Idosos com demência: conhecimentos e atitudes dos médicos nas unidades de saúde

OBJETIVO: Descrever os conhecimentos e atitudes dos médicos generalistas da rede básica de saúde da cidade de São Paulo em relação a pacientes com demência e identificar padrões de atitudes. MÉTODOS: Foram sorteadas aleatoriamente 10% das unidades básicas de saúde da cidade de São Paulo (n = 45), distribuídas proporcionalmente em seis coordenadorias regionais de saúde. Foram entrevistados até dois médicos generalistas em cada unidade, obtendo-se ao todo 81 médicos entrevistados. Eles responderam à versão traduzida e adaptada transculturalmente para o Brasil de dois questionários britânicos, o knowledge quiz (conhecimentos sobre demências) e o attitude quiz (atitudes frente ao paciente dementado), além de um questionário sociodemográfico e ocupacional para o entendimento do perfil dos médicos generalistas que atuam na atenção primária. Realizaram-se análise descritiva dos dados, análise fatorial dos principais componentes do attitude quiz e estudo de associação entre atitudes e conhecimentos, além do teste de regressão linear múltipla para determinar a relação entre o perfil ocupacional e de conhecimento em demência sobre os padrões de atitudes. RESULTADOS: Os médicos entrevistados tinham mediana de tempo de formado de cinco anos; 35,8% trabalhavam exclusivamente com atenção primária, e menos de 40% tinham concluído, ou estavam cursando, residência médica ou especialização. Os médicos mostraram um conhecimento menor sobre diagnóstico de demência do que sobre a epidemiologia da doença e seu manejo terapêutico. Suas atitudes em relação a pacientes dementados resultaram em quatro fatores: otimismo proativo, otimismo delegador, desalento implícito e desalento explícito. O estudo de regressão mostrou que a atitude de desalento explícito diminui quanto maior for a jornada de trabalho semanal do médico nas unidades, e que a atitude otimista delegadora do médico diminui na mesma situação. CONCLUSÕES: O investimento em capacitação é fundamental para melhorar o desempenho do médico no campo da demência na atenção primária.OBJECTIVE: To describe the knowledge and attitudes of general practitioners of the basic health network of the city of São Paulo in relation to patients with dementia and identify patterns of attitudes. METHODS: A total of 10% of the basic health units in the city of São Paulo (n = 45) were randomly distributed into six regional health coordination centers. Up to two general practitioners were interviewed in each unit, with a total of 81 physicians interviewed. They answered the translated and cross-culturally adapted version for Brazil of two British questionnaires, the knowledge quiz (knowledge about dementias) and the attitude quiz (attitude towards the patient afflicted with dementia), as well as a sociodemographic and occupational questionnaire to understand the profile of general practitioners working in primary care. Descriptive data analysis, factor analysis of the main components of the attitude quiz and study of association between attitudes and knowledge were performed, in addition to the multiple linear regression test to determine the relationship between occupational profile and knowledge about attitude patterns in dementia. RESULTS: The physicians interviewed had a median of five-year graduation time; 35.8% worked exclusively with primary care, and less than 40% had completed, or were attending, medical residency or specialization. Physicians showed a lower knowledge about the diagnosis of dementia than about the epidemiology of the disease and its therapeutic management. Their attitudes towards patients afflicted with dementia resulted in four factors: proactive optimism, delegated optimism, implicit dismay, and explicit dismay. The regression study showed that the attitude of explicit dismay decreases the longer the weekly working hours of the physician in the units, and that the delegated optimistic attitude of the physician decreases in the same situation. CONCLUSION: Investment in training is essential to improve physicians’ performance in the field of dementia in primary care

Detection of cognitive impairment in the elderly by general internists in Brazil

BACKGROUND: Cognitive impairment, from mild forms to dementia, is an important social and health concern, principally among older individuals. Elderly patients are usually followed by general internists, who may overlook this condition. OBJECTIVE: Our aim was to determine whether cognitive impairment diagnosed by specialists had been previously detected by general internists. SUBJECTS AND METHODS: A total of 248 elderly individuals randomly selected from a list of outpatients seen by general internists in a public university hospital in São Paulo, Brazil, were evaluated by a geriatrician. Patients were then classified as having probable cognitive impairment or not, based on their performance on the Mini-Mental State Examination and the Informant Questionnaire on Cognitive Decline in the Elderly. Cases of probable impairment were submitted to routine laboratory investigation, brain computed tomography, and neuropsychological evaluation. The final diagnoses were established by a consensus panel comprising two neurologists and the geriatrician who evaluated the patients using all available data. General internists' files for all cognitively impaired cases and for a selected sample of individuals without cognitive impairment were checked for any record of cognitive complaints or decline. RESULTS: Forty-three patients were classified as demented (n = 21) or as cognitively impaired but not demented (n = 22). The evaluation of the general internists' files revealed that information on cognitive complaints or decline was recorded for seven (16.3%) of the 43 patients with dementia or cognitive impairment without dementia. CONCLUSIONS: General internists seldom detected cognitive decline in elderly patients in Brazil. Further studies should be conducted to elucidate the reasons for this low rate of detection

Symptoms of mood disorders in family carers of older people with dementia who experience caregiver burden: a network approach

Background: Informal carers of people with dementia are at greater risk of anxiety and depressive disorders if they find caregiving to be a burden. The aim of this study was to use a network analysis of cross-sectional data to investigate the relationships between anxiety and depressive symptoms in family carers of older people with dementia who experience burden. Methods: Sixty family carers exhibiting high levels of burden using the Zarit Burden Interview were included in the study. Participants completed the Hospital Anxiety and Depression Scale.The network analysis identified the depression and anxiety symptom network using features including a topological graph, network centrality metrics and community analysis. The network was estimated through the graphical LASSO technique in combination with a walktrap algorithm to obtain the clusters within the network and the connections between the nodes (symptoms). A directed acyclic graph was generated to model symptom interactions. Results: The resulting network architecture shows important bridges between depression and anxiety symptoms. Lack of pleasure and loss of enjoyment were identified as potential gateway symptoms to other anxiety and depression symptoms and represent possible therapeutic targets for psychosocial interventions. Fear and loss of optimism were highly central symptoms, indicating their importance as warning signs of more generalised anxiety and depression. Conclusions: This network analysis of depressive and anxiety symptoms in overburdened family carers provides important insights as to what symptoms may be the most important targets for behavioural interventions

Subjective memory complaints in the elderly: a sign of cognitive impairment?

OBJECTIVES: Cognitive impairment in the elderly is frequently overlooked by general practitioners. The use of subjective memory complaints as a sign of cognitive impairment by the general practice is controversial. METHODS: Elderly individuals (N = 248) were asked whether they had memory complaints and underwent a cognitive impairment screening. Subjects classified as exhibiting “probable cognitive impairment” underwent a complete cognitive evaluation, and the final diagnoses were established by expert consensus. RESULTS: A total of 147 patients presented with subjective memory complaints, and 43 were further classified as demented or “cognitively impaired not demented”. Subjective memory complaints presented a sensitivity of 100% and a negative predictive value of 100%. CONCLUSION: Subjective memory complaints are an indicator for cognitive impairment screening

Mild cognitive impairment and progression to dementia of Alzheimer's disease

The increase in life expectancy in the Brazilian population raises questions about the preparation of the public health system in identifying elderly patients with signs of cognitive impairment. Currently, as a consequence of the long duration of preclinical phase of Alzheimer's disease, efforts of early detection have been emphasized. Clinical dementia presents an important impact on the individual's caregivers, family, society and economy. Identifying individuals who already have some cognitive impairment, despite remaining functional, as well as analyzing associated comorbidities, constitutes an opportunity to analyze possibilities for future interventions. Dementias are clinical conditions that impose a burden on the health system with its high costs, whereas the identification of individuals with cognitive impairment without dementia can aid patients and their families to plan the future and mitigate costs. This narrative revision can provide general practitioners with more information on the subject.Univ Fed Sao Paulo, UNIFESP, Escola Paulista Med, Psychiat Dept, Sao Paulo, SP, BrazilUniv Estadual Paulista, UNESP, Fac Med Botucatu, Dept Internal Med,Geriatr, Botucatu, SP, BrazilFMB Unesp, Botucatu, SP, BrazilUniv Sao Paulo, Sao Paulo, BrazilHosp Santa Marcelina, Neurol Residency Program, Sao Paulo, BrazilUniv Sao Paulo, Grp Neurol Cognitiva & Comportamento, Sao Paulo, SP, Brazil|Univ Sao Paulo, Ctr Referencia Disturbios Cognit Ceredic, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, UNIFESP, Escola Paulista Med, Psychiat Dept, Sao Paulo, SP, BrazilWeb of Scienc

Influência do comprometimento excessivo na qualidade de vida e nos sintomas do climatério de profissionais da enfermagem

RESUMOObjetivo: Descrever as características gerais das profissionais de enfermagem e avaliar como o comprometimento excessivo podeinfluenciar na percepção dos sintomas do climatério e na qualidade de vida dessas mulheres.Método: trata-se de estudo transversal analítico, que avaliou 152 auxiliares e técnicas da enfermagem, na faixa etária de 40 anosou mais, em 3 hospitais do interior do estado de São Paulo. Em 2017, foram coletados dados sociodemográficos e aplicados osinstrumentos Índice Menopausal de Blatt-Kupperman, Questionário Saúde da Mulher, Medical Outcome Study 36-item short formHealth Survey e Effort Reward Imbalance. Foi realizada análise descritiva e análise de rede.Resultados: A idade média das participantes foi de 50,23 anos (DP = ±7,1). O grupo 1, composto por 61(40,1%) mulheres comcomprometimento excessivo apresentou pior qualidade de vida e maior intensidade de sintomas climatéricos.Conclusões: Presença de comprometimento excessivo parece influenciar em uma percepção negativa da sintomatologia doclimatério e em uma pior qualidade de vida.Palavras-chave: Climatério. Qualidade de vida. Estresse ocupacional

ENFRENTAMENTO A PANDEMIA DE COVID-19 POR PARTE DOS GESTORES DE INSTITUIÇÕES DE LONGA PERMANÊNCIA PARA IDOSOS NA AMÉRICA LATINA

Introduction: Few information is available on coping and mitigating COVID-19 in long-term care services for older people (ILPIs) in Latin America (LA). Objectives: To describe how ILPI managers in LA planned and adapted their coping routines to the COVID-19 pandemic, and whether they were able to comply with the recommendations of the World Health Organization (WHO). Methodology: Cross-sectional study, based on the application of an online survey aimed at LTCF managers in LA. A 46-question questionnaire (adopting WHO principles) was sent to participants. Descriptive statistics was used to summarize the data. Results: 23 managers answered the survey (excluding Brazilian respondents), totaling 874 older person (5 -270); a questionnaire was excluded due to lack of answers. Fourteen ILPIs (63.60%) were private for profit. The rate of adherence to WHO recommendations was over 70% for most issues. A little more than half of the institutions developed a strategic coping plan, or identified strategies to deal with deaths from suspected cases. Difficulty in acquiring personal protective equipment was reported by 59.10% of the investigated LTCIs. The testing capacity for SARS-Cov-2 has been reduced (36.36% had no test). Conclusions: The rate of adherence to the recommendations proposed by WHO for coping with COVID-19 was over 70% for most investigated LTCIs. Strategic coping plans were developed in just over half of the institutions. The availability of PPE and the testing capacity for SARS-Cov-2 proved to be quite unsatisfactory.Introdução: Pouco se sabe sobre o enfrentamento e mitigação à COVID-19 em serviços de longa permanência para idosos (ILPIs) na América Latina (AL). Objetivos: Descrever como os gestores de ILPIs na AL planejaram e adequaram suas rotinas de enfrentamento à pandemia de COVID-19, e se foram capazes de cumprir com as recomendações da Organização Mundial da Saúde(OMS). Metodologia: Estudo transversal, baseado na aplicação de uma pesquisa online dirigida aos gestores de ILPIs na AL. Um questionário de 46 questões (adotando os princípios da OMS) foi enviado aos participantes. Estatística descritiva foi usada para resumir os dados. Resultados: 23 gestores responderam a pesquisa (excluídos os respondentes brasileiros), totalizando 874 idosos (5 –270); um questionário foi excluído por falta de respostas. Quatorze ILPIs (63,60%) eram privadas com fins lucrativos. A taxa de adesão às recomendações da OMS foi superior a 70% para a maioria das questões. Pouco mais da metade das instituições elaborou um plano estratégico de enfrentamento, ou identificou estratégias para lidar com óbitos de casos suspeitos. Dificuldade para a aquisição de equipamentos de proteção individual foram relatados por 59,10% das ILPIs investigadas. A capacidade de testagem para o SARS-Cov-2 foi reduzida (36,36% não dispunham de nenhum teste). Conclusões: A taxa de adesão às recomendações propostas pela OMS para o enfrentamento da COVID-19 foi superior a 70% para a maioria das ILPIs investigadas. Planos estratégicos de enfrentamento foram elaborados em pouco mais da metade das instituições. A disponibilidade de EPIs e a capacidade de testagem para o SARS-Cov-2 mostrou-se bastante insatisfatória

Evaluation of the Interrater Reliability of End-of-Life Medical Orders in the Physician Orders for Life-Sustaining Treatment Form

IMPORTANCE Despite its spread in much of the United States and increased international interest, the Physician Orders for Life-Sustaining Treatment (POLST) paradigm still lacks supporting evidence. The interrater reliability of the POLST form to translate patients’ values and preferences into medical orders for care at the end of life remains to be studied. OBJECTIVE To assess the interrater reliability of the medical orders documented in POLST forms. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted in a public university hospital in southeastern Brazil. Two independent researchers interviewed the same patients or decision-making surrogates (n = 64) during a single episode of hospitalization within a time frame of 1 to 7 days. Eligible participants were hospitalized adults aged 21 years or older who were expected to remain hospitalized for at least 4 days and whose attending physician responded no to the question, Would I be surprised if this patient died in the next year? Data collection occurred between November 1, 2015, and September 20, 2016, and first data analyses were performed on October 3, 2016. MAIN OUTCOMES AND MEASURES Interrater reliability as measured by κ statistics. RESULTS Of the 64 participants interviewed in the study, 53 (83%) were patients and 11 (17%) were surrogates. Patients’ mean (SD) age was 64 (14) years, and 35 patients (55%) and 8 surrogates (73%) were women. Overall, in 5 cases (8%), disagreement in at least 1 medical order for life-sustaining treatment was found in the POLST form, changing from the first interview to the second interview. The κ statistic for cardiopulmonary resuscitation was 0.92 (95% CI, 0.80-1.00); for level of medical intervention, 0.89 (95% CI, 0.76-1.00); and for artificially administered nutrition, 0.92 (95% CI, 0.83-1.00). CONCLUSIONS AND RELEVANCE The high interrater reliability of the medical orders in POLST forms appears to offer further support for this advance care planning paradigm; in addition, the finding that this interrater reliability was not 100% underscores the need to ensure that patients or their surrogates have decision-making capacity and to confirm that the content of POLST forms accurately reflects patients’ current treatment preferences