Cognitive, functional, physical, and nutritional status of the oldest old encountered in primary care: a systematic review.

BACKGROUND: The oldest old (individuals over 90 years) are a fast-growing population. Characterizing their specificity would be helpful to adapt health care. This study aimed to characterize the cognitive, functional, nutritional, and physical status of individuals over 90. METHODS: We conducted a systematic review of cross-sectional or cohort studies of individuals aged 90 years old or more, living at home or in a nursing home, in April 2018. Two reviewers selected eligible articles, extracted data, and evaluated the risk of bias (assessed by the Newcastle-Ottawa Scale). RESULTS: The search strategy identified 3086 references; 35 articles were included referring to 8 cross-sectional and 27 longitudinal studies. Dementia was diagnosed in 30-42.9% of study participants, cognitive impairment in 12-50%, and 31-65% had no cognitive impairment. In terms of activities of daily living, 14-72.6% of individuals had no difficulty, 35.6-38% had difficulty, and 14.4-55.5% were dependent. For instrumental activities of daily living, 20-67.9% needed help. Regarding nutritional status, the Mini Nutritional Assessment Short Form mean score ranged from 10.3 (SD: 1.8) to 11.1 (SD: 2.4). Eight to 32% of individuals could not stand up from a chair, 19-47% could stand without the use of their arms; and 12.9-15% were not able to walk 4 m. CONCLUSIONS: These results suggest a heterogeneous population with a certain proportion of oldest old with a low level of disability. These findings suggest that a specific approach in the care of the oldest old could help prevent disability.

Becoming frail: a major turning point in patients' life course.

BACKGROUND: The frailty concept requires that practices should be adapted to meet the challenge of dependence. The GP is in the front line of management of frail elderly patients. OBJECTIVES: To explore the perception of elderly persons of the term and concept of frailty and to understand their perception of the risk of loss of independence. METHODS: Two qualitative studies by individual interviews in the homes of elderly persons identified as potentially frail by their GP, or diagnosed as frail and at risk of loss of independence. The sampling was theoretical. The analysis was carried out using an inductive approach following the phases of thematic analysis. The researchers used triangulation and collection was concluded when theoretical saturation had been reached. RESULTS: The concept of frailty was seen as forming an integral part of physiological ageing and appeared to be irreversible. The term of frailty had a negative connotation. The physical, cognitive and psychological components of frailty were present in the participants' discourse. Nutritional and sensory components were less present. Frailty due to inappropriate medication was not cited. Seven risk factors for loss of independence were identified: social isolation, poor physical health, poor mental health, loss of mobility, unsuitable living conditions, unsuitable environment, and low resources. CONCLUSIONS: Becoming frail is a major turning point in patients' life course. Coordinated multiprofessional management that takes account of patients' perceptions could help in negotiating a feasible care plan adapted to the patient's needs.

Primary care physicians and oncologists are partners in cancer announcement.

PURPOSE: The primary care physician (PCP) is central to cancer patients' management. Announcement of the diagnosis is a critical time for patients, even if they wish to be fully informed. The French National Cancer Plan, developed 10 years ago, includes a diagnosis disclosure procedure (DDP) to be used by oncologists, which makes specific provision for a time of communication with PCPs. So, we asked PCPs about their role in cancer announcement since the launching of the DDP. METHODS: A cross-sectional prospective study by postal questionnaire was sent to 500 PCPs in the largest region of France. It addressed (1) the characteristics of cancer disclosure, (2) PCPs' source of information of the diagnosis, (3) time of disclosure, (4) information exchange, and (5) the physicians' knowledge of the DDP. RESULTS: The response rate was 48 %. In 20 % of cases, oncologists delegated the announcement to PCPs. In 19 % of cases, it was the patient or their family who informed the PCP of the diagnosis. We identified three announcement phases of cancer diagnosis in the physicians' clinical practice: pre-disclosure, disclosure, and repeat disclosure. In 57 % of cases, PCPs lacked information on prognosis and in 60 % on treatment. Regarding the DDP, nearly half of PCPs did not know the procedure itself or its content. CONCLUSION: PCPs announce the cancer diagnosis, even if they have not received the necessary information to do so. The DDP needs to be adapted for use in primary care practice.

How general practitioners perceive the aging trajectory of oldest-old - A qualitative study.

BACKGROUND: A new population of older people is growing: the oldest-old. The care of the oldest-old (individuals aged 90 and over) is a new challenge in primary care. This study aimed to analyze the perception of General Practitioners (GP) on (1) the aging process of their patients up to a very advanced age, (2) how to adapt their practice to the care of these patients. METHODS: We conducted a qualitative study using focus group (face to face) and individual (video call) interviews of GPs in southwest France. The sampling was purposive. We analyzed the interviews using an inductive approach based on the phases of thematic analysis. We used researchers' triangulation during the process. Collection was concluded when saturation was reached. RESULTS: Three focus groups and one individual interview were conducted with a total of seventeen general practitioners. GP perception concerning aging and very advanced age were based on their personal experience and their daily clinical practice. Aging was perceived as an individual, unconscious, unpredictable and irreversible phenomenon. The shift towards "very old age" appeared inevitable. It could be a physical or psychological shift, or patients neglecting themselves or lacking a project. The care of the oldest-old became more specific and individual, adapted to the wishes of the patient. Those adaptations involve medical disengagement to focus on the most essential outcomes. The objectives of health care needed to be less strict with limited invasive practices. Prevention needed to focus mainly on prevention of falls and limitation of functional decline. CONCLUSION: GPs identified an inevitable and unpredictable shift from old age to very old age. The adaption of the theory of disengagement allowed us to identify a medical disengagement of the GPs in the care of their oldest patients.

The shift from old age to very old age: an analysis of the perception of aging among older people.

BACKGROUND: The oldest-old (individuals over 90 years) are a fast-growing population. Understanding the perceptions of older people about very old age is the first step towards developing optimal geriatric care for an aging population. This study aimed to explore the potential shift from old age to very old age through the exploration of older people's perception of aging. METHODS: Qualitative study conducted through individual interviews in the homes of older people. We voluntarily chose to include persons a decade under and above 90 years old to explore other factors than age that could participate in the shift from old age to very old age. The sampling was theoretical. We carried out the analyses using an inductive approach based on the phases of grounded theory. The researchers used triangulation. Collection was concluded when theoretical saturation was reached. RESULTS: Fourteen participants were interviewed. The shift from old age to very old age was not based on age but occurred when participants became conscious of the irreversibility of aging and its effects, and when they started living day-by-day, renouncing to any plan in a near future. The transition to very old age seemed to be preceded by a progressive disengagement from non-essentials activities. Participants reported a sensation of progressive social exclusion due to the loss of contemporaries or spouse, the difficulty to connect with younger generations or the absence of relationships in their neighborhood. The last step of life was feared, not because of the idea of death itself but because of the associated suffering and loss of autonomy. CONCLUSION: Precipitating and slowing factors of the shift to very old age were identified to help general practitioners support older patients throughout their life trajectories.

Evolution of Reactions to Uncertainty Among Residents During a Clinical Rotation.

BACKGROUND AND OBJECTIVES: For residents, uncertainty can be a source of motivation, interest, and stimulation, but it can also cause fear and anxiety that can lead to burn-out. Considering the prevalence of uncertainty in family medicine and the potential reactions from residents, reactions to uncertainty constitute an important research topic. This study sought to measure the evolution of reactions to uncertainty of family medicine residents in their first and second year, during a 6-month clinical rotation in a family physician's office. METHODS: This study utilized a prospective epidemiological cohort design of first- and second-year family medicine residents during a 6-month clinical rotation in a family physician's office during the 2018-2019 academic year. Data were collected at the beginning and end of the clinical rotation for the entire student population using the Physicians' Reactions to Uncertainty (PRU) questionnaire. RESULTS: One hundred-two respondents were matched at the end of the clinical rotation and were included in the analysis. At baseline, there were no significant differences between first- and second-year residents in each dimension of the PRU. Anxiety due to uncertainty decreased significantly in residents of both years. Concern about bad outcomes decreased, but not significantly, in both years. Reluctance to disclose uncertainty to patients decreased in first-year residents. CONCLUSIONS: During a 6-month clinical rotation, anxiety due to uncertainty decreased in first- and second-year residents. The frequency and the type of uncertain situations residents encountered could be investigated in future studies to better understand residents' reactions to uncertainty.

Discussing alcohol use with the GP: a qualitative study.

BACKGROUND: Despite most GPs recognising their role in the early diagnosis of alcohol use disorder (AUD), only 23% of GPs routinely screen for alcohol use. One reason GPs report for not screening is their relationship with patients; questions regarding alcohol use are considered a disturbance of a relationship built on mutual trust. AIM: To analyse the feelings and experiences of patients with AUD concerning early screening for alcohol use by GPs. DESIGN & SETTING: A qualitative study of patients (n = 12) with AUD in remission or treatment, recruited from various medical settings. METHOD: Semi-structured interviews were conducted, audiorecorded, and transcribed verbatim. The authors conducted an inductive analysis based on grounded theory. The analysis was performed until theoretical data saturation was reached. RESULTS: The participants experienced AUD as a chronic, destructive, and shameful disease. The participants expected their GPs to play a primary role in addressing AUD by kind listening, and providing information and support. If the GPs expressed a non-judgmental attitude, the participants could confide in them; this moment was identified as a key milestone in their trajectory, allowing relief and a move toward treatment. The participants thought that any consultation could be an opportunity to discuss alcohol use and noted that such discussions required a psychological and benevolent approach. CONCLUSION: The participants felt fear or denial from the GPs, even though they felt that discussing alcohol use is part of the GP's job. The participants requested that GPs adopt non-judgmental attitudes and kindness when approaching the subject of alcohol use.

[General practitioners' satisfaction after a geriatric assessment into primary care: data from FAP study]. / Ressentis des médecins généralistes ayant participé à un projet d'évaluation gériatrique en soins premiers : données issues de l'étude FAP.

In response to demographic challenges, primary care need to get familiar with the concept of frailty and the early detection of cognitive impairment. The « Frailty and Alzheimer's disease prevention into primary care ¼ (FAP) project introduced a geriatric evaluation with a nurse in primary care in order to assess older patients. Our work aimed to evaluate the general practitioner's (GPs) opinion involved in FAP project. METHODS: This is an observational descriptive study performed in Occitanie region. 26 GPs have involved in this project. The gathering of information was performed through an online survey. RESULTS: GPs estimated that most of the patients benefiting from a primary care geriatric evaluation would have declined hospital evaluation. 92% of the surveyed GPs gave a strongly positive or positive opinion regarding the detection of previously unidentified health issues and the improvement of patient care following this evaluation. 42% of the GPs found that the personalized plan of cares is difficult or very difficult to do. 73% of the GPs considered that they have a better knowledge of frailty syndrome and cognitive impairment after the evaluation. CONCLUSION: GPs feedback was very positive and promising for the future. It could be interesting to develop this geriatric evaluation in primary care into new regions.

Patients' satisfaction after a geriatric assessment into primary care: data from FAP study.

Given the current demographic situation, the primary care must consider the frailty concept. The « Frailty and Alzheimer's disease prevention into Primary care ¼ project (FAP) enabled geriatric assessment by a nurse in general practitioner's office to assess older persons. The aim of our study was to evaluate patients' satisfaction after geriatric assessment into primary care. METHODS: This is an observational descriptive study performed in the Occitanie area on a population of 268 older patients. Gathering of information was performed through a phone survey. RESULTS: A total of 133 questionnaires were filled in. Average age was 80 (±6) years old and 60% were women. 75.2% (n=100) were frail or pre-frail; 72% (n=89) of participants have been completely satisfied by this assessment; 71% (n=24) have been completely satisfied about their personalized plan of care; 79% (n=89) of them thought the general practitioners' office as the best place for geriatric assessment; 42% (n=52) would have refused the evaluation in the hospital. DISCUSSION: Patient's feedback is very encouraging. They were favorable to the development of the geriatric assessment into primary care and the generalization of the FAP project in other areas. Further studies must be carried out in order to evaluate the medico-economic effect of this care model.

Implementing Assessment of Cognitive Function and Frailty Into Primary Care: Data From Frailty and Alzheimer disease prevention into Primary care (FAP) Study Pilot.

BACKGROUND: Aging can be affected by frailty and chronic diseases causing physical, cognitive, sensory, and functional decline evolving gradually to disability. The assessment of older patients is carried out in some geriatric day hospitals (GDHFs). However, it seems difficult to assess all patients in these GDHFs. In this context, a care model, which uses a specialist nurse trained in primary care and geriatric assessment, has been developed. In this article, we describe the organization, details of the evaluation, and provide the main characteristics of the first 200 patients assessed over a 6-month period. METHODS: Persons aged 70 years and older were invited to undergo an evaluation at the general practitioner's (GP) office by a nurse if the GP thought that the patient was frail or if the patient had cognitive complaint or for both reasons. RESULTS: A total of 200 patients from 14 GP offices were assessed. Overall, the mean age was 81.3 (±5.92) years. More than one-half were female (66%), and 32% of participants lived alone. The average Mini-Mental State Examination score was 25.2 (±4.23); 16.7% had dementia; 12% of mild cognitive impairment were identified; 78% of patients were followed by their GP; and 2.5% were referred to a GDHF, 12% to specialized memory center, and 7.5% to geriatric consultation. CONCLUSIONS: This work foreshadows any other ambulatory options for older persons in his/her living area representing an alternative to the GDHF. It seems to meet the needs for this population and demonstrates the feasibility to implement in primary care a nurse trained to assess older patients in a GP office.

General Practitioners' Clinical Impression in the Screening for Frailty: Data From the FAP Study Pilot.

BACKGROUND: The progression of frailty is marked by an increased risk of adverse health outcomes in the elderly including falls, physical and/or cognitive disability, hospitalizations, and mortality. In primary care, the general practitioner's (GP's) clinical impression about their elderly patients' frailty state seems to be a key point in identifying frail individuals in their clinical practice. The aim of this article is to examine if GPs' clinical impressions regarding frailty concurs with objective measures of the gold standard frailty phenotype as described by Fried in community-dwelling older persons. DESIGN: Cross-sectional study in 14 primary care GP offices in the Toulouse area from May 1st to October 31st, 2015. PARTICIPANTS: Fourteen GPs screened their patients ≥70 years old. MEASUREMENTS: GPs' "frailty impression" was based on the Gérontopôle Frailty Screening Tool. "Objective measures of the five Fried frailty criteria" were obtained by a geriatric nurse through standardized testing. The capacity of the GPs' clinical impression to detect participants objectively measured as frail was examined with diagnostic values of observed sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). RESULTS: A total of 268 participants were screened by GPs and assessed by a nurse. Mean age was 81 years and 62.3% were female. According to the objective measures of Fried's criteria, frailty (three to five criteria) and pre-frailty (one to two criteria) states were identified in 31% and 45.2% of participants, respectively. The Se of the GPs' impression was good (80.39%; 95% confidence interval [CI], 74.27%-85.61%), and the Sp was moderate (64.06%; 95% CI, 5.10%-75.68%). The overall PPV of the GPs' impression was 87.70% (95% CI, 82.12%-92.04%), and the NPV was 50.51% (95% CI, 39.27%-61.91%). Although the PPV increased with age reaching 93.33% (95% CI, 85.12%-97.80%) among patients ≥ 85 years old, the NPV decreased accordingly to a minimal 21.43% (95% CI, 4.66%-50.80%) in that subgroup. CONCLUSION: The present study highlights the importance of the GPs' clinical impression on frailty as a fair means to identify this syndrome in community-dwelling older patients in primary care. This clinical impression may not be sufficient, however, and some objective tests could be added to improve the accuracy of frailty detection in older patients in primary care.

RETRACTED: Development and Implementation of the Advanced Practice Nurse Worldwide With an Interest in Geriatric Care.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editors-in-Chief. The authors have plagiarized part of a report that had already appeared in Delamaire M-L, Lafortune G. Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries. OECD Health Working Papers No. 54. Paris: Organisation for Economic Co-operation and Development, 2010. One of the conditions of submission of a paper for publication is that authors declare explicitly that their work is original and has not appeared in a publication elsewhere. Re-use of any data should be appropriately cited. As such this article represents a severe abuse of the scientific publishing system. The scientific community takes a very strong view on this matter and apologies are offered to readers of the journal that this was not detected during the submission process.