Prescribing of antipsychotics in people with dementia in acute general hospitals in England: 2010–2012

Behavioural analysis of factors influencing prescribing for neurodegenerative diseases: A rapid review

BACKGROUND

The incidence and prevalence of neurodegenerative diseases (NDs) are growing worldwide. In an environment where healthcare resources are already stretched, it is important to optimise treatment choice to help alleviate healthcare burden. This rapid review aims to consolidate evidence on factors that influence healthcare professionals (HCPs) to prescribe medication for NDs and map them to theoretical models of behaviour change to identify the behavioural determinants that may support in optimising prescribing.

METHODS AND FINDINGS

Embase and Ovid MEDLINE were used to identify relevant empirical research studies. Screening, data extraction and quality assessment were carried out by three independent reviewers to ensure consistency. Factors influencing prescribing were mapped to the Theoretical Domains Framework (TDF) and key behavioural determinants were described using the Capability, Opportunity, Motivation - Behaviour (COM-B) model. An initial 3,099 articles were identified, of which 53 were included for data extraction. Fifty-six factors influencing prescribing were identified and categorised into patient, HCP or healthcare system groups, then mapped to TDF and COM-B domains. Prescribing was influenced by capability of HCPs, namely factors mapped to decision making (e.g., patient age or symptom burden) and knowledge (e.g., clinical understanding) behavioural domains. However, most factors were influenced by HCP opportunity, underpinned by factors mapped to social (e.g., prescribing support or culture) and contextual (e.g., lack of resources or medication availability) domains. Less evidence was available on factors influencing the motivation of HCPs, where evident; factors primarily related to HCP belief about consequences (e.g., side effects) and professional identify (e.g., level of specialism) were often described.

CONCLUSIONS

This systematic analysis of the literature provides an in-depth understanding of the behavioural determinants that may support in optimising prescribing practices (e.g., drug costs or pressure from patients' family members). Understanding these approaches provides an opportunity to identify relevant intervention functions and behaviour change techniques to target the factors that directly influence HCP prescribing behaviour.

Prospective predictors of decline v. stability in mild cognitive impairment with Lewy bodies or Alzheimer's disease

BACKGROUND

Mild cognitive impairment (MCI) may gradually worsen to dementia, but often remains stable for extended periods of time. Little is known about the predictors of decline to help explain this variation. We aimed to explore whether this heterogeneous course of MCI may be predicted by the presence of Lewy body (LB) symptoms in a prospectively-recruited longitudinal cohort of MCI with Lewy bodies (MCI-LB) and Alzheimer's disease (MCI-AD).

METHODS

A prospective cohort (n = 76) aged ⩾60 years underwent detailed assessment after recent MCI diagnosis, and were followed up annually with repeated neuropsychological testing and clinical review of cognitive status and LB symptoms. Latent class mixture modelling identified data-driven sub-groups with distinct trajectories of global cognitive function.

RESULTS

Three distinct trajectories were identified in the full cohort: slow/stable progression (46%), intermediate progressive decline (41%) and a small group with a much faster decline (13%). The presence of LB symptomology, and visual hallucinations in particular, predicted decline v. a stable cognitive trajectory. With time zeroed on study end (death, dementia or withdrawal) where available (n = 39), the same subgroups were identified. Adjustment for baseline functioning obscured the presence of any latent classes, suggesting that baseline function is an important parameter in prospective decline.

CONCLUSIONS

These results highlight some potential signals for impending decline in MCI; poorer baseline function and the presence of probable LB symptoms - particularly visual hallucinations. Identifying people with a rapid decline is important but our findings are preliminary given the modest cohort size.

Sex and gender differences in polypharmacy in persons with dementia: A scoping review

PURPOSE

To date, research studies in most disciplines have not made sex-based analysis a priority despite increasing evidence of its importance. We now understand that both sex and gender impact medication prescribing, use, and effect. This is particularly true for older adults with dementia who have alterations in drug metabolism, drug response, and the permeability of the blood-brain barrier. To better understand the influence of sex and gender on drug use in older adults with dementia, we conducted a scoping review.

METHODS

This scoping review systematically searched the Medline, Embase, Web of Science, CINAHL, and ProQuest databases to find published reports on polypharmacy in populations of older adults with dementia that included a sex- or gender-based analysis.

RESULTS

A total of 12 published reports were identified. Findings were cohort studies and case-control trials that commented on sex-related differences in medication use as a secondary analysis to the studies' primary objective. These studies showed that community-dwelling women received more potentially inappropriate medications and more psychotropic medications, while nursing home dwelling men received more potentially inappropriate medications, cholinesterase inhibitors, and antipsychotics. None of the identified studies explicitly examined gender-related differences in medication use.

CONCLUSION

This scoping review supports that there is inadequate understanding of both sex and gender differences in drug use in older men and women with dementia. To tailor medication-specific interventions to improve drug therapy for older adults with dementia, it is important that future work includes sex- or gender-based analysis of drug use.

Linking individual-level data on diagnoses and dispensing for research on antibiotic use: Evaluation of a novel data source from English secondary care

PURPOSE

There has been a focus on stewardship programmes to curb inappropriate antibiotic prescribing and reduce antimicrobial resistance. In-hospital, patient-level prescribing linked to indication is needed to support surveillance, evaluation of stewardship initiatives, as well as other antibiotic research. We evaluated whether a novel dataset linking hospital pharmacy records to Hospital Episode Statistics data can be used for antibiotic research.

METHODS

Using the Hospital Treatment Insights (HTI) database, which links Hospital Episode Statistics to pharmacy records from 43 out of 153 hospital trusts in England, we estimated the proportion of missed linkage and identified characteristics associated with missing data.

RESULTS

Linkage of antibiotics to patients was inconsistent and dependent on drug type and clinical setting, so that linkage for some specific antibiotics was high (80-100%), but overall, only 27.6% (CI: 27.4%-27.8%) for all antibiotics dispensed. Linkage was best for quinolones (62.6%; CI: 61.8%-63.8%), but only 21.1% (CI: 21.1%-21.2%) for penicillins. Linkage was lower for common antibiotics and in emergency departments; however, 80% linkage was achieved for individual drugs like clindamycin, especially on wards with reduced ward stock use.

CONCLUSIONS

For those antibiotics with high linkage, HTI might be used to study associations between indication, dispensing, and outcomes. However, the majority of common antibiotics had insufficient linkage, likely due to extensive use of ward stocks. Therefore, HTI in its current form is not suitable for general antibiotic surveillance or evaluation of stewardship initiatives. For drugs in HTI other than antibiotics, linkage should be similarly evaluated before a study is conducted.

Dementia ascertainment using existing data in UK longitudinal and cohort studies: a systematic review of methodology

BACKGROUND

Studies investigating the risk factors for or causation of dementia must consider subjects prior to disease onset. To overcome the limitations of prospective studies and self-reported recall of information, the use of existing data is key. This review provides a narrative account of dementia ascertainment methods using sources of existing data.

METHODS

The literature search was performed using: MEDLINE, EMBASE, PsychInfo and Web of Science. Included articles reported a UK-based study of dementia in which cases were ascertained using existing data. Existing data included that which was routinely collected and that which was collected for previous research. After removing duplicates, abstracts were screened and the remaining articles were included for full-text review. A quality tool was used to evaluate the description of the ascertainment methodology.

RESULTS

Of the 3545 abstracts screened, 360 articles were selected for full-text review. 47 articles were included for final consideration. Data sources for ascertainment included: death records, national datasets, research databases and hospital records among others. 36 articles used existing data alone for ascertainment, of which 27 used only a single data source. The most frequently used source was a research database. Quality scores ranged from 7/16 to 16/16. Quality scores were better for articles with dementia ascertainment as an outcome. Some papers performed validation studies of dementia ascertainment and most indicated that observed rates of dementia were lower than expected.

CONCLUSIONS

We identified a lack of consistency in dementia ascertainment methodology using existing data. With no data source identified as a "gold-standard", we suggest the use of multiple sources. Where possible, studies should access records with evidence to confirm the diagnosis. Studies should also calculate the dementia ascertainment rate for the population being studied to enable a comparison with an expected rate.

Antipsychotic Use in Dementia

Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exists over the role of antipsychotics in the management of neuropsychiatric symptoms (NPS) in persons with dementia. Although some NPS may be appropriately and safely treated with antipsychotics, a fine balance must be achieved between the benefits of these medications, which are often modest, and adverse events, which may have significant consequences. Approximately one-third of all persons with dementia are currently prescribed antipsychotic medications, and there is significant variation in the use of antipsychotics across care settings and providers. Reducing the inappropriate or unnecessary use of antipsychotics among persons with dementia has been the focus of increasing attention owing to better awareness of the potential problems associated with these medications. Several approaches can be used to curb the use of antipsychotics among persons with dementia, including policy or regulatory changes, public reporting, and educational outreach. Recently, there has been encouraging evidence of a downward trend in the use of antipsychotics in many long-term care settings, although prescribing rates are still higher than what is likely optimal. Although reducing the inappropriate use of antipsychotics is a complex task, psychiatrists can play an important role via the provision of clinical care and research evidence, contributing to improved care of persons with dementia in Canada and elsewhere.

Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem

Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.

Identifying fallacious arguments in a qualitative study of antipsychotic prescribing in dementia

BACKGROUND

Dementia can result in cognitive, noncognitive and behavioural symptoms which are difficult to manage. Formal guidelines for the care and management of dementia in the UK state that antipsychotics should only be prescribed where fully justified. This is because inappropriate use, particularly problematic in care-home settings, can produce severe side effects including death. The aim of this study was to explore the use of fallacious arguments in professionals' deliberations about antipsychotic prescribing in dementia in care-home settings. Fallacious arguments have the potential to become unremarkable discourses that construct and validate practices which are counter to guidelines.

METHODS

This qualitative study involved interviews with 28 care-home managers and health professionals involved in caring for patients with dementia. Potentially fallacious arguments were identified using qualitative content analysis and a coding framework constructed from existing explanatory models of fallacious reasoning.

KEY FINDINGS

Fallacious arguments were identified in a range of explanations and reasons that participants gave for in answer to questions about initiating, reducing doses of and stopping antipsychotics in dementia. The dominant fallacy was false dichotomy. Appeal to popularity, tradition, consequence, emotion, or fear, and the slippery slope argument was also identified.

CONCLUSIONS

Fallacious arguments were often formulated to present convincing cases whereby prescribing antipsychotics or maintaining existing doses (versus not starting medication or reducing the dose, for example) appeared as the only acceptable decision but this is not always the case. The findings could help health professionals to recognise and mitigate the effect of logic-based errors in decisions about the prescribing of antipsychotics in dementia.

Piperazine scaffold: A remarkable tool in generation of diverse pharmacological agents

Piperazine is one of the most sought heterocyclics for the development of new drug candidates. This ring can be traced in a number of well established, commercially available drugs. Wide array of pharmacological activities exhibited by piperazine derivatives have made them indispensable anchors for the development of novel therapeutic agents. The review herein highlights the therapeutic significance of piperazine derivatives. Various therapeutically active piperazine derivatives developed by several chemists are reported here.