitude est responsable d'une souffrance sans issue et insupportable. Le fait que la souffrance soit sans issue doit être évalué de manière professionnelle pour répondre à la question de savoir si une perspective de traitement et de soins est encore présente, ce qui est souvent objectivable. Le fait que la souffrance soit insupportable est strictement personnel et toujours subjectif. L'éventuelle prise en compte d'une demande d'euthanasie en cas de fatigue de vivre est déterminée par les critères de la législation actuelle sur l'euthanasie, la réversibilité des causes sous-jacentes de la lassitude et le caractère insupportable de la souffrance. Si, comme cela arrive de temps à autre, la demande d'euthanasie se situe en dehors du cadre proposé, l'avis multidisciplinaire mûrement réfléchi d'un comité d'éthique est alors souhaitable.

Prevalence of orthostatic hypotension and relationship with drug use amongst older patients.

INTRODUCTION: Orthostatic hypotension (OH) is said to be highly prevalent in older people. Drugs are often involved as causative factor. Nevertheless, few data are available about the prevalence of OH and its relationship with drugs in olders. OBJECTIVES: To review data about (i) the prevalence and characteristics of OH in older patients; and (ii) the relationship between OH and drugs. METHODS: Review of publications from Ovid (PubMed) from 1980 to May 2011 using the following key words: "orthostatic hypotension" combined with "elderly" or equivalent for the analysis of prevalence (first search) and "orthostatic hypotension" combined with "drugs" or equivalent to assess the relationship between OH and drugs (second search). RESULTS: Fifty-one publications (of which 14 with original data) were retrieved from the prevalence search, 31 for the second search (8 with original data: 7 retrospective studies and 1 prospective cohort study) and 12 reviews or experts opinions. Prevalence of OH varies according to the characteristics of the subjects, the settings of the studies, and the procedures of blood pressure measurement. In acute geriatrics units, two studies reported a prevalence of over 30% and one study mentioned that 68% of the patients presented with at least one episode during the day. OH was associated with several geriatric problems: gait disorders, balance disorders, falls, cerebral hypoperfusion, transient ischemic attacks, cognitive impairment, acute myocardial infarct and systolic hypertension. OH can also be asymptomatic or with atypical presentation: falls, gait disorders and confusion. Psychotropic agents (antipsychotics, sedatives, antidepressants), and cardiovascular drugs (antihypertensive agents, vasodilators, diuretics) were associated with OH. DISCUSSION: If the hypothesis of causality between drug treatment and OH is confirmed, the identification of the involved drugs could be of value for the prevention of OH and its complications. In this context, the Working Group Pharmacology Pharmacotherapy and Pharmaceutical Care of the Belgian Society of Gerontology and Geriatrics proposes to conduct a multicentre study to assess the prevalence of OH in Belgian acute geriatrics units and its relationship with drugs.

Zorgdiagnose bij thuiswonende, dementerende patiënten : Een nieuw concept?

SAMENVATTING: Inleiding: De zorg voor dementerende patiënten is een belangrijke maatschappelijke uitdaging. Naast de ziektediagnostiek is de vaststelling van de zorgbehoefte van de patiënt van groot belang. In dit artikel wordt op basis van literatuur en expertadvies een werkdocument opgesteld om de zorgdiagnose bij thuiswonende dementerenden in kaart te brengen. Methode: Via een systematisch literatuuronderzoek werden de componenten van zorgdiagnose geïnventariseerd. Vervolgens werd na semigestructureerde interviews bij zestien zorgverleners en twee mantelzorgers de inventaris verder ontwikkeld en een werkdocument opgesteld.Resultaten: De literatuur over zorgdiagnose is recent en er zijn slechts weinig studies met eenduidige resultaten. Alle auteurs zijn het er echter over eens dat het inventariseren van de zorgbehoefte leidt tot een betere zorgplanning en een hogere levenskwaliteit van zowel patiënt als mantelzorger. Als synthese van het literatuuronderzoek en semigestructureerde interviews wordt een werkdocument voorgesteld om tijdens een multidisciplinair overleg (MDO) de zorgbehoefte bij een thuiswonende, dementerende patiënt en zijn mantelzorger te inventariseren. Besluit: Het in kaart brengen van de zorgbehoefte van een thuiswonende, dementerende patiënt en zijn mantelzorger is belangrijk. Het voorgestelde document kan dienen als leidraad tijdens een multidisciplinair overleg.

[Care diagnosis for demented patients living at home. A new concept?]. / Zorgdiagnose bij thuiswonende, dementerende patiënten. Een nieuw concept?

OBJECTIVES: In addition to diagnosing the disease, establishing the care needs of people suffering from dementia is of paramount importance. Based on a literature review and expert advice, a working document has been drawn up in this article to determine the care diagnosis of dementia patients living at home. METHOD: The components of care diagnosis were listed by means of a systematic literature review. The inventory was then further adapted and a working document was developed using semi-structured interviews of sixteen professional caregivers and two informal carers. RESULTS: The literature on care diagnosis is recent, and there are only a few studies with unequivocal results. However, all authors agree that making an inventory of the care needs results in better care planning and a better quality of life for both patient and informal carer. A synthesis of the literature review and semi-structured interviews led to a working document proposing the creation of an inventory of the care needs for a dementia patient living at home and his/her informal carer during a multidisciplinary consultation. CONCLUSION: It is important to determine the care needs of a dementia patient living at home and his/her informal carer. The proposed document may serve as a guideline during a multidisciplinary consultation.

[Role of the community pharmacist in the management of drug related problems in home care patients]. / Rôle du pharmacien d'officine dans la gestion des problèmes liès aux médicaments dans le cadre des soins à domicile.

Medication management in home care is an error prone process. In a small pilot project in Flanders, community pharmacists collaborated with physicians and home care nurses through a shared electronic care plan, to optimize the medication management of their home care patients. The pilot project shows that GPs and nurses are positive about the possible contribution of the pharmacist in medication management of home care patients. A larger follow up study is necessary to further identify possible roles of pharmacists in home care and to show related health benefits.

[Stigmatisation of psychiatric patients by general practitioners and medical students: a review of the literature]. / Stigmatisering van psychiatrische patiënten door huisartsen en studenten geneeskunde: een literatuuronderzoek.

BACKGROUND: In clinical practice general practitioners (GPS) and society tend to stigmatise patients with psychiatric problems. AIM: To attempt to describe this stigmatisation by GPS and medical students on the basis of information given in the literature. METHOD: We searched the literature via PubMed using mesh terms: 'family practice', 'physicians', 'family', 'mental disorder', 'attitude' and 'psychiatry' and the word 'stigma'. In addition, literature was supplied by experts and articles were located by the snowball method. RESULTS: Stigmatisation constitutes a major obstacle in the psychiatric and somatic care that gps provide for patients with a psychiatric disorder. Although such patients have a higher somatic vulnerability as a result of their psychiatric problems, they receive fewer technical and exploratory investigations than other categories of patients. Medical students too have a negative attitude towards patients with a psychiatric disorder. More education and training could lead to less stigmatisation but the effect would probably be only temporary. Personal experience is the main factor that leads to greater empathy. CONCLUSION: The literature suggests that psychiatric patients are victims of self-inflicted stigmatisation and stigmatisation by society and doctors. This leads to social exclusion and poorer healthcare. By tackling the problem of stigmatisation we could greatly improve the quality of life and healthcare for this group of patients.

[Critical reflections concerning euthanasia for persons with dementia]. / Réflexions critiques à propos de l'euthanasie de personnes atteintes de démence.

In the public debate on the extension of euthanasia for people with dementia, in addition to ethical considerations and arguments, other issues have to be kept in mind. The diagnosis of dementia is difficult and the clinical picture is very fluctuating. The assessment and especially the operationalization of legal capacity and the use of advance directives are complex problems. The discussion should be conducted against the backdrop of a cultural framework in which the interpretation and development of palliative care is crucial. The development of a framework like advance care planning creates opportunities. The question remains whether the legal issues can be clarified and whether a legal approach generates solutions for the problems described.

[How to improve the continuity of pharmacotherapy at hospital admission and discharge]. / Comment optimiser la continuité du traitement médicamenteux entre l'hôpital et le domicile?

The continuity of pharmacotherapy is of vital importance when patients move from one health care setting to another. Unfortunately, this continuity is not always guaranteed. The aim of this study is to propose solutions to enhance the continuity of pharmacotherapy at hospital admission and discharge. The study consists of a systematic review of the international literature and an analysis of seamless care initiatives in seven selected countries; a summary of Belgian data on problems as well as solutions with regard to continuity of care; a quantification of the extent of medication changes as a result of a hospital stay in Belgium; and a qualitative analysis of the perception of Belgian health care professionals (HCPs) on approaches to improve seamless care. The literature review yielded 15 papers of sufficient quality. However, this review did not generate definitive conclusions on the clinical impact and the cost-effectiveness of interventions aiming to enhance the continuity of pharmacotherapy. The most important initiatives that have been put in practice in foreign countries include the development and implementation of guidelines for HCPs; national information campaigns; education of HCPs; and the development of information technologies as to share patient and prescription data between settings of care. For Belgium, 66 seamless care initiatives were identified. The high number and variety of projects show the interest for this topic as well as the involvement of various HCPs from diverse settings in the development of solutions. Based on this research, and the solutions discussed in the focus groups, the following elements are proposed to enhance the continuity of pharmacotherapy: a national guideline governing the continuity of pharmacotherapy; a national campaign to sensitize HCPs and patients in this area; the availability of a comprehensive and up to date medication list for each patient; and electronic healthcare infrastructure that facilitates sharing of information.

An evaluation of a computer based education program for the diagnosis and management of dementia in primary care. An international study of the transcultural adaptations necessary for European dissemination.

OBJECTIVES: The aim of this study is to make an inventory of the changes that are needed to make an interactive computer based training program (ICBT) with a specific educational content, acceptable to professional communities with different linguistic,cultural and health care backgrounds in different European countries. METHODS: Existing educational software, written in two languages was reviewed by GPs and primary care professionals in three different countries. Reviewers worked through the program using a structured critical reading grid. RESULTS: A 'simple' translation of the program is not sufficient. Minor changes are needed to take account of linguistic differences and medical semantics. Major changes are needed in respect of the existing clinical guidelines in every country related to differences in the existing health care systems. CONCLUSIONS: ICTB programs cannot easily be used in different countries and cultures. The development of a structured educational program needs collaboration between educationalists, domain experts, information technology advisers and software engineers. Simple validation of the content by local expert groups will not guarantee the program's exportability. It is essential to involve different national expert groups at every phase of the development process in order to disseminate it in other countries.

The primary care diagnosis of dementia in Europe: an analysis using multidisciplinary, multinational expert groups.

OBJECTIVES: To explore the extent of variation in the detection of dementia in primary care across Europe, and the potential for the development of European guidelines. METHOD: A mixture of focus group and adapted nominal group methods involving 23 experts of different disciplines and from eight European countries. RESULTS: The diagnosis of dementia should be 'timely' rather than 'early'. Timeliness has an impact on the patient, on the caregiver, on healthcare professionals, and on society. Ethical and moral issues may interfere with the aim of timely diagnosis. Guidelines may be important for facilitating a timely diagnosis of dementia, but were infrequently used and not even available in three of the eight countries. Referral pathways often depended on health care system characteristics, differing throughout the eight European countries, whilst diagnostic strategies differed due to varied cultural influences. There was consensus that national variations can be reduced and timely diagnosis enhanced by combining simple tests using a systematic stepwise case-finding strategy, in conjunction with a strong infrastructure of multidisciplinary collaboration. CONCLUSIONS: This study identified three key themes that should be considered in harmonizing European approaches to the diagnosis of dementia in primary care: (1) a focus on timely diagnosis, (2) the need for the development and implementation of guidelines, and (3) the identification of appropriate referral pathways and diagnostic strategies including multi-professional collaboration. The content of guidelines may be determined by the perspectives of the guideline developers.

Relationship between quality of life and cognitive decline in dementia.

AIMS: We aimed to examine the association of cognitive decline with quality of life (QoL) in dementia compared to controls and to determine variables associated with QoL. METHODS: Every subject was placed within a specific group depending on their designation by the Mini Mental State Examination and evaluated by the Alzheimer's Disease Related Quality of Life (ADRQL) and clinical assessments. RESULTS: QoL for the mild dementia group was lower (p = 0.08) than that of controls. The very severe dementia group had a significantly lower QoL than the other dementia groups, which all had similar ADRQL scores. The only predictor of ADRQL scores was found to be the behavioral and psychological symptoms of dementia. CONCLUSION: There is no direct relationship between cognitive decline and QoL.

[How do the elderly function? A study from the general practice]. / Hoe functioneren ouderen? Een studie vanuit de huisartspraktijk.

UNLABELLED: Problems with instrumental activities of daily living are important in the caring for elderly people, in general practice as well. Impairment in activities and instrumental activities of daily living may be important indicators for early dementia. This study explored how people aged 65 years and over in general practice are performing on four instrumental activities of daily living. METHOD: General practitioners screened all people, aged 65 years and over, and meeting the inclusion criteria, they met during a period of one month. Personalia, instrumental activities of daily living and cognitive functioning were registered. RESULTS: Twentytwo general practitioners included 1003 persons, with a mean age of 75 year. The majority of this group (81.6%) was rather autonomous. The main cause of functional impairment were transport problems. Cognitive functioning and functional loss were correlated. CONCLUSION: Elderly people in general practice function better than is generally assumed. This phenomenon has important consequences for training and functioning of GPs as to the evaluation of activities of daily living. The fundamental role of IADL assessment therefore needs attention in the professional development of GPs.