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European General Practice Research Network (EGPRN).

Abstracts from the EGPRN meeting in Edirne, Turkey, 17–20 October, 2015. Theme: ‘Research on Active Ageing in Family Medicine/General Practice.’

Ageing is not a disease, but a natural developmental process (if we are lucky). As we age, many of our bodily functions decline. Heart, lung, muscle, kidney and cognitive functions are some examples of expected decline with ageing. One should however be aware of the great variability within the elderly. Many different factors affect the variability in the elderly, e.g. heredity, previous diseases, environmental factors, but also different coping abilities. Healthy ageing means that everyone has a right to the highest attainable standard of physical and mental health, no matter what age. To accomplish this, primary care has an important role to play. Effective interventions within the following areas will be presented: Appropriate use of medications is especially important for older people. Drug-related problems (DRPs) are a well-known cause of morbidity and mortality in the elderly-but are often preventable. Older people are vulnerable to DRPs for several reasons-including physiological alterations that affect pharmacodynamics and pharmacokinetics, resulting in enhanced and prolonged drug effects; increased prevalence of chronic diseases; and concomitant use of other medications. Medication review and other kinds of interventions have successfully reduced the use of inappropriate medications and also led to positive health outcomes. Physical activity has a number of positive effects for older people. The health benefits of exercise and risks of inactivity have become increasingly evident in the twenty-first century. Physical activity improves quality of life in adults with chronic conditions, has positive effects on coronary heart disease as well as diabetes type 2 risk and reduces the risk of falls. Despite these facts, many older adults are physically inactive and this inactivity increases with age. It is not easy to increase physical activity in older adults but there are examples of effective interventions within primary care. Falls are the most common cause of injuries among older people. A significant number of hospital admissions of patients older than 65 years are due to falls. Upper extremity fractures and hip fractures are the most common fall-related injuries that lead to emergency department visits. The risk of falls also affects quality of life and may cause social isolation. Some falls are due to inappropriate medications and this is an area where primary care is suitable for interventions. Vaccination of older people affects morbidity and mortality. There is overwhelming evidence regarding the positive effects of vaccination for older people. Loneliness increases with age, especially among the elderly. Loneliness and social isolation are important risk factors of ill health. There is a lack of evidence even if some smaller studies in primary care have been effective.
State of the art of family medicine in Turkey also defined as a core competence in the European General Practice/Family Medicine (GP/FM) definition and the subject has been also included by the EGPRN research strategy. However, both concepts as one would expect, have been widely discussed in the childhood and early adulthood leaving actions to be undertaken for the seniors. Nevertheless, the key factors that have an impact on an active and healthy ageing and exploration of existing potentialities for GP/FM are important. This keynote will address conceptually the subject of prevention in the elderly and will attempt to illustrate the determinants of active and healthy ageing based on evidence available in the current literature. There are efforts that need to be undertaken to assist seniors to live not only longer but also to decrease cognitive decline or dependency and the related consequences. This requires comprehensive and wellcoordinated actions under a patient-centered approach, focused on avoiding malnutrition, in strengthening of muscles and physical activity, prevention of falls and reduction of fractures, complete vaccination coverage as well as in reducing the side effects of polypharmacy in multimorbid patients. Assessment tools, which can be used in a primary care setting, can elucidate and analyse the concepts and the theory. The European Commission has determined active and healthy ageing as a major societal challenge common to all Member States and to that direction a 2020 strategy that includes the European Innovation Partnership and aims 'to improve the quality of life of older people and enable them to stay active for as long as possible' has been put forward. Good practices that can be used in early diagnosis of frailty in the European setting are illustrated in the EU edition of an action group on 'Prevention and early diagnosis of frailty and functional decline, both physically and cognitive, in older people.' Data and first results of initiatives relevant to early diagnosis of frailty and improvement of the quality of life of older people undertaken by the Cretan Rural-practice-based research network as well as their experiences can also shed light. Challenges of both family practice research and clinical practice exist, and can be resolved by indicating areas of high priority and suggesting collaborative work with EGPRN. Background: Behavioral and psychological symptoms of dementia (BPSD) are treated with neuroleptics that are associated with severe side effects. There is an incresing evidence of potencial harms associated with the use of these drugs and guidelines increasingly recommend restricting their use. Research question: To evaluate the effectiveness of a support intervention for nursing home staff in reducing the number of neuroleptics in Nursing Homes (NH) patients with dementia. Methods: Multicenter, longitudinal, prospective study pre-post intervention. Five NH (441 residents, 42.94% dementia) in Barcelona. Participants: Residents of five NH with dementia and prescription of one or more neuroleptics. Exclusion: Residents with severe mental illness. Guideline for teatment of BPSD was created by a multidisciplinary team. A family physician and a pharmacist conducted a medication review and elaborated a therapeutic plan (TP) for each patient included, based on the guideline and focusing on alternatives to drugs for the management of BPSD. This TP was delivered to NH staff in a personalized interview. Pre-post intervention, at one and six months (12 July-14 February). Primary: Number of neurolepyics prescribed before/after intervention, at months one and six. The differences within groups pre and post intervention were assessed using paired t-test. All analysis was bilateral with a confidence level of 95% and was carried out using Stata. Results: n = 182, mean age 96.85 (Standard deviation [SD]:7.45). Mean number of neuroleptics prescribed per patient before intervention was 2.78 (SD:1.53) and 1.93 (SD: 1.25) after (P < 0.001). Total number of neuroleptics before intervention was 508 and 332 after, with a withdrawal of 176 (34.65%). The reduction at one and six months was 39.57 and 40.55%, respectively. Proportions of drop outs were 11.35% at the first month and 16.22% at the sixth month. Conclusion: The intervention conducted by a multidisciplinary skilled team with the elaboration of a patient-centred therapeutic plan provides an effective reduction of neurolepyics use for management of behavioral and psychological symptoms of dementia. The effectiveness of this intervention continues after six months.

THEME PRESENTATIONS
The GPs' considerations on medication management for older complex patients: a qualitative study Judith Sinnige, Joke C Korevaar, Jan van Lieshout, Gert P Westert, Francois G. Schellevis and Joz e C. Braspenning Radboud University Medical Center, Nijmegen, the Netherlands. Email: Judith.Sinnige@radboudumc.nl Background: In older patients with multimorbidity attention to appropriate medicine prescribing is of major importance. Due to the heterogeneity of this complex patient group, it is often difficult for general practitioners (GPs) to make decisions concerning medication management. It is unclear what kind of strategy GPs follow in the patient's medication management, how the GP takes decisions, and by what factors medication management is influenced. Research question: What are the GP's considerations on medication management for older patients with multimorbidity and polypharmacy, and how does this differ between GPs? What are the GP's perspectives, and needs, on decision making support to facilitate medication management for these patients? Methods: In this qualitative study, focus groups were organized with experienced GPs in the Netherlands. GPs completed a survey individually, presenting questions about medication management of four case vignettes of older patients with multimorbidity and polypharmacy. The vignettes were discussed to answer our research questions. The focus groups were recorded, transcribed and analyzed using the Framework approach. Results: Twelve GPs participated in two focus groups. Preliminary results showed that variation existed in the medication management approach described by GPs. Four predominant themes were related to GPs' considerations on medication management: (1) prioritizing treatment according to determined treatment goals; (2) focus on one or two problems rather than treatment of all problems at once; (3) clinical guidelines as the basis; and (4) influence of patient characteristics. As regards decision making support, GPs value the concept of medication reviews on consult and practice level, electronic decision aids and interventions to identify frail elderly. Conclusion: Several factors are related to GPs' considerations on medication management, and can complicate treatment of older patients with multimorbidity and polypharmacy. Yet, medication reviews, electronic decision aids and insight into the practice's frail population seem promising tools to facilitate management.
Randomized clinical trial evaluating the effectiveness of a primary care intervention using the Nintendo TM Wii console to improve balance and decrease falls in the elderly Research question: Can an intervention utilizing the Nintendo TM console improve balance, thereby decreasing both the fear of falling as well as the number of falls? Methods: This is a controlled, randomized clinical trial, carried out on patients over 70 years in age, from five primary care centers in the city of Matar o (Barcelona). Overall 380 patients were necessary for the intervention group (IG) that carried out the balance board exercises in two sessions per week for a three-month period, and 380 patients in the control group (CG). Balance was evaluated using the Tinetti's test, the one foot stationary test and with the console, at the start of the study, at the end of the intervention (three months) and one year later. Telephone follow-up was also conducted to keep track of falls and their consequences. Preliminary results: A total of 951 patients; 461 CG and 490 IG. The sample got bigger since losses were more than expected. After three months, analyzing data from 312 patients in the CG and 214 in the IG, we found improvement on the one foot stationary test in the IG (77.9% first visit and 89.4% after training P = 0.001) and improvement of the fear of falling. On Tinetti's test, we found just a trend, without achieving statistical significance. At one year and after analyzing 34.7% of the whole sample, we found fewer falls in the IG, achieving statistical significance. Conclusion: An easy and economical training by means Nintendo TM Wii improves the one foot stationary test and reduces the fear of falling. It could reduce the number of falls but it is prudent to wait for further results from the whole sample.
Active ageing? Patient's motivation to participate in a health check-up in general practice Regine B€ olter, U. Kilian, K. Goetz and A. Miksch Heidelberg University Hospital, Heidelberg, Germany. E-mail: regine.boelter@med.uni-heidelberg.de Background: In 1989, the German health insurance system introduced 'check-up 35' as a biennial tool for prevention and health promotion. Health goals should be avoiding chronic conditions, maintaining physical health and promoting wellbeing for active ageing. Although this is used by about 50% of eligible subjects over 35years old, the motivation of these patients is underinvestigated. The 2012 Cochrane review reports that health checks did not reduce morbidity or mortality.
Research question: The aim of the study was to evaluate patients' motivation for this health check-up. Methods: A qualitative study was performed. Patients were interviewed to evaluate their motivation for participation in this check-up. Data analysis of the qualitative study was conducted using content analysis according to Mayring. Results: To date, 10 patients (on average 56 years old) have been interviewed; 80% were female. The main category 'patient motivation' could be divided into four subcategories: (1) affirmation of good health; (2) individual responsibility; (3) follow-up of pre-existing conditions; and (4) early diagnosis and healing. Most participants wanted a full physical examination. They wanted to affirm themselves as being in good physical health. Their active participation was experienced as a form of individual responsibility for their own health. Furthermore, they wished for monitoring of a pre-existing condition. Another motivation was early diagnosis in the hope of a better chance for full healing of a disease. Conclusion: From the viewpoint of our participants, checkups were important to confirm good physical health. Considering the background of the Cochrane review, there is a conflict existing between the expectations and the hopes of our participants for an affirmation of physical health and the existing scientific evidence. Opportunities and limitations of the check-up must be communicated clearly. General practitioners should support patients to enable them to live with uncertainty and enhance health education, in order to empower patient's individual responsibility in active ageing. Background: Due to the increase in the population of old subjects (over 85 years), it is important to know whether the factors of mortality in young adults are similar in this age. Our group discovered that tools used in community geriatric assessment were useful for community-dwelling subjects aged 85 years at baseline to predict mortality at three years of follow up. Research question: Which are the predictors of death in an oldest old cohort after five years of follow-up? Methods: The Octabaix study is a prospective, communitybased study involving 328 subjects aged 85 years in the geographical area of Baix Llobregat (Spain). The intervention consisted in a community-based multifactorial program. The control participants received usual care. Data on functional and cognitive status, comorbidity, nutritional and risk of falls, quality of life, social risk, long-term drug prescription and laboratory analysis were collected. Proportional hazards and linearity assumptions were evaluated for the Cox models to determine the variables associated with five-year mortality. Results: Mortality after five years was 42.073%. Patients who survive were predominately women and had significantly better baseline functional status of daily living (P < 0.001) (Barthel and Lawton Index), better cognitive performance (P < 0.001) (Spanish version of the Mini-Mental State Examination), lower comorbidity (P < 0.001) (Charlson), lower nutritional risk (P < 0.001) (Mini Nutritional Assessment), lower risk of falls (P < 0.001) (Tinetti Gait Scale), lower percentage of heart failure (P = 0.002) and COPD (P = 0.03) and were taking less chronic prescription drugs (P = 0.02). Cox regression analysis identified the Lawton Index (Hazard Ratio [HR] = 0.83, 95% CI = 0.75-0.91) and the comorbidity (HR = 1.17, 95% CI = 1.01-1.36) as independent predictors of mortality at five years. These are preliminary results of an ongoing study. Conclusion: The ability to perform instrumental activities of daily living and the global comorbidity at baseline are the best predictors of mortality in 85-year-old community-dwelling subjects after a five-year follow-up period. Background: The prevalence of disability increases with age. Identifying the frail population to conduct effective interventions that can prevent or delay the loss of autonomy is a public health priority. Research question: To evaluate the effectiveness of a multifactorial intervention based on physical activity, diet, memory workshops and medication review, to modify muscle strength and physical and cognitive performance in frail people 65 years or older. Methods: A randomized clinical trial with control group (CG) and blind evaluations, conducted in eight Primary Care Centers in Barcelona. A total of 352 patients, 176 in each group. Inclusion criteria: 65 years old, Barber test 1, Get up and go test (TGUGT) 10 to 30 seconds, no severe cognitive impairment. Intervention group (IG): Rehabilitative therapy, hyperproteic shakes, memory workshop, review of medication. Measurements: Short Physical Performance Battery (SPPB, range 0-12), Hand Grip Strength (HGS), neuropsychological evaluation (Barcelona Test) and number of prescriptions at baseline and after the intervention, in both groups. Analysis of variance for repeated measures was performed between baseline and after intervention. Results: Overall, 75.3% women, mean age 77.3 (SD:7.2). Mean number of prescriptions 7.5, mean TGUGT 14.8 seconds, mean SPPB 7.2, mean HGS 16.5. No differences between groups at baseline. After intervention, in the IG prescriptions decreased (7.7 to 6.9) and SPPB and HGS improved (7.1 to 8.1 and 16.5 to 18.7), P < 0.001, while the contrary was observed in CG. Cognitive performance (Verbal Memory, Animal Naming Test, Evocation of words, Verbal abstraction) also improved in the IG, and compared to CG (P < 0.001). Conclusion: The intervention on frail patients has proved to be effective in terms of strength and cognitive performance at short term. Long-term effectiveness and adverse outcomes (falls, disability, hospitalization, institutionalization, death) will be evaluated in the follow-up. The satisfaction among IG patients also encourages the continuity of these types of interventions.

Effectiveness of a multifactorial intervention to modify frailty parameters in the elderly
Frailty syndrome among younger and elder adults during times of austerity Background: Frailty as a dynamic predictability has received prompt attention in the literature by research institutes and funding organizations, while it has been noted as one of the most challenging tasks for general practitioners (GPs) in Greece. The Greek economic crisis that has increased unemployment, homelessness and leaving people uninsured is anticipated to impact vulnerable individuals with frailty. Research question: The main aim was to assess the burden of frailty among economically vulnerable population groups in the city of Heraklion in Crete? Which determinants can predict frailty? Methods: Participants (n = 314; response rate = 98%) were all adults (over 18 years old) who attended any of the services of the 'Social Space,' a hospice (Foundation Kalokairinou). Frailty syndrome was assessed through the 'Frail scale,' along with the WHO well-being index, EuroQol and several supplementary questions. All analysis tests were performed using SPSS V20.0 (a = 0.05). Results: Frailty prevalence among all participants was 9.5% (pre-frailty = 18.4%; frailty and pre-frailty = 28.1%). These rates increased among eldest adults (over 65 years) reaching 55.5% (22.2 and 33.3% men and women, respectively). Age, marital status, way of living, children living away from the participants, low income, years of smoking, alcohol consumption and the number of co-morbidities were related to 'frailty syndrome' (P < 0.05). Wellbeing score and self-perceived health status were conversely related to frailty and pre-frailty stages (P < 0.02). Exercise acts protectively on frailty (OR = 0.2, 95% CI = 0-0.4, P = 0.01) whereas living alone (OR = 2.6), number of co-morbidities (OR = 2.5), years of smoking (OR = 1.4), alcohol consumption (OR = 1.4) and age (OR = 1.1) were the major risk factors (P < 0.05). Conclusion: The burden of the 'Frailty syndrome' cannot be ignored during the period of austerity among elder adults. A diagnostic model based on the explored identified determinants of frailty could be formed to guide GPs in its early diagnosis and intervention.

Support measures for informal caregivers
Evi Willemse, Sibyl Anthierens, Maria Isabel Farf an-Portet, Veronique Verhoeven and Roy Remmen University of Antwerp, 2610 Antwerp, Belgium. E-mail: evi.willemse@thomasmore.be Background: The number of very old people in Europe will increase drastically and there will be an increase in need of long-term care over time. Care provided by family members, friends and neighbours remains an essential piece of longterm care in all European countries. Providing informal care may have negative consequences on people's physical and psychological health and may affect labour market participation. How to support informal caregivers is an important topic in how to ensure the sustainability of the long-term care system. Research question: What are the experienced advantages and short-comings of available support measures for informal caregivers in Belgium and in four other European countries? Methods: An empirical qualitative study using an embedded multiple case-study design was performed. Semi-structured interviews were carried out with 38 ICG, with at least five informal caregivers living in each geographical region (Belgium, France, Germany, the Netherlands and Luxembourg). A thematic analysis was done per region. Results: In all regions, informal caregivers ensure the continuity of care through coordination of the services provided by health and care professionals. Information on available services often is provided at discharge from the hospital. Timely access to proactive information seems one of the key issues that is lacking in Belgium, this in contrast with the cases abroad. Conclusion: Informal caregivers deal every day with the complex home care system in Belgium. Coordinators of care in close collaboration with the GP, can help to coordinate home care services and provide coordination support to dependent elderly and their informal caregivers. Existing tools such as the general medical record (GMD/DMG) and the BelRAI could help care workers to better support informal caregivers and elderly. Background: Testing cognition in general practice is often difficult, because many of the established tests do require more time than is affordable. The AQT (A Quick Test of Cognitive Speed) can be performed in a short time and is based on naming of colors, forms and numbers.
Research question: The current investigation was set out to determine the time that mentally healthy German general practice patients need to perform tasks of the AQT to determine standard values. Methods: Consecutive patients (60 years or older) were recruited by their attending general practitioner from three practices in Saxony, Germany. SIDAM (Structured Interview for the Diagnoses of Dementia of the Alzheimer type) was performed as a pre-test to rule out cognitive deficits. The AQT was analysed based on audio-files using Audacity 2.1. All numbers are presented as mean ± SEM. Results: Twenty-two patients refused to participate, 10 were excluded due to a SIDAM-Score less than 34 points and data from four patients could not be included due to recording problems. Finally data of 204 patients (age 71.18 ± 0.41 years; 109 women) were analysed. The mean time for the different tasks were 27.34 ± 0.36 (color), 36.9 ± 0.63 (form), 70.31 ± 0.38 (color & form) and 27.08 ± 0.38 (color), 18.57 ± 0.23 (number), 57.1 ± 0.94 (color & number) seconds. There were no gender related differences. For most of the tasks, the time needed increased with age and was statistically significant, comparing the groups from 60 to 69, 70 to 79 and 80 to 89 years. Conclusion: We report standard values for the AQT in German speaking patients. Further investigations should focus on the analysis of pauses in speech during the tasks, the reliability of the AQT and possible learning effects. Also the correlation to SIDAM-Score needs to be assessed. Research question: What factors are associated with appropriate knowledge of the indications for drugs prescribed to older patients with polypharmacy? Methods: In a primary care setting, using home interviews and postal questionnaires, patients aged 60 years and over who were taking five or more prescribed drugs simultaneously, were asked about their medication. With multiple logistic regression analysis, we evaluated the association (odds ratio, OR) between medication knowledge and explanatory variables like medication use, sex, age, living situation and educational level.
Results: Seven hundred and fifty-four participants reported an average daily intake of nine (SD 3.0) prescribed drugs. Only 15% of the patients could disclose the indication of all their prescribed drugs. Variables that were negatively associated with appropriate reporting of all indications were: taking many prescribed drugs (e.g. 10 vs. 5: OR 0.05, 95% CI 0.02-0.11), age 80 years or over (vs. 60-69 years: OR 0.47, 95% CI 0.24-0.91), and male sex (OR 0.53, 95% CI 0.32-0.88). Patients living with a partner were more knowledgeable than patients living alone (OR 2.11, 95% CI 1.17-3.81). We did not find an association with 'educational level.' Conclusion: Among older patients using five or more prescribed drugs, there was little understanding of the indication for their drugs, in particular in patients taking the highest number of drugs, patients aged 80 years or over, and men. Background: This is an update on research using data from routine family practice structured using Episodes of Care (EoC) and coded using ICPC to study the contribution of patients' reasons for encounter (RfE) to the final diagnoses of common problems.We will review the current state of the art of research, demonstrate current tools to implement a Learning Healthcare System, and show how the research is to be expanded within an international collaborative study with the involvement of several EGPRN partners. Objectives: To improve and extend data capture of all elements of the doctor-patient encounter in primary care through new optimised electronic medical record systems. To make such tools available to keen researchers in clinical practice in many European countries to collect new datasets of such size and scope as were previously not available. To extend the analysis of diagnostic associations with these new enlarged datasets, to create new evidence to support the process of diagnosis in primary care worldwide. To perform new statistical analyses of the diagnostic process to allow the calculation of the effect of multiple predictors for a diagnosis, the calculation of the associations between reasons for encounter themselves, and the effect of time on a diagnostic association, during the development of an episode of care. Methods: Databases collected directly from the electronic patient records of participating family doctor (FD) practices in different European countries.The relationships between RfEs and episode titles have been analysed with Bayesian methods. The extension to Latent Class Analysis models shall be demonstrated. Results: The relationships between patients' RfEs and doctors' diagnosis within EoCs of common health problems, as coded using ICPC, are presented, and practical applications demonstrated. needs expertise in interpretation. Research question: The aim of our survey was to find out potential differences in the use of ECGs in general practices in Europe. Methods: We asked at least two key-informants-active members of the European General Practice Research Network (EGPRN). From each membership country to complete a questionnaire on ECG use in their country. In case of inconsistency of answers, we asked a third person from their country to confirm the validity of the answers. Data about the clinical situation in which responders record ECG were also analysed. Results: Representatives from 27 out of 31 (87.1%) EGPRN membership countries responded. Complete data were available for analysis from 25 countries (80.6%). In 23 (92%) countries GPs record and interpret ECG, but in only nine countries (36.0%) an ECG device is an obligatory item of equipment. Education about ECGs at all levels of training is present in most countries (from 84.0 to 88.0%). Based on the key-informants' opinion, in 21 countries (84.0%) GPs are skilled enough to interpret ECGs. There was no consensus about the use of ECGs in particular indications (e.g. panic attack, preventive check-ups). National ECG guidelines exist in only two (8.0%) countries. Conclusion: This is the first study exploring the situation about ECG use in general practice in European countries. Lack of guidelines about ECG in general practice in most of the countries and organisational differences could be a reason for differences in indications for recording ECGs.