Older People In Primary Care Research Articles

Clinical Effectiveness of Individual Cognitive Behavioral Therapy for Depressed Older People in Primary Care: A Randomized Controlled Trial

Clinical Effectiveness of Individual Cognitive Behavioral Therapy for Depressed Older People in Primary Care: A Randomized Controlled Trial

Managing older people in primary care

Managing older people in primary care

Clinical Effectiveness of Individual Cognitive Behavioral Therapy for Depressed Older People in Primary Care

In older people, depressive symptoms are common, psychological adjustment to aging is complex, and associated chronic physical illness limits the use of antidepressants. Despite this, older people are rarely offered psychological interventions, and only 3 randomized controlled trials of individual cognitive behavioral therapy (CBT) in a primary care setting have been published. To determine the clinical effectiveness of CBT delivered in primary care for older people with depression. A single-blind, randomized, controlled trial with 4- and 10-month follow-up visits. A total of 204 people aged 65 years or older (mean [SD] age, 74.1 [7.0] years; 79.4% female; 20.6% male) with a Geriatric Mental State diagnosis of depression were recruited from primary care. Treatment as usual (TAU), TAU plus a talking control (TC), or TAU plus CBT. The TC and CBT were offered over 4 months. Beck Depression Inventory-II (BDI-II) scores collected at baseline, end of therapy (4 months), and 10 months after the baseline visit. Subsidiary measures were the Beck Anxiety Inventory, Social Functioning Questionnaire, and Euroqol. Intent to treat using Generalized Estimating Equation and Compliance Average Causal Effect analyses were used. Eighty percent of participants were followed up. The mean number of sessions of TC or CBT was just greater than 7. Intent-to-treat analysis found improvements of -3.07 (95% confidence interval [CI], -5.73 to -0.42) and -3.65 (95% CI, -6.18 to -1.12) in BDI-II scores in favor of CBT vs TAU and TC, respectively. Compliance Average Causal Effect analysis compared CBT with TC. A significant benefit of CBT of 0.4 points (95% CI, 0.01 to 0.72) on the BDI-II per therapy session was observed. The cognitive therapy scale showed no difference for nonspecific, but significant differences for specific factors in therapy. Ratings for CBT were high (mean [SD], 54.2 [4.1]). Cognitive behavioral therapy is an effective treatment for older people with depressive disorder and appears to be associated with its specific effects. isrctn.org Identifier: ISRCTN18271323.

Potentially inappropriate prescribing in an Irish elderly population in primary care

* Potentially inappropriate prescribing in older people is a well-documented problem and has been associated with adverse drug reactions and hospitalization. * Beers' criteria, Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) are screening tools that have been formulated to help physicians and pharmacists identify potentially inappropriate prescribing and potential prescribing omissions. * The prevalence of potentially inappropriate prescribing and prescribing omissions in the elderly population presenting to hospital with acute illness is high according to STOPP and START criteria. * Potential errors of prescribing and of omission of medicines are prevalent among medically stable older people in primary care. * Screening tools should be incorporated into the everyday practice of primary care doctors and community pharmacists as a means of preventing potential errors of prescribing commission and prescribing omission in older people. Screening tools have been formulated to identify potentially inappropriate prescribing (IP) in older people. Beers' criteria are the most widely used but have disadvantages when used in Europe. New IP screening tools called Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) have been developed to identify potential IP and potential prescribing omissions (PPOs). The aim was to measure the prevalence rates of potential IP and PPOs in primary care using Beers' criteria, STOPP and START. Case records of 1329 patients >or=65 years old from three general practices in one region of southern Ireland were studied. The mean age +/- SD of the patients was 74.9 +/- 6.4 years, 60.9% were female. Patients' current diagnoses and prescription medicines were reviewed and the Beers' criteria, STOPP and START tools applied. The total number of medicines prescribed was 6684; median number of medicines per patient was five (range 1-19). Overall, Beers' criteria identified 286 potentially inappropriate prescriptions in 18.3% (243) of patients, whilst the corresponding IP rate identified by STOPP was 21.4% (284), in respect of 346 potentially inappropriate prescriptions. A total of 333 PPOs were identified in 22.7% (302) of patients using the START tool. Potentially inappropriate drug prescribing and errors of drug omission are highly prevalent among older people living in the community. Prevention strategies should involve primary care doctors and community pharmacists.

Incidence and mortality of falls amongst older people in primary care in the United Kingdom

Despite the role of primary care in the falls care pathway, there are almost no data on the extent of falls seen in general practices. To quantify the incidence and mortality of falls amongst older people in primary care in the UK. Cohort study of people aged >or=60 years and registered in a UK practice contributing data to The Health Improvement Network primary care database (THIN) throughout 2003-06. Analysis of crude incidence and estimation of incidence rate ratios using negative binomial regression, and survival using Cox regression. Sensitivity analysis of criteria for distinguishing discrete fall events from follow-up appointments. Amongst people aged >or=60 years the overall crude incidence rate of recorded falls was 3.58/100 person-years (95% CI 3.56-3.61). The rate of recurrent falls was 0.67/100 person-years (95% CI 0.66-0.68). The incidence rate of recorded falls and recurrent falls was higher in older age groups, in women and least advantaged social groups. Incidence of recorded falls was constant through the time period 2003-06. Mortality for recurrent fallers was about twice that of general population controls. These data suggest that more than 475,000 fall events in older people are recorded in general practice each year in the UK, and are associated with increased mortality and relative deprivation. The underlying incidence rate has remained stable in recent years.

Is Medication Review by Primary-Care Pharmacists for Older People Cost Effective?

The nature, definition and history of medication review of long-term conditions and treatment is discussed. A literature search for studies of medication review of older people in primary care by pharmacists yielded 16 reports of studies in English, and only ten of these were randomized controlled trials. Extracting meaningful conclusions from the data was problematic because of variations in the nature of the review described, the populations studied, the outcome data measured and the evaluation criteria used. There is a dearth of economic measurement and often inadequate descriptions of the interventions performed. Those interventions that were described in detail varied in the skills, training and approach of the pharmacists. Therefore, there was no possibility of aggregating results of studies, and the review conclusions are based on trends and impression rather than meta-analysis. There was no suggestion in any reports that patients were harmed by the interventions, and some consistency in suggesting that falls and hospital admissions might be reduced with modest cost savings, at least in terms of drug costs. No studies reported a benefit in terms of mortality, mental capacity or activities of daily living. The authors conclude that clinical medication review is probably of value and may be cost effective, but propose a large-scale, long-term, multicentre, collaborative clinical trial with carefully chosen (and clearly described) interventions and outcome measures to confirm this.

Prescribing for the Elderly

We live in an ageing society. Since the early 1930s, the number of people aged over 65 has more than doubled and today, a fifth of the population is over 60 (Fig. 1). This has implications for prescribing in primary care. Prescription drug usage increases with age. One in three NHS prescriptions is issued to a patient over the age of 65 years, and 90% of these prescriptions are for repeat medications. Furthermore, adverse drug events are common reasons for hospital admission in the over-75 age group, accounting for 5–17% of admissions. Many are avoidable. This article aims to outline the principles of prescribing for older people in primary care.

Family physicians need easy instruments for frailty

SIR—This is with reference to the article ‘Development of an easy prognostic score for frailty outcomes in the aged’ written by G. Ravaglia, P. Forti, A. Lucicesare, N. Pisacane, E. Rietti, C. Patterson[1]. As general practitioners involved in research about primary care for older people we agree that frailty is an emerging concept with important clinical consequences. Ravaglia et al. describe ‘an easy …

A study of self-harm in older people: Mental disorder, social factors and motives

Data was collected on seventy-six older people who presented to a specialist self-harm team. Data included: diagnosis, suicide intent, motives for self-harm, social contacts and life events and difficulties. The majority of elderly who harmed themselves had high suicide intent and 69% were depressed. Patients were frequently living alone with an isolated life-style and poor physical health. Depressed self-harm subjects had higher suicide intent scores than non-depressed and to gain relief from an unbearable state of mind was a frequently recorded motive for these patients. Other motives for self-harm appear to be similar between depressed and non-depressed self-harmers. It is important that older people who self-harm receive an appropriate assessment of both risk and need by an experienced mental-health professional skilled at recognising depression in later life. The need for adequate recognition and management of depression in older people in primary care is also highlighted.

Effect of Telephone Counseling on Physical Activity for Low‐Active Older People in Primary Care: A Randomized, Controlled Trial

To assess the long-term effectiveness of a telephone counseling intervention on physical activity and health-related quality of life in low-active older adults recruited through their primary care physician. Randomized, controlled trial. Three primary care practices from different socioeconomic regions of Auckland, New Zealand. One hundred and eighty-six low-active adults (aged 65) recruited from their primary care physicians' patient databases. Eight telephone counseling sessions over 12 weeks based on increasing physical activity. Control patients received usual care. Change in physical activity (as measured using the Auckland Heart Study Physical Activity Questionnaire) and quality of life (as measured using the Short Form-36 Health Survey (SF-36)) over a 12-month period. Moderate leisure physical activity increased by 86.8 min/wk more in the intervention group than in the control group (P=.007). More participants in the intervention group reached 2.5 hours of moderate or vigorous leisure physical activity per week after 12 months (42% vs 23%, odds ratio=2.9, 95% confidence interval=1.33-6.32, P=.007). No differences on SF-36 measures were observed between the groups at 12 months. Telephone-based physical activity counseling is effective at increasing physical activity over 12 months in previously low-active older adults.

Professional Development in Geriatrics for Community‐Based Generalist Faculty

Generalist physicians provide most primary care for older people. Increasingly, undergraduate clinical education occurs in community sites. Hence, community-based generalist faculty members need continuing education in geriatrics to support clinical practice and teaching. The Geriatrics Scholars Program provided continuing medical education (CME) in geriatrics over a 3-year period to 88 participants. Sixty physicians completed 30 or more hours of education and were designated Geriatrics Scholars. On an anonymous exit survey, Scholars reported being better equipped to care for elderly patients and to teach geriatrics and improved patient care in specific aspects of geriatrics, including medication use, cognition, and functional assessment. In summary, community-based generalist faculty who participated in a substantial, 3-year program of geriatrics CME reported that their care of older people and their teaching of geriatrics were enhanced.

Development of a series of patient information leaflets for constipation using a range of cognitive interview techniques: LIFELAX.

BackgroundThe aim of the LIFELAX randomised controlled trial (diet and lifestyle vs. laxatives in the management of chronic constipation) is to develop and evaluate a cost effective intervention to promote diet and lifestyle in the treatment and management of chronic constipation for older people in Primary Care. Constipation affects the quality of life in around 20% of older people in the community. In the 65 years plus population, a significant proportion of men and women both living in institutions (81% and 75% respectively) and free living (30% and 37% respectively) use laxatives.Approximately £42 million is spent each year on prescribed laxatives in England in addition to laxatives purchased over the counter. Although bowel problems are often multifactorial, diet and lifestyle have an extremely important role in their management. This paper describes one aspect of the main study, the development and piloting of the Patient information leaflets (PILs).MethodsFollowing review of the literature and interviews with practitioners and patients, 8 PILs were designed on: constipation, activity, bowel health, fruit and vegetables, fibre, fluid, alternative therapies and laxatives. To check the patient's understanding of terms used in the PILS and the clarity and accessibility of the information understanding, cognitive interviews (CI) were used with nine patients (selected from 3 GP surgeries), aged ≥ 55 years, who had received ≥ 3 prescriptions of laxatives over 12 months. Interviews were recorded and transcribed.ResultsChanges made following the CI process included the lay-out, words used (e.g. 'exercise' was changed to 'activity', 'gut motility' changed to 'bowel movement') and descriptions and examples were adapted to be more appropriate for the target population.ConclusionPilot testing with CIs resulted in improvements in the PILs, which emphasises the need to pilot PILs with the target population before use. The techniques employed are relatively inexpensive and could be routinely used when preparing literature for research or clinical use including those intended for use with healthcare professionals and patients.

Older people in primary care

Older people in primary care

Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556

Falls in older people are a major public health concern in terms of morbidity, mortality and cost. Previous studies suggest that multifactorial interventions can reduce falls, and many geriatric day hospitals are now offering falls intervention programmes. However, no studies have investigated whether these programmes, based in the day hospital are effective, nor whether they can be successfully applied to high-risk older people screened in primary care.The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling. This will be tested by a pragmatic parallel-group randomised controlled trial in which the participants, identified as at high risk of falling, will be randomised into either the intervention Day hospital arm or to a control (current practice) arm. Those participants preferring not to enter the full randomised study will be offered the opportunity to complete brief diaries only at monthly intervals. This data will be used to validate the screening questionnaire. Three day hospitals (2 Nottingham, 1 Derby) will provide the interventions, and the University of Nottingham's Departments of Primary Care, the Division of Rehabilitation and Ageing Unit, and the Trent Institute for Health Service Research will provide the methodological and statistical expertise. Four hundred subjects will be randomised into the two arms. The primary outcome measure will be the rate of falls over one year. Secondary outcome measures will include the proportion of people experiencing at least one fall, the proportion of people experiencing recurrent falls (>1), injuries, fear of falling, quality of life, institutionalisation rates, and use of health services. Cost-effectiveness analyses will be performed to inform health commissioners about resource allocation issues. The importance of this trial is that the results may be applicable to any UK day hospital setting.SitesGeneral practices across Nottinghamshire and Derbyshire.Day hospitals:Derbyshire Royal Infirmary (Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service (Nottingham City Hospital Trust)Leengate Day Hospital (Queen's Medical Centre Nottingham University Hospital NHS Trust)

Identification of psychological morbidity in older people in primary care by practice nurses.

Older people with psychological morbidity often come into contact first with primary care services, thus researchers have devoted much attention to how effective such contacts may be. In this study, carried out in inner London, assessments of 190 older patients undertaken by eight practice nurses were compared with the results provided by the General Health Questionnaire (GHQ). The results indicated that the practice nurses identified only about a quarter of the probable cases of psychological morbidity.

Identification of psychological morbidity in older people in primary care by practice nurses

Older people with psychological morbidity generally first present to health services in primary care, where they are increasingly seen by primary care nurses. In order to evaluate primary care nurses’ identification of psychological morbidity, 190 older patients attending eight practice nurses completed the General Health Questionnaire (GHQ) and the practice nurses made an assessment as to the presence or absence of psychological problems. The practice nurses identified only 26% of probable cases of psychological morbidity identified by the GHQ. Their threshold for identification was high, rating only 12% of patients as experiencing psychological problems compared to 29% probable cases identified by the GHQ, and their accuracy was low (kappa for agreement between GHQ and nurse ratings = 0.23). Likelihood of identification depended on length and type of visit. The findings suggest that it may be unrealistic to expect practice nurses, without additional training and reorganisation of their work, to identify more than a minority of older patients with psychological morbidity in the course of their routine work.

Dementia in the community: Challenges for primary care development

The National Service Frameworks for Older People and for Mental Health are setting standards for services in areas where problems are complex and solutions limited. Primary Care Trusts seeking to raise the quality of primary care for older people and commission specialist services rationally face many challenges. Specialists in old age medicine and old age psychiatry will find themselves working closely with primary care practitioners to develop services and extend professional skills, for it is uncertain that specialist services will be able to deal with the scale of the clinical and social problems unaided.

Just keep taking the tablets: adherence to antidepressant treatment in older people in primary care.

poor adherence to antidepressant medication may account for a significant proportion of treatment failures. Adherence levels and factors associated with adherence have not previously been studied in older people. to report the prevalence and correlates of adherence to antidepressants in people > or = 65 years of age in a primary care setting. sixty-seven patients currently being prescribed antidepressants from a single rural general practice were assessed using a range of questionnaires measuring adherence to antidepressants, severity of depression, specific health education about antidepressants, level of side-effects, insight, positive and negatives beliefs about medication in general and antidepressants in particular, level of intellectual functioning (past and present), a past history of recovery from depression, type of antidepressant, complexity of prescriptions, age and living arrangements. forty-five participants (67.2%) were fully adherent; seven (10.4%) mostly adherent, three (4.5%) adhered sometimes, three rarely and nine (13.4%) never. Backwards linear regression found that adherence increased with information given and cognitive impairment and decreased with concerns about taking antidepressants and severity of side-effects. non-adherence to antidepressant medication is a significant problem in older patients. Our study probably overestimated adherence as it was self-report, which usually overestimates adherence and the refusals are more likely to have been people not taking tablets but still found nearly one third of the patients were non-adherent. An intervention comprising education, eliciting and addressing specific concerns about antidepressant medication and using medication, which minimises side effects, may be helpful.

Mental health in older adult recipients of primary care services: is depression the key issue? Identification, treatment and the general practitioner.

Mental health services for older people in primary care are relatively underdeveloped. This study has sought to determine the nature and extent of mental health problems in older people presenting to primary care and to compare this with the detection and management of mental health problems by the primary health care team (PHCT). Participants were patients aged 65 years and above attending a representative inner city general practice. Screening tools included the General Health Questionnaire (GHQ-28), Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE). The PHCT used a brief checklist to rate participants for the presence of mental health problems. Follow-up interviews using the Geriatric Mental State (GMSA), Cambridge Examination for Mental Disorders in the Elderly (CAMDEX)-cognitive subscale (CAMCOG), National Adult Reading Test (NART), were carried out. A high level of psychological morbidity was identified at screening (48.1%). There was a considerable degree of agreement between the HADS and GMSA, and the MMSE and GMSA at follow-up. Agreement rates between the PHCT and initial screening tools were low suggesting under-recognition of mental health problems at primary care level by the PHCT. Contributory factors included: short consultation times with a concentration on physical symptoms; few patients presenting explicitly with mental health problems; few decisions to treat or refer patients; and the general practitioners tended to monitor, or defer decisions. This study found lower levels of severe mental health problems, especially depression, than reported elsewhere, but higher prevalence of psychological distress. High levels of physical and mental health co-morbidity were found. These findings suggest that planning for primary care services needs to adopt a flexible assessment model. The development of effective, time-limited protocols and screening tools to assist the PHCT in improving their identification rates is recommended. This needs to be supported by the availability of appropriate treatments for the psychological distress.

Primary Care for Older People

During the past century the UK has experienced a major demographic shift as people have lived longer. The proportion of the population over 60 is now 20%. By 2025 the number of people over 80 will increase by almost half and the number over 90 will double. These changes will have profound implications for provision of health and social care, particularly at primary care level, the site of most healthcare. Already 40% of the National Health Service budget and 50% of the social care and social services budget is spent on the over-65s. This is the background against which Steve Iliffe and Vari Drennan, experienced in general practice and community nursing, respectively, review the subject. They take us from the establishment of the NHS in 1948, through various organizational changes, to the current state with the advent of primary care groups. Although they make clear that this is not a textbook of geriatric medicine, they touch on the important causes of morbidity, mortality and disability in this age group. Where possible the authors base the text on their personal research. For example, Iliffe highlights the 75-and-over screening programme on which he did seminal work in the 1990s. The discussions are well referenced and have an international perspective. But I do have some criticisms. More could have been said about the implications of demographic change in different ethnic groups—especially since there is a widespread, and false, assumption that elderly people from minority groups will have supportive extended families. Also, the authors could have said more about the housing needs for long-term care of the elderly. But in general I recommend this latest addition to the Oxford General Practice Series.