Study Participants and Relevant Topics
All study participants (n = 20) were senior general practitioners in community health centres or clinics in Guangzhou city, who were actively involved in the training of GP trainees. Six modules were delivered during the course that covered the following topics: (1) polypharmacy and de-prescribing, (2) dementia, (3) antibiotic stewardship, (4) fall prevention and frailty assessment, (5) vaccination, (6) atrial fibrillation.
Course Satisfaction
A summary of course satisfaction ratings is shown in Fig. 1. For modules 1, 2, 3, 4, 5, and 6, percentages of participants reporting minimal prior knowledge of course content were 93.75%, 96.34%, 98.06%, 98.70%, 100%, and 97.65%, respectively; percentages of participants reporting course content being relevant were 100%, 96.34%, 97.09%, 94.81%, 97.69%, 98.82%, respectively; percentages of participants reporting course content being relevant were 97.92%, 96.34%, 93.21%, 96.10%, 98.98%, and 98.82%, respectively, percentages of participants reporting overall course satisfaction were 96.88%, 93.90%, 86.41%, 84.42%, 92.96%, and 92.94%, respectively.
Salient learning points that trainers perceived as relevant to educate GPs regarding promoting healthy ageing in Guangzhou, China
Through group discussion and online survey responses from participants (GP trainers) identified salient points regarding promotion of healthy ageing in China for each of the six topics presented and these are summarized below.
Module 1: Polypharmacy and de-prescribing
1. Polypharmacy is frequent clinical presentation in general practice in China.
2. Inappropriate polypharmacy is one of the top ten problems identified in Guangzhou GP clinics.
3 .Older adults with several comorbidities are more exposed to the risk of polypharmacy.
4. Medication therapy must be optimized to minimize the risk of adverse drug reactions.
5. All medicines should be prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient.
6. The patient should be motivated to adhere to their regime and competent to safely take medicines as prescribed.
7. The patient’s social determinants of health & lifestyle should be considered when prescribing.
8. There are multiple risk factors for inappropriate polypharmacy, including advanced age, multiple comorbidities, multiple prescribers or pharmacies, self-treatment with over-the-counter medications, a history of hospitalizations and attending practices with poor medication tracking processes,
9. De-prescribing should be recognised as a staged process that includes stopping, stepping down and dose reduction for up to three months with 12 months clinical follow-up.
10. More evidence is needed to guide de-prescribing in the older population.
Module 2: Dementia
1. Dementia is a syndrome, not a disease. It is also an umbrella terminology.
2. Dementia is not just a decline in mental ability affecting memory and thought processes but is often under recognised as including social and behavioural manifestation and affecting daily tasks.
3. The ‘head turn sign’[14] may serve as a spot diagnostic tool for clinical screening.
4. Patients should be informed that there are many reversible causes of dementia that can be controlled.
5. Non-pharmacological intervention that should be recommended for dementia prevention include regular physical activity, smoking cessation and key elements of the Mediterranean diet (i.e. fish consumption) adapted for Chinese older adults.
6. A multidisciplinary approach for dementia management should be taken and recognise the important roles of family members and carers.
Module 3: Antibiotic stewardship
1. Tendinopathy is one of the often-overlooked side effects of fluoroquinolones in general practice.
2. Antibiotic stewardship should be promoted in the GP community to improve patient health outcomes, reducing drug resistance and decreasing unnecessary costs.
3. Antibiotics guidelines in general practice should be tailored to the local context.
Module 4: Fall prevention and frailty assessment
1. Frailty is a medical syndrome with increased morbidity and mortality in the older population. Understanding the difference between older age and a diagnosis of frailty is important for GP clinics.
2. There are many risk factors for falls, while frailty has a genetic basis.
3. Assessment tools useful for clinical screening for falls and frailty should be used.
4. There are many predictable causes of falls. Preventive strategies should be individualized for older patients who present to Chinese GP clinics with a fall.
5. All older patients in China are not presently given information about falls prevention.
6. A Frailty assessment clinic in Australia and its role in delaying or reversing the frailty progress with exercise prescription has shown consistent benefits.
7. The multidisciplinary approach for both fall prevention and frailty management should recognise important roles of general practitioners, nurses, physiotherapists and carers.
Module 5: Vaccination
1. Vaccination for older adults is relatively under-recognized in China.
2. It is necessary to encourage a selected group of older patients to consider vaccination to enhance protection of vulnerable older adults in China.
3. There should be a risk and benefit ratio discussion for the patient before vaccination.
4. There are documented benefits of vaccination in reducing morbidity and mortality.
5. Increasing public awareness of the antigenic drift and shift of the influenza virus should be promoted in community settings in China.
Module 6: Atrial fibrillation
1. The prevalence of atrial fibrillation in older adults in China is increasing.
2. There are multiple risk factors for atrial fibrillation, some of which are controllable at the level of general practice.
3. There are several useful frameworks of clinical assessment for atrial fibrillation, including the CHADS2-VASc score[15] and HAS-BLED score[16], which can and should be promoted in general practice.
4. The pros and cons of rate control versus rhythm control strategies for older patients should be discussed.
5. Anticoagulation therapy for stroke prevention is important for older patients, which can and should be managed in general practice.
Subsequently, salient points according to the above six modules were further categorized into three domains including personal, interpersonal, and societal domains to address promotion of healthy ageing in Guangzhou, China. These domains are presented in Table 1 along with illustrative quotes. The Personal domain primarily concerned the knowledge and skills needed to be equipped for the GP trainees. The Interpersonal domain concerned the interaction needed between the GP and the older patient. The Societal domain concerned the coordinated efforts needed by academic societies or society as a whole.
Table 1
Domains required to address Promotion of Healthy Aging in Guangzhou, China
Modules | Salient Points per Domains | Illustrative Quotes |
Polypharmacy and de-prescribing | Personal - Polypharmacy is a frequent clinical encounter in general practice. - Inappropriate polypharmacy is one of the top ten problems in GP clinics. - Older people with several comorbidities are more exposed to the risk of polypharmacy. - Medication therapy has been optimized to minimize the risk of adverse drug reactions. - De-prescribing is a lengthy process that includes stopping, stepping down and dose reduction up to three months with 12 months clinical follow-up. Interpersonal - All medicines should be prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient. - The patient should be motivated and able to take all medicines as intended. - The patients’ social determinants of health & lifestyles should be considered when prescribing. - There are several risk factors for inappropriate polypharmacy that need to be addressed on an interpersonal level with the patients, e.g. self-treatment with over-the-counter medications, etc. Societal - More evidence is needed to guide de-prescribing in the elderly population. - There are several risk factors for inappropriate polypharmacy that need to be addressed in the wider sociocultural context: practices with poor medication tracking processes | In order to avoid inappropriate polypharmacy, the GP needs to be well acquainted with adverse effects and possible interactions of different medications often prescribed for an older patient with multiple comorbidities. (trainer #4) |
Dementia | Personal - Dementia is a syndrome, not a disease. It is also an umbrella terminology. - Dementia is not just a decline in mental ability affecting memory and thought processes but also a decline in functional and behavioural capacity of various domains including motor disturbance, language defect and social function. - The ‘head turn sign’ can serve as a spot diagnostic tool for clinical screening. - There are many reversible causes of dementia that can be controlled. Interpersonal - Non-pharmacological intervention for dementia prevention includes regular physical activity, smoking cessation and the Mediterranean diet. Societal - A multidisciplinary approach for dementia management should involve the important roles of family members and carers. | “The GP needs to be trained to rule out organic diseases for older patients with dementia.” (trainer #3) |
Antibiotic stewardship | Personal - Tendinopathy is one of the often-overlooked side effects of fluoroquinolones in general practice. Societal - Antibiotic stewardship should be promoted in the professional community to improve patient health outcomes, reducing drug resistance and decreasing unnecessary costs. - Data regarding antibiotics usage in general practice should be collected and relevant guidelines for GPs should be developed in China. | It is advisable to collect data concerning the use of antibiotics in GP clinics in relation to patient outcomes in China. (trainer #6) |
Fall prevention and frailty assessment | Personal - Frailty is a medical syndrome with increased morbidity and mortality in older adults. - There are many risk factors for falls, while frailty has a genetic basis. - There are assessment tools useful for clinical screening for fall and frailty. Interpersonal - There are many predictable causes of falls. Prevention strategies should be individualized. Societal - A Frailty assessment clinic in Australia and its role in delaying or reversing the frailty progress with exercise prescription has shown consistent benefits. - The multidisciplinary approach for both fall prevention and frailty management should involve the important roles of general practitioners, nurses, physiotherapists and carers. | “The Australian experience of frailty assessment and fall prevention in the older populations can inform general practice in China.” (trainer #7) |
Vaccination | Personal - Vaccination in older population is relatively under-recognized in China. - There are documented benefits of vaccination in reducing morbidity and mortality. Interpersonal - It is necessary to encourage selective older patients to consider vaccination. - There should be a risk and benefit ratio discussion with older patients before vaccination. Societal - There should be an increasing public awareness of the antigenic drift and shift of the influenza virus. | “Careful history-taking and discussion of risks and benefits for the older patients should precede the GP’s recommendation for vaccination.” (trainer #13) |
Atrial fibrillation | Personal - The prevalence of atrial fibrillation in the older population is on the rise. - There are many risk factors for atrial fibrillation, some of which are controllable at the level of general practice. - There are several useful frameworks of clinical assessment for atrial fibrillation, including the CHADS2-VASc score and HAS-BLED score, which can and should be promoted in general practice. Interpersonal - The pros and cons of rate control versus rhythm control strategies for the older patients should be discussed. Societal - Anticoagulation therapy for stroke prevention can and should be managed in general practice. | “Anticoagulation therapy for atrial fibrillation, as well as many other cardiovascular disease prevention measures, can and should be managed by GPs in the community.” (trainer #17) |