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1.
J Am Med Dir Assoc ; 2019 Oct 28.
Artigo em Inglês | MEDLINE | ID: mdl-31672569

RESUMO

OBJECTIVES: The prevalence of different geriatric syndromes in older home care (HC) recipients is yet to be determined. Dizziness is often regarded as a geriatric syndrome. The natural course of dizziness in older people is still unknown, because of a lack of longitudinal studies. The objective of this study was to investigate the prevalence and persistence of dizziness in HC recipients. DESIGN: Prospective cohort study. SETTING: Home care organizations in 6 European countries participating in the EU-funded Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project. PARTICIPANTS: 2616 community-dwelling long-term HC recipients aged 65 years or older. METHODS: Data were collected at baseline and 6 and 12 months by using the interRAI Home Care instrument (interRAI-HC). Dizziness status was assessed by the number of days people experienced dizziness in the last 3 days (0-3) and later dichotomized for analyses (present or not in the last 3 days). Dizziness persistence was defined as the odds for dizzy people at baseline to also report dizziness at subsequent follow-up moments, compared with people who were not dizzy at baseline. The pattern of dizziness was descriptively analyzed in recipients who completed all measurements. Generalized estimating equations analysis was used to determine the persistence of dizziness symptoms. RESULTS: The prevalence of dizziness of 2616 eligible HC recipients at baseline was 25.1%, ranging from 16.2% (Belgium) to 39.7% (Italy). The majority of dizzy recipients at baseline also experienced dizziness after 6 and 12 months (79.1%). Dizziness persistence was high at 6 months [odds ratio (OR) 57.8, 95% confidence interval (CI) 43.1-77.5] and at 12 months (OR 30.2, 95% CI 22.3-41.1). CONCLUSIONS AND IMPLICATIONS: Dizziness in older HC recipients in Europe is common, and dizziness persistence is high. This warrants a more active approach in treating dizziness in older HC recipients.

2.
BMJ ; 367: l5922, 2019 11 05.
Artigo em Inglês | MEDLINE | ID: mdl-31690561

RESUMO

OBJECTIVE: To investigate the clinical effectiveness and safety of stand alone and blended internet based vestibular rehabilitation (VR) in the management of chronic vestibular syndromes in general practice. DESIGN: Pragmatic, three armed, parallel group, individually randomised controlled trial. SETTING: 59 general practices in the Netherlands. PARTICIPANTS: 322 adults aged 50 and older with a chronic vestibular syndrome. INTERVENTIONS: Stand alone VR comprising a six week, internet based intervention with weekly online sessions and daily exercises (10-20 minutes a day). In the blended VR group, the same internet based intervention was supplemented by face-to-face physiotherapy support (home visits in weeks 1 and 3). Participants in the usual care group received standard care from a general practitioner, without any restrictions. MAIN OUTCOME MEASURES: The primary outcome was vestibular symptoms after six months as measured by the vertigo symptom scale-short form (VSS-SF range 0-60, clinically relevant difference ≥3 points). Secondary outcomes were dizziness related impairment, anxiety, depressive symptoms, subjective improvement of vestibular symptoms after three and six months, and adverse events. RESULTS: In the intention-to-treat analysis, participants in the stand alone and blended VR groups had lower VSS-SF scores at six months than participants in the usual care group (adjusted mean difference -4.1 points, 95% confidence interval -5.8 to -2.5; and -3.5 points, -5.1 to -1.9, respectively). Similar differences in VSS-SF scores were seen at three months follow-up. Participants in the stand alone and blended VR groups also experienced less dizziness related impairment, less anxiety, and more subjective improvement of vestibular symptoms at three and six months. No serious adverse events related to online VR occurred during the trial. CONCLUSION: Stand alone and blended internet based VR are clinically effective and safe interventions to treat adults aged 50 and older with a chronic vestibular syndrome. Online VR is an easily accessible form of treatment, with the potential to improve care for an undertreated group of patients in general practice. TRIAL REGISTRATION: Netherlands Trial Register NTR5712.


Assuntos
Medicina Geral/métodos , Modalidades de Fisioterapia , Qualidade de Vida , Telemedicina/métodos , Doenças Vestibulares/reabilitação , Idoso , Doença Crônica/psicologia , Doença Crônica/reabilitação , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Países Baixos , Síndrome , Resultado do Tratamento , Doenças Vestibulares/diagnóstico , Doenças Vestibulares/psicologia
3.
Ned Tijdschr Geneeskd ; 1632019 Feb 15.
Artigo em Holandês | MEDLINE | ID: mdl-30816652

RESUMO

Falls and fall injuries among older adults are common. Exercise interventions are a safe and effective way to reduce falls. Tai chi is a form of exercise therapy aimed at improving postural control, sensory integration and anticipatory control. In recent years, tai chi has already been shown to reduce the number of falls in older adults, compared to a control intervention. Recently, an American study reported that tai chi is also more effective than conventional exercise programme in reducing the number of falls. Implementation of tai chi in daily practice may be an effective solution for an important health problem.

4.
BMC Psychiatry ; 19(1): 64, 2019 02 11.
Artigo em Inglês | MEDLINE | ID: mdl-30744601

RESUMO

BACKGROUND: Since anxiety and depressive disorders often recur, self-management competencies are crucial for improving the long-term course of anxiety and depressive disorders. However, few relapse prevention programmes are available that focus on improving self-management. E-health combined with personal contact with a mental health professional in general practice might be a promising approach for relapse prevention. In this protocol, the GET READY (Guided E-healTh for RElapse prevention in Anxiety and Depression) study will be described in which a relapse prevention programme is developed, implemented and evaluated. The aim of the study is to determine patients' usage of the programme and the associated course of their symptoms, to examine barriers and facilitators of implementation, and to assess patients' satisfaction with the programme. METHODS: Participants are discharged from mental healthcare services, and are in complete or partial remission. They receive access to an E-health platform, combined with regular contact with a mental health professional in general practices. Online questionnaires will be completed at baseline and after 3, 6 and 9 months. Also, semi-structured qualitative individual interviews and focus group interviews will be conducted with patients and mental health professionals. DISCUSSION: This mixed-methods observational cohort study will provide insights into the use of a relapse prevention programme in relation to the occurrence of symptoms, as well as in its implementation and evaluation. Using the results of this study, the relapse prevention programme can be adapted in accordance with the needs of patients and mental health professionals. If this programme is shown to be acceptable, a randomized controlled trial may be conducted to test its efficacy. TRIAL REGISTRATION: Retrospectively registered in the Netherlands Trial Register ( NTR7574 ; 25 October 2018).


Assuntos
Transtornos de Ansiedade/prevenção & controle , Ansiedade/prevenção & controle , Depressão/prevenção & controle , Transtorno Depressivo/prevenção & controle , Prevenção Secundária , Telemedicina , Ansiedade/psicologia , Transtornos de Ansiedade/psicologia , Estudos de Coortes , Depressão/psicologia , Transtorno Depressivo/psicologia , Humanos , Saúde Mental , Serviços de Saúde Mental , Países Baixos , Estudos Retrospectivos , Inquéritos e Questionários , Resultado do Tratamento
5.
PLoS One ; 13(10): e0204876, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30300371

RESUMO

OBJECTIVES: Dizziness is common in older people. Physicians are often unable to identify a specific cause for dizziness in older people, even after an extensive diagnostic work-up. A prognosis-oriented approach, i.e. treating modifiable risk factors for an unfavourable course of dizziness, may reduce dizziness-related impairment in older people in primary care. DESIGN: Cluster randomized controlled trial. SETTING: 45 primary care practices in The Netherlands. PARTICIPANTS: 168 participants aged ≥65y who consulted their general practitioner for dizziness and experienced significant dizziness-related impairment (Dizziness Handicap Inventory (DHI) ≥30). Participants were part of to the intervention group (n = 83) or control group (n = 85), depending on whether they were enlisted in an intervention practice or in a control practice. INTERVENTIONS: The multifactorial intervention consisted of: medication adjustment in case of ≥3 prescribed fall-risk-increasing drugs (FRIDs) and/or stepped mental health care in case of anxiety disorder and/or depression and/or exercise therapy in case of impaired functional mobility. The intervention was compared to usual care. OUTCOME MEASURES: The primary outcome was dizziness-related impairment. Secondary outcomes were quality of life (QoL), dizziness frequency, fall frequency, anxiety and depression, use of FRIDs. RESULTS: Intention-to-treat analysis showed no significant intervention effect on dizziness-related impairment (DHI score difference -0.69 [95% CI -5.66;4.28]; p = 0.79). The intervention proved effective in reducing the number of FRIDs (FRID difference -0.48 [95% CI -0.89;-0.06]; p = 0.02). No significant intervention effects were found on other secondary outcomes. The uptake of and adherence to the interventions was significantly lower in patients eligible for ≥2 interventions compared to patients eligible for one intervention (p<0.001). CONCLUSIONS: The multifactorial intervention for dizziness in older patients showed no significant intervention effect on most outcomes and adherence to the multifactorial intervention was low. Although multifactorial treatment for older dizzy people seems promising in theory, we question its feasibility in daily practice. Future research could focus on a sequential treatment for dizziness, e.g. measuring effectiveness of various evidence-based therapies in a stepwise approach.


Assuntos
Tontura/diagnóstico , Tontura/terapia , Terapia por Exercício/métodos , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Países Baixos , Atenção Primária à Saúde , Fatores de Risco
6.
Ann Fam Med ; 16(5): 428-435, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30201639

RESUMO

PURPOSE: Because dizziness in older people is often chronic and can substantially affect daily functioning, it is important to identify those at risk for an unfavorable course of dizziness to optimize their care. We aimed to develop and externally validate a prediction model for an unfavorable course of dizziness in older patients in primary care, and to construct an easy-to-use risk prediction tool. METHODS: We used data from 2 prospective cohorts: a development cohort with 203 patients aged 65 years or older who consulted their primary care physician for dizziness and had substantial dizziness-related impairment (Dizziness Handicap Inventory [DHI] ≥30), and a validation cohort with 415 patients aged 65 years or older who consulted their primary care physician for dizziness of any severity. An unfavorable course was defined as presence of substantial dizziness-related impairment (DHI ≥30) after 6 months. RESULTS: Prevalence of an unfavorable course of dizziness was 73.9% in the development cohort and 43.6% in the validation cohort. Predictors in the final model were the score on the screening version of the DHI, age, history of arrhythmia, and looking up as a provoking factor. The model showed good calibration and fair discrimination (area under the curve = 0.77). On external validation, discriminative ability remained stable (area under the curve = 0.78). The constructed risk score was strongly correlated with the prediction model. Performance measures for risk score cut-off values are presented to determine the optimal cut-off point for clinical practice. CONCLUSIONS: We developed an easy-to-use risk score for dizziness-related impairment in primary care. The risk score, consisting of only 4 predictors, will help primary care physicians identify patients at high risk for an unfavorable course of dizziness.


Assuntos
Avaliação da Deficiência , Tontura/diagnóstico , Avaliação Geriátrica , Atenção Primária à Saúde/métodos , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Calibragem , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Risco
7.
BMC Fam Pract ; 19(1): 43, 2018 04 03.
Artigo em Inglês | MEDLINE | ID: mdl-29614977

RESUMO

BACKGROUND: Due to the raised public awareness of Lyme Borreliosis (LB), its increased incidence and the increased availability of serological tests, the demand for diagnostic testing on LB has increased. This may affect the diagnostic behaviour of general practitioners (GPs). Aim of our study was to describe GPs' diagnostic behaviour when suspecting LB. METHODS: In this descriptive study from January 2010 to June 2015, we used the anonymized electronic medical records of 56,996 patients registered in 12 general practices in Amsterdam, The Netherlands. The target population was identified by means of an extensive search strategy, based on International Classification of Primary Care (ICPC-1) codes, free text and diagnostic test codes. All contacts related to LB were included in the analysis. RESULTS: 2311 patients were included, accounting for 3861 LB contacts and 2619 LB episodes. The distribution of LB contacts showed annual peaks during spring and summer. Serological testing was performed in 36.4% of LB episodes and was mostly requested in patients presenting with general symptoms (71.4%). Unnecessary testing often occurred and only 5.9% of the tests turned out to be positive by immunoblot. From January 2010 to June 2015, no significant differences were found in the number of requested serological tests. The level of serological testing during LB episodes differed significantly between the general practices (19.2% to 75.8%). CONCLUSIONS: Contrary to clinical guidelines, GPs regularly requested serology even when there was a low suspicion of LB. The development of an easy-to-use diagnostic algorithm may decrease overuse of diagnostic tests and thereby reduce overtreatment of LB.


Assuntos
Clínicos Gerais , Doença de Lyme/diagnóstico , Sobremedicalização/estatística & dados numéricos , Padrões de Prática Médica , Testes Sorológicos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Registros Eletrônicos de Saúde , Feminino , Humanos , Incidência , Doença de Lyme/epidemiologia , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Adulto Jovem
9.
Scand J Prim Health Care ; 35(1): 19-26, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28277043

RESUMO

OBJECTIVE: To investigate the use of canalith repositioning manoeuvres and vestibular rehabilitation (VR) by GPs and to assess reasons for not using these techniques in patients with vertigo. DESIGN: Online survey. SETTING: GPs in the western and central part of the Netherlands. SUBJECTS AND METHOD: Of GPs, 1169 were approached to participate in the survey. A sample of 426 GPs filled out the questionnaire (36.4% response rate). The 22-item questionnaire contained both multiple choice and free-text questions on the Epley manoeuvre, the Brandt-Daroff exercises and VR. Results of the survey were descriptively analyzed. MAIN OUTCOME MEASURES: The use of the Epley manoeuvre, the Brandt-Daroff exercises and VR by GPs; reasons that deter GPs from using these techniques. RESULTS: The repositioning manoeuvres (Epley manoeuvre and Brandt-Daroff exercises) were used by approximately half of all GPs (57.3 and 50.2%), while only a small group of GPs applied VR (6.8%). The most important reason for GPs not to use the Epley manoeuvre, Brandt-Daroff exercises and VR was that they did not know how to perform the technique (49.5, 89.6 and 92.4%). CONCLUSIONS: Despite the proven effectiveness, repositioning manoeuvres and VR are remarkably underused by Dutch GPs. Not knowing how to perform the technique is the most important reason for GPs not to use these techniques. Efforts should be made to increase the knowledge and skills of GPs regarding canalith repositioning manoeuvres and VR. Key points Dizziness is a common symptom with limited therapeutic options. • Canalith repositioning manoeuvres and vestibular rehabilitation represent the best treatment options currently available for vertigo. • Canalith repositioning manoeuvres and vestibular rehabilitation are still widely underused by GPs. • The most important reason for GPs not to use these techniques is that they do not know how to perform them. • Efforts should be made to increase the knowledge and skills of GPs regarding canalith repositioning manoeuvres and vestibular rehabilitation.


Assuntos
Competência Clínica , Tontura/terapia , Clínicos Gerais , Manipulações Musculoesqueléticas/estatística & dados numéricos , Padrões de Prática Médica , Vertigem/terapia , Vestíbulo do Labirinto , Adulto , Exercício , Medicina de Família e Comunidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manipulações Musculoesqueléticas/métodos , Países Baixos , Inquéritos e Questionários
10.
BMJ Open ; 7(1): e015479, 2017 01 20.
Artigo em Inglês | MEDLINE | ID: mdl-28110290

RESUMO

INTRODUCTION: Dizziness is a common symptom in general practice with a high prevalence among older adults. The most common cause of dizziness in general practice is peripheral vestibular disease. Vestibular rehabilitation (VR) is a safe and effective treatment for peripheral vestibular disease that entails specific exercises to maximise the central nervous system compensation for the effects of vestibular pathology. An internet-based VR intervention has recently been shown to be safe and effective. Online interventions are low cost and easily accessible, but prone to attrition and non-adherence. A combination of online and face-to-face therapy, known as blended care, may balance these advantages and disadvantages. METHODS AND ANALYSIS: A single-blind, three-arm, randomised controlled trial among patients aged 50 years and over presenting with dizziness of vestibular origin in general practice will be performed. In this study, we will compare the clinical and cost-effectiveness of stand-alone internet-based VR and internet-based VR with physiotherapeutic support ('blended care') with usual care during 6 months of follow-up. We will use a translated Dutch version of a British online VR intervention. Randomisation will be stratified by dizziness severity. The primary outcome measure is the Vertigo Symptoms Scale-Short Form. Intention-to-treat analysis will be performed, adjusting for confounders. The economic evaluation will be conducted from a societal perspective. We will perform an additional analysis on the data to identify predictors of successful treatment in the same population to develop a clinical decision rule for general practitioners. ETHICS AND DISSEMINATION: The ethical committee of the VU University Medical Center approved ethics and dissemination of the study protocol. The insights and results of this study will be widely disseminated through international peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: Pre-results, NTR5712.


Assuntos
Tontura/reabilitação , Terapia por Exercício , Internet , Modalidades de Fisioterapia , Vertigem/reabilitação , Doenças Vestibulares/reabilitação , Vestíbulo do Labirinto/patologia , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Equilíbrio Postural , Projetos de Pesquisa , Resultado do Tratamento
11.
BMC Fam Pract ; 17: 74, 2016 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-27421651

RESUMO

BACKGROUND: Dizziness-related impairment is a strong predictor for an unfavourable course of dizziness in older people. In this study we explored the experiences of older patients with significant dizziness-related impairment and their wishes and expectations regarding general practitioner (GP) care. Knowing the expectations and priorities of people with dizziness may enable the GP to provide tailor-made care, which in turn may substantially increase the quality of life and decrease the use and costs of health care. METHODS: We conducted a qualitative study with semi-structured interviews. We selected patients from ten Dutch general practices. Patients were invited to participate in the study if they were ≥ 65 years, visited their GP because of dizziness and were significantly impaired due to dizziness (Dizziness Handicap Inventory ≥ 30). We applied content analysis to the semi-structured interviews. RESULTS: Thirteen participants participated, seven were female. Analysis of the interviews resulted in the overall theme "Dizziness in older people: at risk of shared therapeutic nihilism by the patient and the GP". Firstly, this can explained by the fact that participants frequently presented dizziness as a secondary complaint when they visited the GP for another complaint. Secondly, participants reported that the GP often could not help them with any treatment. Despite a poor therapeutic outcome, the vast majority of participants was satisfied how the GP handled their dizziness. Yet, understanding the cause of dizziness seems important for dizzy older patients. CONCLUSIONS: Despite significant dizziness-related impairment, older dizzy patients may not present dizziness as main reason for encounter. Presenting dizziness as a secondary complaint may give GPs the - wrong - impression that the dizziness-related impairment is only mild. GPs need to be aware of this potential underreporting. Knowing the cause of dizziness seems important for older patients. Yet, GPs regularly did not succeed in identifying the underlying cause of dizziness. Therefore, GPs should manage the expectations of older dizzy patients regarding diagnosis and successful treatment, by informing them about the uncertainty and unpredictability of dizziness. We also recommend GPs to focus on improving functional ability; this is the key to escape from therapeutic nihilism by the GP.


Assuntos
Tontura/complicações , Tontura/terapia , Medicina Geral , Satisfação do Paciente , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Tontura/etiologia , Tontura/psicologia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Limitação da Mobilidade , Pesquisa Qualitativa
12.
Br J Gen Pract ; 66(649): e531-9, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27324627

RESUMO

BACKGROUND: Although continuity of care is a widely accepted core principle of primary care, the evidence about its benefits is still weak. AIM: To investigate whether continuity of care in general practice is associated with better survival in older people. DESIGN AND SETTING: Data were derived from the Longitudinal Aging Study Amsterdam, an ongoing cohort study in older people in the Netherlands. The study sample consisted of 1712 older adults aged ≥60 years, with 3-year follow-up cycles up to 17 years (1992-2009), and mortality follow-up until 2013. METHOD: Continuity of care was defined as the duration of the ongoing therapeutic relationship between patient and GP. The Herfindahl-Hirschman Index was used to calculate the continuity of care (COC). A COC index value of 1 represented maximum continuity. COC index values <1 were divided into tertiles, with a fourth category for participants with maximum COC. Cox regression analysis was used to investigate the association between COC and survival time. RESULTS: Seven hundred and forty-two participants (43.3%) reported a maximum COC. Among the 759 participants surviving 17 years, 251 (33.1%) still had the same GP. The lowest COC category (index >0-0.500) showed significantly greater mortality than those in the maximum COC category (hazard ratio (HR) = 1.20, 95% CI = 1.01 to 1.42). There were no confounders that affected this HR. CONCLUSION: This study demonstrates that low continuity of care in general practice is associated with a higher risk of mortality, strengthening the case for encouragement of continuity of care.


Assuntos
Doença Crônica , Continuidade da Assistência ao Paciente/normas , Atenção Primária à Saúde , Idoso , Doença Crônica/mortalidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Países Baixos , Relações Médico-Paciente , Atenção Primária à Saúde/normas , Modelos de Riscos Proporcionais , Estudos Prospectivos , Análise de Sobrevida , Fatores de Tempo
13.
Scand J Prim Health Care ; 34(2): 165-71, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27049170

RESUMO

OBJECTIVE: For general practitioners (GPs) dizziness is a challenging condition to deal with. Data on the management of dizziness in older patients are mostly lacking. Furthermore, it is unknown whether GPs attempt to decrease Fall Risk Increasing Drugs (FRIDs) use in the management of dizziness in older patients. The aim of this study is to gain more insight into GP's management of dizziness in older patients, including FRID evaluation and adjustment. DESIGN: Data were derived from electronic medical records, obtained over a 12-month period in 2013. SETTING: Forty-six Dutch general practices. PATIENTS: The study sample comprised of 2812 older dizzy patients of 65 years and over. Patients were identified using International Classification of Primary Care codes and free text. MAIN OUTCOME MEASURES: Usual care was categorized into wait-and-see strategy (no treatment initiated); education and advice; additional testing; medication adjustment; and referral. RESULTS: Frequently applied treatments included a wait-and-see strategy (28.4%) and education and advice (28.0%). Additional testing was performed in 26.8%; 19.0% of the patients were referred. Of the patients 87.2% had at least one FRID prescription. During the observation period, GPs adjusted the use of one or more FRIDs for 11.7% of the patients. CONCLUSION: This study revealed a wide variety in management strategies for dizziness in older adults. The referral rate for dizziness was high compared to prior research. Although many older dizzy patients use at least one FRID, FRID evaluation and adjustment is scarce. We expect that more FRID adjustments may reduce dizziness and dizziness-related impairment. Key Points It is important to know how general practitioners manage dizziness in older patients in order to assess potential cues for improvement. This study revealed a wide variety in management strategies for dizziness in older patients. There was a scarcity in Fall Risk Increasing Drug (FRID) evaluation and adjustment. The referral rate for dizziness was high compared with previous research.


Assuntos
Acidentes por Quedas/prevenção & controle , Tontura/complicações , Tontura/terapia , Medicamentos sob Prescrição/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Gerenciamento Clínico , Tontura/epidemiologia , Registros Eletrônicos de Saúde , Feminino , Medicina Geral , Clínicos Gerais , Humanos , Masculino , Países Baixos/epidemiologia , Padrões de Prática Médica , Medicamentos sob Prescrição/uso terapêutico , Risco
14.
Trials ; 16: 313, 2015 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-26209097

RESUMO

BACKGROUND: The management of dizziness in older patients is primarily diagnosis-oriented. However, in 40% of older patients with dizziness, GPs are not able to identify an underlying cause, and a number of common underlying causes of dizziness cannot (or hardly) be treated. In this study we will investigate the effectiveness of a prognosis-oriented approach in the management of dizziness in older patients. This prognosis-oriented approach comprises identification of patients at risk for chronic dizziness with persistent impairment by identifying risk factors for an unfavourable course of dizziness. Patients at risk for chronic dizziness with persistent impairment will be offered treatment addressing the identified modifiable risk factors. METHODS/DESIGN: This study will be performed in primary care. An intervention study and a validation study will be conducted in a three-arm cluster randomised design. In the intervention study we will investigate a risk factor guided multi-component intervention. The risk factor guided intervention includes: (1) medication adjustment in case of three or more prescribed fall-risk-increasing drugs, (2) stepped care in case of anxiety disorder and/or depression, and (3) exercise therapy in case of impaired functional mobility. The primary outcome measure is dizziness-related impairment, which will be assessed with the Dizziness Handicap Inventory. Secondary outcome measures are quality of life, anxiety disorder and depression, use of fall-risk-increasing drugs, dizziness frequency, fall frequency, and healthcare utilization. DISCUSSION: This study is, to date, the first study that will investigate the effectiveness of a prognosis-oriented approach for reducing dizziness-related impairment in older people in primary care. Offering treatment that addresses identified modifiable risk factors to patients at high risk for chronic dizziness is unique. The pragmatic design of this study will enable evaluation of the outcomes in real-life routine practice conditions. An effective intervention will not only reduce dizziness-related impairment, but may also decrease healthcare utilization and healthcare costs. The previously developed risk score that will be validated alongside the intervention study will enable GPs to identify patients at high risk for chronic dizziness with persistent impairment. TRIAL REGISTRATION: Netherlands Trial Register (identifier: NTR4346), registration date 15 December 2013.


Assuntos
Acidentes por Quedas/prevenção & controle , Tontura/terapia , Terapia por Exercício , Conduta do Tratamento Medicamentoso , Atenção Primária à Saúde , Fatores Etários , Idoso , Doença Crônica , Protocolos Clínicos , Avaliação da Deficiência , Tontura/diagnóstico , Tontura/etiologia , Tontura/fisiopatologia , Tontura/psicologia , Feminino , Humanos , Masculino , Saúde Mental , Limitação da Mobilidade , Países Baixos , Polimedicação , Qualidade de Vida , Projetos de Pesquisa , Medição de Risco , Fatores de Risco , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento
15.
BMC Geriatr ; 14: 133, 2014 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-25510936

RESUMO

BACKGROUND: The current diagnosis-oriented approach of dizziness does not suit older patients. Often, it is difficult to identify a single underlying cause, and when a diagnosis is made, therapeutic options may be limited. Identification of predictors of dizziness may provide new leads for the management of dizziness in older patients. The aim of the present study was to investigate long-term predictors of regular dizziness in older persons. METHODS: Population-based cohort study of 1,379 community-dwelling participants, aged ≥60 years, from the Longitudinal Aging Study Amsterdam (LASA). Regular dizziness was ascertained during face-to-face medical interviews during 7- and 10-year follow-up. We investigated 26 predictors at baseline from six domains: socio-demographic, medical history, medication, psychological, sensory, and balance/gait. We performed multivariate logistic regression analyses with presence of regular dizziness at 7- and 10-year follow-up as dependent variables. We assessed the performance of the models by calculating calibration and discrimination. RESULTS: Predictors of regular dizziness at 7-year follow-up were living alone, history of dizziness, history of osteo/rheumatoid arthritis, use of nitrates, presence of anxiety or depression, impaired vision, and impaired function of lower extremities. Predictors of regular dizziness at 10-year follow-up were history of dizziness and impaired function of lower extremities. Both models showed good calibration (Hosmer-Lemeshow P value of 0.36 and 0.31, respectively) and acceptable discrimination (adjusted AUC after bootstrapping of 0.77 and 0.71). CONCLUSIONS: Dizziness in older age was predicted by multiple factors. A multifactorial approach, targeting potentially modifiable predictors (e.g., physical exercise for impaired function of lower extremities), may add to the current diagnosis-oriented approach.


Assuntos
Gerenciamento Clínico , Tontura/diagnóstico , Previsões , Vigilância da População/métodos , Medição de Risco/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Progressão da Doença , Tontura/epidemiologia , Tontura/terapia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Valor Preditivo dos Testes , Estudos Prospectivos
16.
Front Med (Lausanne) ; 1: 50, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25593923

RESUMO

Although the etiology of dizziness in older patients differs significantly from that of younger patients, most guidelines on dizziness advocate the same diagnosis-oriented approach for all patients regardless of their age. However, this diagnosis-oriented approach may be insufficient for older patients presenting with dizziness in general practice, because (1) general practitioners are often not able to identify an underlying cause of dizziness, (2) general practitioners regularly identify causes of dizziness that cannot be treated, and (3) general practitioners may identify causes of dizziness for which treatment is available but not desirable. In this article, the authors present a simultaneous diagnosis- and prognosis-oriented approach for older dizzy patients. This approach may enable general practitioners to improve their care for a voluminous group of impaired older patients, even if a diagnosis is not available (yet).

17.
Ned Tijdschr Geneeskd ; 159: A8301, 2014.
Artigo em Holandês | MEDLINE | ID: mdl-25589281

RESUMO

It has been suggested that chronic dizziness in older people may constitute a multifactorial geriatric syndrome. Considering dizziness to be a geriatric syndrome with multiple contributory factors may provide additional leads for treatment. A structured history, followed by physical examination and additional tests if necessary, can yield clues to factors that may contribute to dizziness. To illustrate such a multifactorial approach, we present two patients with chronic dizziness. In both cases, the general practitioner considered multifactorial dizziness with several treatable contributory factors. By treating these contributory factors, the frequency of dizziness and dizziness-related impairment decreased temporarily in one patient and permanently in the other.


Assuntos
Envelhecimento/patologia , Tontura/diagnóstico , Exame Físico , Idoso , Idoso de 80 Anos ou mais , Diagnóstico Diferencial , Tontura/etiologia , Feminino , Humanos , Masculino , Síndrome , Vertigem/diagnóstico , Vertigem/etiologia
18.
J Am Geriatr Soc ; 60(12): 2263-9, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23231549

RESUMO

OBJECTIVES: To investigate the 6-month functional prognosis of dizziness in older adults in primary care, to identify important predictors of dizziness-related impairment, and to construct a score to assist risk prediction. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: Twenty-four primary care practices in the Netherlands. PARTICIPANTS: Four hundred seventeen older adults (mean age 78.5, range 65-95, 74% female) presenting consecutively to primary care with dizziness. MEASUREMENTS: Tests, including history and physical and additional examination, previously selected by an international expert panel and based on an earlier systematic review, were performed. The main outcome measure was 6-month dizziness-related impairment score measured using the Dizziness Handicap Inventory. RESULTS: Follow-up was complete for 92% of participants. Although 61% of participants experienced less impairment at 6 months, 130 participants (34%) showed persistent dizziness-related impairment. Factors most predictive of dizziness-related impairment at 6 months were onset of dizziness at least 6 months before inclusion, standing still as a dizziness-provoking circumstance, trouble with walking or (almost) falling (associated symptom), polypharmacy, absence of diabetes mellitus, presence of anxiety or depressive disorder, and impaired functional mobility. A score was constructed using these predictors to estimate the functional prognosis of dizziness at 6 months. CONCLUSION: A score based on the presence of easily obtainable clinical information facilitates identification of older adults in primary care with poor functional prognosis of their dizziness without exactly knowing the cause(s) of their dizziness. Clinical management might be most effective by treating factors that can be influenced, such as polypharmacy, anxiety and depression, and functional mobility.


Assuntos
Tontura/diagnóstico , Atenção Primária à Saúde , Idoso , Idoso de 80 Anos ou mais , Tontura/etiologia , Feminino , Humanos , Masculino , Probabilidade , Prognóstico , Sensibilidade e Especificidade
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