Disentangling the concept of "the complex older patient" in general practice: a qualitative study

BACKGROUND

The rising life expectancy in the developed world leads to an increase in the number of older patients and the complexity of their complaints in general practice. Although interventions and support for general practitioners are available, implementation lags. Knowledge on what determines a complex older patient, the problems of which general practitioners encounter and the situations they actually need support for, is necessary for better implementation.

METHODS

To provide support to general practitioners in their struggle with complex older patients, the aim of this research was to disentangle the concept of the complex older patient in general practice. A qualitative approach was used consisting of 15 semi-structured interviews with general practitioners. The general practitioner was asked to prepare a case of a complex older patient out of their own practice that could be discussed during the interview. Transcripts of the interview were analysed using inductive thematic analysis.

RESULTS

Analysis of the interviews resulted in twelve themes that could be categorised into five factors that contribute to the complexity of cases of older patients. The five factors are: not being in charge, different views on necessary care, encountering the boundaries of medicine, limits to providing social care, ill-equipped.

CONCLUSION

The factors that were found imply that a better organisational structure for elderly care and consulting elderly care physicians could support general practitioners in providing care for older complex patients. Furthermore, understanding the current concept of patient autonomy seems unjustified in cases of complex older patients.

[Hidden care needs in elderly people: a descriptive study of an outpatient geriatric consultation practice in the Netherlands]

In general older adults, even the oldest old are community dwelling and vital. However, vulnerability can silently or suddenly exist. Multidisciplinary assessment of health problems and disabilities is necessary to compose a comprehensive intervention program. In the Netherlands, a team specialised in elderly care accomplishes home-based assessments. In 2009 we conducted a case study aiming to describe the characteristics of the patients and the reasons for consultation. A total of 84 records were analysed. 60% of the clients were 85 years or older, 32% were living independently and 61% were residents in homes for elderly people. The majority of clients was female and living alone (widowed). Most clients had multiple issues and were referred for cognitive evaluation. During the process of assessment many underlying behavioural, emotional and social problems became manifest. These findings support that symptoms and complaints of frail elderly are complex. A systematic multidisciplinary approach enhances the dialogue with patients and caregivers to discuss their needs and their attitude towards care. More research, however, is necessary to evaluate the effectiveness of this intervention.

Quality of life of nursing-home residents with dementia subject to surveillance technology versus physical restraints: an explorative study

OBJECTIVE

As physical restraints should only be used in exceptional cases, there is an urgent need for alternatives to restraint use. Surveillance technology could be such an alternative. This study explored whether nursing-home residents with dementia subjected to surveillance technology had better quality of life scores for mood, behavioral and societal dimensions than residents with physical restraints.

METHODS

Quality of life was assessed longitudinally, with three measurements in six psychogeriatric nursing homes of residents with surveillance technology (n = 170) and residents with physical restraints (n = 22). QUALIDEM subscales were used to measure five dimensions of quality of life. Multilevel longitudinal univariate and multivariate regression techniques were used to analyze the data.

RESULTS

Because physical restraints were almost exclusively used in residents with low activities of daily living (ADL) independency (18 of the 22), we restricted the regression analyses to residents with a Barthel Index score ≤ 5 (overall n = 53). Univariate results showed that highly ADL-dependent residents with surveillance technology had significantly more positive affect than highly ADL-dependent residents with physical restraints. However, this difference proved to be no longer significant after adjustment for the confounders: age, sex and stage of dementia.

CONCLUSIONS

Quality of life of highly ADL-dependent nursing-home residents with dementia seems to be unrelated to the use of surveillance technology as opposed to physical restraints.

Developing quality indicators for general practice care for vulnerable elders; transfer from US to The Netherlands

BACKGROUND

Measurement of the quality of healthcare is a first step for quality improvement. To measure quality of healthcare, a set of quality indicators is needed. We describe the adaptation of a set of systematically developed US quality indicators for healthcare for vulnerable elders in The Netherlands. We also compare the US and the Dutch set to see if quality indicators can be transferred between countries, as has been done in two studies in the UK, with mixed results.

METHOD

108 US quality indicators on GP care for vulnerable elders, covering eight conditions, were assessed by a panel of nine clinical experts in The Netherlands. A modified version of the RAND/UCLA appropriateness method was used. The panel members received US literature reviews, extended with more recent and Dutch literature, summarising the evidence for each quality indicator.

RESULTS

72 indicators (67% of US set) were (nearly) identical in the Dutch and US sets. For some conditions, this percentage was much lower. For undernutrition, only half of the US indicators were included in the Dutch set. For depression, many indicators were discarded or changed in a significant way, with the result that only five of the original 17 indicators (29%) are the same in the Dutch and the US set.

CONCLUSIONS

Quality indicators can be transferred between countries, but with caution, because in two of the three studies on transferring indicators between the US and Europe, 33-44% of the indicators were discarded. For some conditions in the current study, this percentage is much higher. For undernutrition, there is hardly any evidence, and differences between the indicator sets can be attributed to differences in expert opinion between the countries. For depression, it seems that different evidence is considered important in the US and in The Netherlands, of which the Dutch body of knowledge is not known in the US.

[Small-scale group living for elderly with dementia: a clarification]

This article discusses the results of a Concept Mapping, held to clarify the concept of small-scale group living for elderly with dementia. Seventeen experts from different backgrounds formulated 91 statements about small-scale group living. These were subsequently depicted on a concept map with two dimensions: care versus living and individual versus context. The statements were then divided into six clusters by hierarchical cluster analysis. Five of these clusters centred around the arrangements of the individual lives of the residents and the collective lives of residents and staff, while only one held statements about the physical characteristics of small-scale group living. Therefore, it can be concluded from this Concept Map that small-scale group living is not so much determined by the physical characteristics but by the organisational features of the care context.

The relationship between characteristics of supported housing and the quality of life of older adults with severe mental illness

This study examined whether group living (as opposed to single living), staff availability and degree of personal freedom are associated with the quality of life of older adults with severe mental illness. A cross-sectional study was carried out in 18 supported living programmes in residential homes for the elderly that differed in terms of these three characteristics. The study included 35 patients with a psychotic disorder and 38 with an anxiety or mood disorder. Quality of life was assessed with the Philadelphia Geriatric Centre Morale Scale (PGCMS) and the Manchester Short Assessment of Quality of Life (MANSA). No association was found between group living and quality of life. Availability of psychiatrically trained staff was associated with life quality only for patients with a psychotic disorder, and perceived amount of personal freedom was associated with life quality only for patients with a non-psychotic disorder. Both differences were seen only on the PGCMS Agitation subscale. Older people with psychotic disorders appear to have relatively high needs for professional psychiatric support, and those with non-psychotic disorders for control over their daily lives. Further research is needed in other settings for older people with severe mental illness, preferably using longitudinal designs.

Supported living in residential homes for the elderly: impact on patients and elder care workers

To enable older people with severe and persistent mental illness to live in the community, the Dutch mental health sector has developed a program for supported living in residential homes for the elderly. It provides for the permanent stationing of mental health workers (MHWs) in elder care facilities to support both the resident patients and the elder care staff. The authors examined associations between the number of MHW staff and the degree to which (1) patients were integrated into the community and (2) elder care workers had developed effective working alliances with their patients. Participants included 110 patients participating in 18 supported living programs in the Netherlands. Community integration was assessed in face-to-face interviews with the patients about their perceived influence over daily life, involvement in social activities, and social network size. The quality of the worker-patient relationship was assessed using the Dutch Working Alliance Questionnaire for Community Care, completed by the elder care worker primarily responsible for each patient. After differentiation of the MHW staff into medically trained and nurse-trained professionals, associations with outcome measures were found only for the nurse-trained staff. The more hours of nurse-trained staff capacity per patient, the more influence perceived by the patients, and the more directiveness shown by the elder care workers in their contacts with patients. The impact of supported living programs in residential homes for the elderly appears to be determined in part by the caseloads of the on-site MHWs.