Frailty in primary care: challenges, innovations, and future directions.

Frailty is one of the biggest challenges to healthy ageing, and yet our understanding and management of frailty is in its infancy. In this editorial we outline challenges, innovations and future directions in frailty research in primary care, and invite contributions to BMC Primary Care's "Frailty in Primary Care" Collection.

Diabetes-related quality of life in six European countries measured with the DOQ-30.

BACKGROUND: The quantification of diabetes-related quality of life (DR-QoL) is an essential step in making Type 2 Diabetes (T2DM) self-management arrangements. The European General Practitioners Research Network (EGPRN) initiated the EUROBSTACLE study to develop a broadly conceptualised DR-QoL instrument for diverse cultural and ethnic groups; high and low-income countries. In 2016 the Diabetes Obstacles Questionnaire-30 (DOQ-30) was introduced. OBJECTIVES: The research aimed to study obstacles a patient with diabetes (PWD) may face in everyday life. First, we assessed how descriptive and clinical characteristics and the residential country were associated with the obstacles. Secondly, we calculated the proportion of respondents who expressed obstacles. METHODS: Data were collected in 2009 in a cross-sectional survey in Belgium, France, Estonia, Serbia, Slovenia, and Turkey. Multiple linear regressions were computed to detect associations between descriptive and clinical characteristics, residential country, and obstacles. Percentages of respondents who perceived obstacles were calculated. RESULTS: We found that although descriptive and clinical characteristics varied to quite a great extent, they were weakly associated with the perception of obstacles. The residential country was most often associated with the existence of some obstacle. The highest percent (48%) of all respondents perceived 'Uncertainty about Insulin Use' as an obstacle. CONCLUSION: Descriptive and clinical characteristics were weakly associated with perceived obstacles. However, the residential country plays an essential role in the decline of the QoL of PWDs. Education of both PWDs and healthcare professionals (HCPs) plays an essential role in countering the fear of insulin.

Ciencias del deporte, basadas en la evidencia / Ciências do esporte baseadas em evidência / Evidence-based sports sciences

Resumen Las prácticas basadas en la evidencia son una herramienta útil y necesaria para las ciencias del deporte. La experiencia de las ciencias médicas, basadas en la evidencia podría ser útil para la implementación de este nuevo enfoque. Las prácticas basadas en datos empíricos, en las ciencias del deporte, también podrían afectar además de los campos de la práctica de la formación, como la gestión, la legislación y la educación. Esto permitirá que la toma de decisiones se base en las mejores pruebas científicas disponibles. En esta revisión, se resumen los enfoques y modelos de cómo aplicar la práctica basada en la evidencia, en las ciencias del deporte. También se comparte un enfoque de cinco pasos, con el objetivo de proporcionar una herramienta práctica. Ciertas condiciones requieren comenzar con la práctica de la evidencia. En primer lugar, la literatura científica debe responder a la pregunta. Acceso a bases de datos científicos, saber caminar por la selva del conocimiento, dominio del inglés (ya que la mayoría de los trabajos se publican en inglés) es obligatorio. Un compromiso de las partes interesadas en las ciencias del deporte, con la práctica basada en la evidencia y la eliminación de los obstáculos a la aplicación, sería un enfoque prometedor para las prácticas basadas en la evidencia, en las ciencias del deporte, en un corto período de tiempo.

Resumo A prática baseada em evidência é uma ferramenta útil e necessária para a ciência do esporte. A experiência da ciência médica baseada em evidência poderia ser útil para a implementação desta nova abordagem. As práticas baseadas em evidência em ciências do esporte também poderiam afetar, além das áreas de prática de treinamento, como gestão, legislação e educação. Isto permitiria que a tomada de decisões fosse baseada nas melhores evidências científicas disponíveis. Esta revisão resume abordagens e modelos de como aplicar a prática baseada em evidência na ciência do esporte. Também compartilha uma abordagem em cinco etapas com o objetivo de fornecer uma ferramenta prática. Certas condições exigem que se comece com a prática da prova. Em primeiro lugar, a literatura científica deve responder à pergunta. O acesso às bases de dados científicos, saber caminhar pela selva do conhecimento, o domínio do inglês (já que a maioria dos artigos são publicados em inglês) é obrigatório. Um compromisso das partes interessadas na ciência do esporte com a prática baseada em evidências e a remoção de barreiras à implementação seria uma abordagem promissora para a prática baseada em evidência na ciência do esporte em um curto período de tempo.

Abstract Evidence-based practice is a useful and necessary tool for sports science. The experience of evidence-based medical science could be useful for the implementation of this new approach. Evidence-based practices in sport sciences could also affect, in addition to the fields of training practice, such as management, legislation and education. This will allow decision making to be based on the best available scientific evidence. This review summarises approaches and models of how to apply evidence-based practice in sport science. It also shares a five-step approach with the aim of providing a practical tool. Certain conditions require starting with the practice of evidence. First, the scientific literature must answer the question. Access to scientific databases, knowing how to walk through the jungle of knowledge, mastery of English (since most papers are published in English) is mandatory. A commitment by sport science stakeholders to evidence-based practice and the removal of barriers to implementation would be a promising approach to evidence-based practice in sport science in a short period of time.

Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment.

BACKGROUND: Vitamins and minerals have many functions in the nervous system which are important for brain health. It has been suggested that various different vitamin and mineral supplements might be useful in maintaining cognitive function and delaying the onset of dementia. In this review, we sought to examine the evidence for this in people who already had mild cognitive impairment (MCI). OBJECTIVES: To evaluate the effects of vitamin and mineral supplementation on cognitive function and the incidence of dementia in people with mild cognitive impairment. SEARCH METHODS: We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's (CDCIG) specialised register, as well as MEDLINE, Embase, PsycINFO, CENTRAL, CINAHL, LILACs, Web of Science Core Collection, ClinicalTrials.gov, and the WHO Portal/ICTRP, from inception to 25 January 2018. SELECTION CRITERIA: We included randomised or quasi-randomised, placebo-controlled trials which evaluated orally administered vitamin or mineral supplements in participants with a diagnosis of mild cognitive impairment and which assessed the incidence of dementia or cognitive outcomes, or both. We were interested in studies applicable to the general population of older people and therefore excluded studies in which participants had severe vitamin or mineral deficiencies. DATA COLLECTION AND ANALYSIS: We sought data on our primary outcomes of dementia incidence and overall cognitive function and on secondary outcomes of episodic memory, executive function, speed of processing, quality of life, functional performance, clinical global impression, adverse events, and mortality. We conducted data collection and analysis according to standard Cochrane systematic review methods. We assessed the risk of bias of included studies using the Cochrane 'Risk of bias' assessment tool. We grouped vitamins and minerals according to their putative mechanism of action and, where we considered it to be clinically appropriate, we pooled data using random-effects methods. We used GRADE methods to assess the overall quality of evidence for each comparison and outcome. MAIN RESULTS: We included five trials with 879 participants which investigated B vitamin supplements. In four trials, the intervention was a combination of vitamins B6, B12, and folic acid; in one, it was folic acid only. Doses varied. We considered there to be some risks of performance and attrition bias and of selective outcome reporting among these trials. Our primary efficacy outcomes were the incidence of dementia and scores on measures of overall cognitive function. None of the trials reported the incidence of dementia and the evidence on overall cognitive function was of very low-quality. There was probably little or no effect of B vitamins taken for six to 24 months on episodic memory, executive function, speed of processing, or quality of life. The evidence on our other secondary clinical outcomes, including harms, was very sparse or very low-quality. There was evidence from one study that there may be a slower rate of brain atrophy over two years in participants taking B vitamins. The same study reported subgroup analyses based on the level of serum homocysteine (tHcy) at baseline and found evidence that B vitamins may improve episodic memory in those with tHcy above the median at baseline.We included one trial (n = 516) of vitamin E supplementation. Vitamin E was given as 1000 IU of alpha-tocopherol twice daily. We considered this trial to be at risk of attrition and selective reporting bias. There was probably no effect of vitamin E on the probability of progression from MCI to Alzheimer's dementia over three years (HR 1.02; 95% CI 0.74 to 1.41; n = 516; 1 study, moderate-quality evidence). There was also no evidence of an effect at intermediate time points. The available data did not allow us to conduct analyses, but the authors reported no significant effect of three years of supplementation with vitamin E on overall cognitive function, episodic memory, speed of processing, clinical global impression, functional performance, adverse events, or mortality (five deaths in each group). We considered this to be low-quality evidence.We included one trial (n = 256) of combined vitamin E and vitamin C supplementation and one trial (n = 26) of supplementation with chromium picolinate. In both cases, there was a single eligible cognitive outcome, but we considered the evidence to be very low-quality and so could not be sure of any effects. AUTHORS' CONCLUSIONS: The evidence on vitamin and mineral supplements as treatments for MCI is very limited. Three years of treatment with high-dose vitamin E probably does not reduce the risk of progression to dementia, but we have no data on this outcome for other supplements. Only B vitamins have been assessed in more than one RCT. There is no evidence for beneficial effects on cognition of supplementation with B vitamins for six to 24 months. Evidence from a single study of a reduced rate of brain atrophy in participants taking vitamin B and a beneficial effect of vitamin B on episodic memory in those with higher tHcy at baseline warrants attempted replication.

The validation of the PRISMA-7 questionnaire in community-dwelling elderly people living in Antalya, Turkey.

BACKGROUND: The screening of frailty in older adults is an important issue in the preventive approach in medicine. Frailty is one of the leading causes of morbidity and premature mortality in older adults. OBJECTIVE: The aim of this study was to validate the PRISMA-7 questionnaire in community-dwelling elderly people living in Antalya, Turkey. METHODS: This study was cross-sectional and observational in nature and was conducted in Antalya (Turkey) from February 2016 to April 2017. One hundred fifty patients participated in this study. PRISMA-7 and the CSHA Clinical Frailty Scale were applied to these patients along with a questionnaire on socio-demographics. No translations were available for the PRISMA-7 or the CSHA in Turkish language. The PRISMA-7 and the CSHA Clinical Frailty Scale were translated by two translators to Turkish language; after compilation and agreeing to one Turkish translation, the text was translated back by two translators to English. The translation was then compiled to one text and compared with the original text. After agreement on the translation, both translations were piloted in 10 elderly people. The final form has been applied in this study. Data of the ten piloted patients have not been included into the dataset. Data were analyzed by IBM-SPSS version 22, using descriptive statistics, Pearson product-moment correlation, and receiver operator characteristic (ROC) analysis. The level of significance was set at 0.05. RESULTS: Our study showed that participants were in average vulnerability to frailty. The test-retest reliability score for the PRISMA-7 Scale and for the CSHA Clinical Frailty Scale were (r= 99.2; p<0.001) and (r=97.5; p<0.05), respectively. After using CSHA Clinical Frailty Scale as a reference standard, PRISMA-7 showed that the area under ROC curve (AUC) was 0.903; which is the best accuracy; and medium level for internal consistency (Cronbach's α =0.714) as a measure for reliability. A cut-off point of 4 or higher for PRISMA-7revealed high sensitivity (81.5%) and specificity (88.2%) for frailty. CONCLUSION: We would recommend PRISMA-7 as a reliable and valid instrument, with high-level accuracy in the screening process of frailty.

The effect of exercise prescription of primary care physician on the quality of life in patients.

PURPOSE: The aim of this study was to examine the effect of exercise prescribed by primary care physicians (PCPs) on the quality of life (QoL) of elderly people. METHOD: Randomisation was performed at PCPs level from 16 primary healthcare centers. Patients were divided into intervention and control groups. Both groups of physicians received theoretical training (14 h), and the intervention group received additional practical training on exercise prescription (10 h). Patients in the intervention group were prescribed endurance, flexibility, balance, and strength exercises and were given training packs. QoL was measured using Short Form-36. Measurements were taken at the beginning of the study, after the 3rd month, and at the end of the 6th month to evaluate the effectiveness of the intervention. RESULTS: The age of participants (Intervention group n = 69, Control group n = 110) was 57.68 ± 5.08 years. At the end of the study, physical function, physical role function, social role function, mental health, vitality, general health perception, and emotional role function scores increased and body pain scores decreased in the intervention group. Significant differences (p < 0.05) between the intervention and control groups were observed for physical function, physical role function, body pain, mental health, vitality, and emotional role function scores but not for social role function or general health perception scores. CONCLUSIONS: Exercise prescriptions given by PCPs containing endurance, strength, flexibility, and balance exercises improve QoL in elderly people.

Exploring dementia management attitudes in primary care: a key informant survey to primary care physicians in 25 European countries.

I read with great interest the study of Petrazzuoli et al. (2017) on exploring dementia management attitudes in primary care. The authors made a laudable effort to evaluate this important issue, which certainly needs timely attention. The high response rate from 25 member countries of the European General Practice Research Network is astonishing.

The diabetic brain and cognition.

The prevalence of both Alzheimer's disease (AD) and vascular dementia (VaD) is increasing with the aging of the population. Studies from the last several years have shown that people with diabetes have an increased risk for dementia and cognitive impairment. Therefore, the authors of this consensus review tried to elaborate on the role of diabetes, especially diabetes type 2 (T2DM) in both AD and VaD. Based on the clinical and experimental work of scientists from 18 countries participating in the International Congress on Vascular Disorders and on literature search using PUBMED, it can be concluded that T2DM is a risk factor for both, AD and VaD, based on a pathology of glucose utilization. This pathology is the consequence of a disturbance of insulin-related mechanisms leading to brain insulin resistance. Although the underlying pathological mechanisms for AD and VaD are different in many aspects, the contribution of T2DM and insulin resistant brain state (IRBS) to cerebrovascular disturbances in both disorders cannot be neglected. Therefore, early diagnosis of metabolic parameters including those relevant for T2DM is required. Moreover, it is possible that therapeutic options utilized today for diabetes treatment may also have an effect on the risk for dementia. T2DM/IRBS contribute to pathological processes in AD and VaD.

Does social support affect development of cognitive dysfunction in individuals with diabetes mellitus?

[No Abstract Available].

Family practice in Turkey: Observations from a pilot implementation.

OBJECTIVE: Turkey has implemented family practice on a pilot basis as part of the reform in health care, since 2005. This paper aims to understand and describe the prevalent practice patterns and clinic characteristics during the transition period. DESIGN: A cross-sectional descriptive study design was used. SUBJECTS: An online survey was conducted among Turkish GPs working as primary care doctors (without vocational training) during the reform period. Clinic and GP characteristics are analysed with descriptive statistics. RESULTS: List size is an important factor; larger lists lead to shorter consultation time and a longer wait for patients. GPs are generally satisfied with the reform. CONCLUSION: During the transition to family practice access of patients to health care has improved and GPs are satisfied with their job. KEY POINTS: Patients in Turkey have adequate access to primary health care services. The waiting time for consultation is relatively short. Basic prevention activities occupy the majority of the GPs' time. Reducing the panel size and introducing appointment systems may be useful.

Development and validation of the short version of the diabetes obstacles questionnaire (DOQ-30) in six European countries.

BACKGROUND: Patients with type 2 diabetes reveal different obstacles in living with the disease. The EGPRN initiated a qualitative research EUROBSTACLE to create a broadly conceptualized diabetes-related quality of life (DR-QoL) instrument. It led to the development of the diabetes obstacle questionnaire (DOQ), a five-point Likert-scaled measure, consisting of 78 items in eight scales. OBJECTIVES: To develop and validate a short, easy-to-use version of the DOQ. METHODS: A cross-sectional study with the DOQ was carried out. Participants answered the DOQ and GPs added some clinical data from their medical records. Data of 853 patients from Belgium, France, Estonia, Serbia, Slovenia, and Turkey were included in the analysis. The selection of items for the short version of the DOQ was achieved with exploratory factor analysis (EFA). Construct validity was proved with EFA and Pearson correlations between the DOQ and the new DOQ-30. Internal reliability was established with Cronbach's alpha. RESULTS: DOQ-30 resulted in 30 items in nine subscales. It explained 49.8% of items' variance. It shows a considerable good internal reliability and construct validity. CONCLUSION: The DOQ-30 is a five-point Likert-scaled broadly conceptualized measure of DR-QoL. It addresses a variety of obstacles, such as social, psychological, cognitive and behavioural. The DOQ-30 is ready for implementation in general practice and research in Europe as a valuable instrument to assess DR-QoL.

The use of mobile smart devices and medical apps in the family practice setting.

RATIONALE, AIMS AND OBJECTIVES: In this study smartphones/tablet PCs and medical application utilization by family physicians and factors concerning the acceptance of medical application in family practice setting have been studied. METHODS: One hundred seventy-six participants voluntarily agreed to fill out a 27-item questionnaire. Data were analysed with descriptive statistics and eight items (acceptability of utilization of applications) revealed Cronbach's alpha of 0.965 and the factor analysis showed one factor explaining 80.6% of total variance. RESULTS: The mean age of respondents was 35.7 [standard deviation (SD) = 8.12; min-max = 24-52], 79 were male (45.9%) and 88 female (51.2%), 56 (32.5%) were single and 113 (65.7%) married, and the mean experience duration as a physician was 11.1 years (SD = 11.1; min-max = 1-28). One hundred sixty-seven (97.1%) had a smartphone and/or tablet PC. Smartphone and/or tablet PC were used since 3.7 (SD = 2.17; min-max = 0-12) years. Sixty-one (35.5%) felt that smartphone and/or tablet PC are very important, 92 (53.5%) important, 2 (1.2%) unimportant and 12 (7%) were undecided about this. One hundred eleven (64.5%) participants had a medical application on the smartphone and 66 (38.4%) on the tablet PC. They used 1.7 (SD = 2.04; min-max = 0-10) medical applications for 1.45 (SD = 2.53; min-max = 0-25) times on average. Eighty respondents (66.7%) used a medical application for any medical problem. CONCLUSIONS: Almost all family physicians used smartphone and/or tablet PC during daily practice, and the reason of use was commonly for communication and Internet purposes. Usage during working hours was limited, but medical apps were perceived mainly positively for receiving medical information via Internet. Looking at the medical apps' acceptability scale, participants were in agreement with the security, cost, contents' quality, ease of use, support, ease of finding, ease of accessing and motivation to use medical applications.

Dementia subtypes in Antalya, Turkey: a retrospective study.

The frequency of dementia is increasing steadily, and it is currently estimated that 60% of patients suffering from this disease reside in developing countries. An improvement in health care services for this elderly patients must be anticipated to assist in reducing the patient burden to their communities, families, and health systems; alternately, contributions made by hospitals through their diagnostic efforts and treatment of patients are of great importance. The purpose of this study was to evaluate the health records (n = 246) of patients in a dementia clinic for data regarding age, sex, occupation, reason for presentation, laboratory findings, neuropsychological tests, diagnoses made at presentation, and follow-up visits. Patients aged ≥ 60 years with cognitive symptoms were included in the study; mean age was 74.4 (SD, 7.58) years, with a predominantly female population (n = 142; 57.7%). The main reason for patient presentation was memory problems (n = 238; 96.7%). Administration of the Mini-Mental State Examination (MMSE) revealed a mean score of 19.14 (SD, 8.24) across the patient population; Montreal Cognitive Assessment mean test scores were 20.9 (SD, 5.31); and Clock Drawing Test median score was 2 points (min-max, 0-4). The most common diagnoses were Alzheimer-type dementia (n = 167; 67.9%) and mild cognitive impairment (n = 49; 19.9%). During a 31-month period, the dementia outpatient clinic was visited an average of 2.79 (SD, 2.32) times. Findings indicated that women had higher vitamin B12 levels (P = 0.001), lower MMSE scores (P = 0.022), fewer follow-up visits (P = 0.006), and higher low-density lipoprotein cholesterol levels (P = 0.02).

Control of Allergic Rhinitis and Asthma Test (CARAT): dissemination and applications in primary care.

Asthma frequently occurs in association with allergic rhinitis and a combined management approach has been suggested. The Control of Allergic Rhinitis and Asthma Test (CARAT) is the first questionnaire to assess control of both diseases concurrently. However, to have an impact on healthcare it needs to be disseminated and adopted. In this paper we discuss the dissemination of CARAT in different countries and its possible applications in primary care. At present, the adaptation of CARAT for use in different languages and cultures is being led by volunteer researchers and clinicians in 15 countries. Website and smartphone applications have been developed, and a free open model of distribution was adopted to contribute to the dissemination of CARAT. Examples of dissemination activities include distribution of leaflets and posters, educational sessions on the use of the questionnaire in the follow-up of patients, development of clinical studies, collaborations with professional organisations and health authorities, and the inclusion of CARAT in clinical guidelines. The adoption of innovations is an important challenge in healthcare today, and research on the degree of success of dissemination strategies using suitable methods and metrics is much needed. We propose that CARAT can be used in a range of settings and circumstances in primary care for clinical, research and audit purposes, within the overall aim of increasing awareness of the level of disease control and strengthening the partnership between patients and doctors in the management of asthma and rhinitis.

Family practice in Turkey: views of family practice residents.

Turkey's family practice training program is aimed at providing further training to clinically proficient family physicians who serve the community. A survey conducted in 2001 revealed that there was a need for providing additional training and more time in a specially dedicated family practice placement for family practitioners. Recent changes in the Turkish health care system have also impacted the training environment of family practice residents. Clearly, training needs to change with time. The aims of this study are to investigate the attitudes of resident family practice physicians regarding their training in the health care system in order to gather their views on the hospital learning environment, and to estimate their burnout levels. For this research, the design included a 1-phase cross-sectional study. This study was undertaken in 2008 in departments of family medicine at universities (n = 21) and training and research hospitals of the Ministry of Health (n = 11). Approximately 250 family practice residents in Turkey were approached. In total, 174 residents participated (70% response rate). The survey instruments included a questionnaire with 25 queries and 2 scales: The Postgraduate Hospital Educational Environment Measure and the Maslach Burnout Questionnaire-Human Services Survey. The average age of the participants was 32.2 years (standard deviation, 4.5 years; range, 24-57 years). The gender distribution was 57.6% women and 42.4% men. Marital status was 34.7% single, 62.9% married, and 2.4% divorced/widowed. In our results, residents affirmed that university hospitals were the best facilities for residency training. Their future plans confirmed that most would like to work in family health centers. This sample showed average levels of emotional exhaustion, depersonalization, and lack of personal accomplishment. Perceptions of professional autonomy, quality of training, and social support were below average. It may be concluded that certain milestones in the development of family practice in Turkey have been fulfilled. The new regulation for postgraduate training has increased the share of family practice training to 50% (18 months). Establishment of educational family health centers has been planned. Introduction of the formative and summative assessment processes in family practice training is anticipated. It is expected that an assessment such as the Membership of the Royal College of General Practitioners (International) (mRCGP[INT]) examination would be helpful for Turkish residents in reaching these goals.

Are caregiving courses useful? An empirical study from Antalya, Turkey.

In 2008, the National Social and Applied Gerontology Society (NSAGS) of Turkey held free caregiving courses for women, caring seniors, as a part of European Union (EU) programs. This course drew great attention and participation was common. The aim of this study was to evaluate the outcome of this course on participants and non-participants of this course. The test-sheet and an envelope with a stamp on it, were sent to the registered addresses of the women who applied for the course. One hundred twenty-four of total 276 questionnaire returned. The average age was 39.4 ± 9.6 years (± S.D.) and the level of education was low. Most of participants (80.6%) lived with the elderly in the same house; 83.9% of them also have a job besides their caring function. Most of the participants (82.1%) were still caring for their patients. The findings presented here are based on the comparison of two groups (i.e., caregivers who attended and who did not attend the course). After caregiving training, participants felt more an "inner peace" when caring for their elderly (p ≤ 0.05). Participants (39.5%) of the course felt more efficient concerning their duty as caregiver. Non-attenders to the course made more negative statements concerning their concentration to their caregiving functioning (55.2% vs. 40.7%) (p ≤ 0.05). Perception on stress showed better results in the group of participants, who attended the course (p<0.05). More attenders (43%) of the course believed they could cope better with stress (p ≤ 0.05). This study showed that caregiving courses might be useful for caregivers of elderly people. The rapid increase of elderly people in need of care, will show a high demand for qualified caregivers. The NSAGS fulfilled an important duty by organizing these caregiving courses. This is an important signal showing that national gerontological organizations in Turkey might address the important needs concerning demographic aging in community.