Análise de consultas triádicas de demência em medicina geral e familiar: um estudo exploratório

Authors

  • Maria Conceição Balsinha Faculdade de Ciências Médicas | NOVA Medical School, Universidade Nova de Lisboa; CHRC, Laboratório Associado REAL. Lisboa, Portugal. USF Marginal. S. João do Estoril, Portugal.
  • Manuel Gonçalves-Pereira Faculdade de Ciências Médicas | NOVA Medical School, Universidade Nova de Lisboa; CHRC, Laboratório Associado REAL. Lisboa, Portugal.
  • Sónia Dias Escola Nacional de Saúde Pública, Centro de Investigação em Saúde Pública, CHRC, REAL, CCAL, Universidade NOVA de Lisboa. Lisboa, Portugal.
  • Alexandre Freitas Faculdade de Ciências Médicas | NOVA Medical School, Universidade Nova de Lisboa. Lisboa, Portugal.
  • Steve Iliffe Research Department of Primary Care & Population Health, University College London. London, England.

DOI:

https://doi.org/10.32385/rpmgf.v39i5.13503

Keywords:

Cuidados de saúde primários, Medicina geral e familiar, Consultas triádicas, Métodos qualitativos, Comunicação clínica

Abstract

Introdução: Apesar das recomendações internacionais, a demência ainda não está consensualmente incluída no âmbito de intervenção dos cuidados de saúde primários. Em trabalhos anteriores estudámos as experiências e as perspetivas das pessoas com demência, dos seus cuidadores, dos médicos de família (MF) e outros profissionais de cuidados de saúde primários relativas às barreiras na prestação de cuidados na demência. No entanto, ainda pouco se sabe sobre as próprias consultas em medicina geral e familiar (MGF), nomeadamente as que envolvem a tríade paciente-cuidador informal-MF.

Objetivo: Explorar a prestação de cuidados na demência nas consultas triádicas em MGF.

Método: Análise de dez consultas com tríades, em seis contextos sociais distintos. Nove MF, dez pacientes e dez cuidadores foram recrutados por amostragem intencional. As consultas triádicas foram audiogravadas, transcritas e analisadas. A abordagem referencial combinou códigos com origem nas transcrições com códigos baseados na literatura. Os temas principais foram as consequências da demência (e.g., necessidade de informação) e a coordenação entre serviços.

Resultados: Os conteúdos especificamente relacionados com a demência ocuparam apenas 30% do tempo das consultas, apesar da duração destas (mediana 27 min). Os MF não pareceram envolvidos na gestão da demência, as suas avaliações foram pouco abrangentes e pouco centradas no doente e as intervenções limitadas. Os cuidadores facilitaram a avaliação dos MF sobre as consequências da demência, mas as suas necessidades foram avaliadas superficialmente. A participação dos doentes foi comprometida pelos estilos de comunicação na tríade.

Conclusão: Num contexto de prestação ‘fragmentada’ de cuidados é difícil para os MF avaliarem a demência entre todos os outros problemas de saúde. São necessárias estratégias para melhorar a avaliação dos cuidadores. A análise de consultas triádicas pode potenciar medidas de processo para avaliar a qualidade da prática clínica e do treino de consulta em MGF, mas é necessária mais investigação nesta área.

Downloads

Download data is not yet available.

References

Despacho nº 5988/2018, de 19 de junho. Diário da República. II Série;(116).

Prince M, Comas-Herrera A, Knapp M, Guerchet M, Karagiannidou M. World Alzheimer report 2016 – Improving healthcare for people living with dementia: coverage, quality and costs now and in the future [homepage]. London: Alzheimer's Disease International; 2016. Available from: https://www.alzint.org/resource/world-alzheimer-report-2016/

Gauthier S, Rosa-Neto P, Morais JA, Webster C. World Alzheimer report 2021: journey through the diagnosis of dementia [Internet]. London: Alzheimer's Disease International; 2021. Available from: https://www.alzint.org/u/World-Alzheimer-Report-2021.pdf

Connolly A, Iliffe S, Gaehl E, Campbell S, Drake R, Morris J, et al. Quality of care pro-vided to people with dementia: utilisation and quality of the annual dementia review in general practice. Br J Gen Pract. 2012;62(595):e91-8.

Wilcock J, Jain P, Griffin M, Thuné-Boyle I, Lefford F, Rapp D, et al. Diagnosis and management of dementia in family practice. Aging Ment Health. 2016;20(4):362-9.

Balsinha C, Iliffe S, Dias S, Freitas A, Grave J, Gonçalves-Pereira M. What is the present role for general practitioners in dementia care? Experiences of general practitioners, patients and family carers in Portugal. Dementia. 2021;20(6):1988-2006.

Peterson K, Hahn H, Lee AJ, Madison CA, Atri A. In the Information Age, do dementia caregivers get the information they need? Semi-structured interviews to determine informal caregivers’ education needs, barriers, and preferences. BMC Geriatr. 2016;16(1):164.

Wang M, Shao S, Li J, Liu Y, Xu X, Du J. The needs of informal caregivers and barriers of primary care workers toward dementia management in primary care: a qualitative study in Beijing. BMC Fam Pract. 2018;19(1):201.

Aminzadeh F, Molnar FJ, Dalziel WB, Ayotte D. A review of barriers and enablers to diagnosis and management of persons with dementia in primary care. Can Geriatr J. 2012;15(3):85-94.

Mansfield E, Noble N, Sanson-Fisher R, Mazza D, Bryant J. Primary care physicians’ perceived barriers to optimal dementia care: a systematic review. Gerontologist. 2019;59(6):e697-e708.

Manthorpe J, Iliffe S. The dialectics of dementia [Internet]. London: King's College; 2016. Available from: https://daanow.org/wp-content/uploads/2016/07/The-dialectics-of-dementia.pdf

Vernooij-Dassen M, Moniz-Cook E, Verhey F, Chattat R, Woods B, Meiland F, et al. Bridging the divide between biomedical and psychosocial approaches in dementia research: the 2019 INTERDEM manifesto. Aging Ment Health. 2021;25(2):206-12.

Balsinha C, Gonçalves-Pereira M, Iliffe S, Freitas JA, Grave J. Health-care delivery for older people with dementia in primary care. In: Lima CM, Ivbijaro G, editors. Primary care mental health in older people: a global perspective. Springer; 2019. p. 311-29. ISBN 9783030108144

Balsinha C, Iliffe S, Dias S, Freitas A, Barreiros FF, Gonçalves-Pereira M. Dementia and primary care teams: obstacles to the implementation of Portugal’s Dementia Strategy. Prim Health Care Res Dev. 2022;23:e10.

Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open. 2017;7(10):e017902.

Direção-Geral da Saúde. Abordagem diagnóstica e terapêutica do doente com declínio cognitivo ou demência: norma clínica nº 053/2011, de 27/09/2011, atualizada em 21/04/2023. Lisboa: DGS; 2023.

Alves RP, Caetano AI. O papel do médico de família no diagnóstico e seguimento dos doentes com declínio cognitivo e demência [The role of the family doctor in the diagnosis and monitoring of patients with cognitive impairment and dementia]. Rev Port Med Geral Fam. 2010;26(1):69-74. Portuguese

Despacho nº 12761/2021, de 29 de dezembro. Diário da República. II Série;(251).

Gonçalves-Pereira M, Leuschner A. Portugal. In: Burns A, Robert PE, editors. Dementia care: international perspectives. Oxford: Oxford University Press; 2019. p. 219-30. ISBN 9780191837210

Fortinsky RH. Health care triads and dementia care: integrative framework and future directions. Aging Ment Health. 2001;5 Suppl 1:S35-48.

Tuijt R, Rees J, Frost R, Wilcock J, Manthorpe J, Rait G, et al. Exploring how triads of people living with dementia, carers and health care professionals function in dementia health care: a systematic qualitative review and thematic synthesis. Dementia. 2021;20(3):1080-104.

Werner P. Family physicians' perceptions and predictors regarding the competence of a person with Alzheimer’s disease. Int J Geriatr Psychiatry. 2007;22(4):320-6.

Quinn C, Clare L, McGuinness T, Woods RT. Negotiating the balance: The triadic relationship between spousal caregivers, people with dementia and Admiral Nurses. Dementia. 2013;12(5):588-605.

Martin JE, Watson J, Barnes RK. Shared decision making about blood tests: secondary analysis of video-recorded primary care consultations. Br J Gen Pract. 2020;70(694):e339-e47.

olde Hartman TC, van Rijswijk E, van Dulmen S, van Weel-Baumgarten E, Lucassen PL, van Weel C. How patients and family physicians communicate about persistent medically unexplained symptoms: a qualitative study of video-recorded consultations. Patient Educ Couns. 2013;90(3):354-60.

Ritchie J, Lewis J, Elam J, Tennant R, Rahim N. Designing and selecting samples. In: Ritchie J, Lewis J, Nicholls CM, Ormston T, editors. Qualitative research practice: a guide for social science students and researchers. 2nd ed. Sage; 2013. p. 77-108. ISBN 9781526450425

World Health Organization ICD-10: international statistical classification of diseases and related health problems (tenth revision). 2nd ed. Geneva: WHO; 2004.

Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59-82.

Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010;25(10):1229-45.

Ritchie J, Spencer L, O'Connor W. Carrying out qualitative analysis. In: Ritchie J, Lewis J, Nicholls CM, Ormston T, editors. Qualitative research practice: a guide for social science students and researchers. 2nd ed. Sage; 2013. p. 219-62. ISBN 9781526450425

Adams T, Gardiner P. Communication and interaction within dementia care triads: developing a theory for relationship-centred care. Dementia. 2005;4(2):185-205.

Dreier-Wolfgramm A, Michalowsky B, Austrom MG, van der Marck MA, Iliffe S, Alder C, et al. Dementia care management in primary care: current collaborative care models and the case for interprofessional education. Z Gerontol Geriatr. 2017;50(Suppl 2):68-77.

Wensing M, Mainz J, Grol R. A standardised instrument for patient evaluations of general practice care in Europe. Eur J Gen Pract. 2000;6(3):82-7.

Bjørland E, Brekke M. What do patients bring up in consultations? An observational study in general practice. Scand J Prim Health Care. 2015;33(3):206-11.

Herrmann LK, Welter E, Leverenz J, Lerner AJ, Udelson N, Kanetsky C, et al. A systematic review of dementia-related stigma research: can we move the stigma dial? Am J Ger-iatr Psychiatry. 2018;26(3):316-31.

Dröes RM, Chattat R, Diaz A, Gove D, Graff M, Murphy K, et al. Social health and dementia: a European consensus on the operationalization of the concept and directions for research and practice. Aging Ment Health. 2017;21(1):4-17.

Petrazzuoli F, Vinker S, Koskela TH, Frese T, Buono N, Soler JK, et al. Exploring dementia management attitudes in primary care: a key informant survey to primary care physicians in 25 European countries. Int Psychogeriatr. 2017;29(9):1413-23.

Foley T, Boyle S, Jennings A, Smithson WH. ‘We’re certainly not in our comfort zone’: a qualitative study of GPs’ dementia-care educational needs. BMC Fam Pract. 2017;18(1):66.

Kales HC, Gitlin LN, Lyketsos CG. Assessment and management of behavioral and psychological symptoms of dementia. BMJ. 2015;350:h369.

World Health Organization. Framework on integrated, people-centred health services: report by the Secretariat [homepage]. Geneva: WHO; 2016. Available from: https://apps.who.int/iris/handle/10665/252698

Stephan A, Bieber A, Hopper L, Joyce R, Irving K, Zanetti O, et al. Barriers and facilitators to the access to and use of formal dementia care: findings of a focus group study with people with dementia, informal carers and health and social care professionals in eight Euro-pean countries. BMC Geriatr. 2018;18(1):131.

Gibson C, Goeman D, Pond D. What is the role of the practice nurse in the care of people living with dementia, or cognitive impairment, and their support person(s)? A systematic review. BMC Fam Pract. 2020;21(1):141.

Themessl-Huber M, Humphris G, Dowell J, Macgillivray S, Rushmer R, Williams B. Audiovisual recording of patient-GP consultations for research purposes: a literature review on recruiting rates and strategies. Patient Educ Couns. 2008;71(2):157-68.

Published

2023-11-02

How to Cite

Análise de consultas triádicas de demência em medicina geral e familiar: um estudo exploratório. (2023). Portuguese Journal of Family Medicine and General Practice, 39(5), 414-26. https://doi.org/10.32385/rpmgf.v39i5.13503