Unburdening dementia - a basic social process grounded theory based on a primary care physician survey from 25 countries.

OBJECTIVE: To explore dementia management from a primary care physician perspective. DESIGN: One-page seven-item multiple choice questionnaire; free text space for every item; final narrative question of a dementia case story. Inductive explorative grounded theory analysis. Derived results in cluster analyses. Appropriateness of dementia drugs assessed by tertiary care specialist. SETTING: Twenty-five European General Practice Research Network member countries. SUBJECTS: Four hundred and forty-five key informant primary care physician respondents of which 106 presented 155 case stories. MAIN OUTCOME MEASURES: Processes and typologies of dementia management. Proportion of case stories with drug treatment and treatment according to guidelines. RESULTS: Unburdening dementia - a basic social process - explained physicians' dementia management according to a grounded theory analysis using both qualitative and quantitative data. Unburdening starts with Recognizing the dementia burden by Burden Identification and Burden Assessment followed by Burden Relief. Drugs to relieve the dementia burden were reported for 130 of 155 patients; acetylcholinesterase inhibitors or memantine treatment in 89 of 155 patients - 60% appropriate according to guidelines and 40% outside of guidelines. More Central and Northern primary care physicians were allowed to prescribe, and more were engaged in dementia management than Eastern and Mediterranean physicians according to cluster analyses. Physicians typically identified and assessed the dementia burden and then tried to relieve it, commonly by drug prescriptions, but also by community health and home help services, mentioned in more than half of the case stories. CONCLUSIONS: Primary care physician dementia management was explained by an Unburdening process with the goal to relieve the dementia burden, mainly by drugs often prescribed outside of guideline indications. Implications: Unique data about dementia management by European primary care physicians to inform appropriate stakeholders. Key points Dementia as a syndrome of cognitive and functional decline and behavioural and psychological symptoms causes a tremendous burden on patients, their families, and society. •We found that a basic social process of Unburdening dementia explained dementia management according to case stories and survey comments from primary care physicians in 25 countries. •First, Burden Recognition by Identification and Assessment and then Burden Relief - often by drugs. •Prescribing physicians repeatedly broadened guideline indications for dementia drugs. The more physicians were allowed to prescribe dementia drugs, the more they were responsible for the dementia work-up. Our study provides unique data about dementia management in European primary care for the benefit of national and international stakeholders.

Spirituality in palliative home care: a framework for the clinician.

PURPOSE: Spiritual care at the end of life remains poorly understood despite its promotion by the World Health Organisation. The purpose of this paper was to develop a consensus-based framework of the main elements of spiritual care in palliative home care. METHODS: Expert meeting using the nominal group technique, followed by a two-stage web-based Delphi process, was used. Experts from three stakeholder groups (physicians, professional spiritual care givers and researchers) representing two countries (Belgium and the Netherlands) participated in this study. RESULTS: Fourteen elements of spiritual care were retained: (1) being sensitive to patient's fear of the dying process; (2) listening to the patient's expectations and wishes about the end of life; (3) giving attention to patient's wishes about the design of the farewell; (4) offering rituals if the patient experiences them as meaningful; (5) listening to the stories, dreams and passions of the patient; (6) helping the patient find strength in inner resources; (7) connecting with the patient in truth, openness and honesty; (8) supporting communication and quality of relationships; (9) making sure the patient feels comfortable and safe; (10) seeing spirituality as an interwoven, though specific dimension; (11) caring for your own spirituality; (12) knowing and accepting your vulnerability; (13) being able to learn from your patient; and (14) having an interdisciplinary team that is there when needed. CONCLUSIONS: The experts agreed to the 14 main elements of spiritual care in palliative home care. There were no differences in this regard between the stakeholder groups. This study provides a first step towards the development of an interdisciplinary spiritual care model in palliative home care.

Diagnosis, prevention and control of urinary tract infections: a survey of routine practices in Belgian nursing homes.

BACKGROUND: Urinary tract infections (UTIs) are one of the most frequently reported infections in older adults and the most common reason for antimicrobial prescribing in nursing homes (NHs). In this vulnerable population, both a good diagnosis and prevention of these infections are crucial as overuse of antibiotics can lead to a variety of negative consequences including the development of multidrug-resistant organisms. OBJECTIVE: To determine infection prevention and control (IPC) and diagnostic practices for UTIs in Belgian NHs. METHODS: Local staff members had to complete an institution-level questionnaire exploring the availability of IPC practices and resources and procedures for UTI surveillance, diagnosis, and urinary catheter and incontinence care. RESULTS: UTIs were the second most common infections in the 87 participating NHs (prevalence: 1.0%). Dipstick tests and urine cultures were routinely performed in 30.2% and 44.6% of the facilities, respectively. In non-catheterised residents, voided or midstream urine sampling was most frequently applied. Protocols/guidelines for urine sampling, urinary catheter care and incontinence care were available in 43.7%, 45.9% and 31.0% of the NHs, respectively. Indwelling catheters were uncommon (2.3% of the residents) and urinary retention (84.9%) and wound management (48.8%) were the most commonly reported indications. Only surveillance was found to significantly impact the UTI prevalence: 2.2% versus 0.8% in NHs with or without surveillance, respectively (P < 0.001). DISCUSSION: This survey identified key areas for improving the diagnosis and prevention of UTIs, such as education and training regarding the basics of urine collection and catheter care.