Development of a complex intervention to improve mobility and participation of older people with vertigo, dizziness and balance disorders in primary care: a mixed methods study

Abstract

Background: Vertigo, dizziness and balance disorders (VDB) are common in older individuals and cause restrictions in mobility and participation. Due to a multifactorial aetiology, health care is often overutilitised, but many patients are also treated insufficiently in primary care. The purpose of this study was to develop a care pathway as a complex intervention to improve mobility and participation in older people with VDB in primary care.Methods: The development followed the UK Medical Research Council guidance using a mixed-methods design with individual and group interviews carried out with patients, physical therapists (PTs), general practitioners (GPs), nurses working in community care and a multi-professional expert panel to create a first draft of a care pathway (CPW) and an implementation strategy using the Consolidated Framework of Implementation Research and the Expert recommendations for Implementing Change. Subsequently, small expert groups modelling of specific components of CPW was carried out, with GPs, medical specialists and PTs. The Behaviour Change Wheel was applied to design the intervention´s behaviour change. To explicate theoretical assumptions, we adopted Kellogg´s Logic Model to consolidate the hypothesized chain of causes leading to patient-relevant outcomes.Results: Individual interviews with patients showed that VDB symptoms need to be taken more seriously by GPs. Patients demanded age-specific treatment offers, group sessions or a continuous mentoring by a PT. GPs required a specific guideline for diagnostics and treatment options adding psycho-social interventions. Specific assignment to and a standardized approach during physical therapy was desired by PTs. Nurses favoured a multi-professional documentation system. The structured three-day expert workshop resulted in a first draft of CPW and potential implementation strategies. Subsequent modelling resulted in a CPW with components and appropriate training materials for involved health professionals. A specific implementation strategy is now available.Conclusion: Mixed-methods design proved to be a suitable approach to develop a complex intervention and its implementation. We will subsequently test the intervention for its acceptability and feasibility in a feasibility study accompanied by a comprehensive process evaluation to inform a subsequent effectiveness trial.Trial Registration: The research project is registered in “Projektdatenbank Versorgungsforschung Deutschland” (Project-ID: VfD_MobilE-PHY_17_003910; date of registration: 30.11.2017).

Associação entre tontura e fragilidade em idosos

“…Outra medida considerada equivocada é a frequente prescrição de antieméticos como a meclizina em idosos com tontura, pois tem potencial para consequências negativas devido as mais de 50 interações medicamentosas e é inadequada em casos benignos como na vertigem posicional paroxística (VPPB) [17,18]. Estudos apontam que apesar da qualidade suficiente das evidências indicando o valor da fisioterapia para o gerenciamento da tontura, a fisioterapia parece não ser uma opção padrão na atenção primária de pacientes em alguns lugares [19,20]. Em última análise, a investigação diagnóstica incompleta irá levar a tentativas de terapia malsucedidas e, eventualmente, a cronificação [16].…”