Barriers to antipsychotic discontinuation in nursing homes: an exploratory study

An integrative systematic review of nurses' involvement in medication deprescription in long-term healthcare settings for older people

Background

Deprescription of medications for older people in long-term care settings is crucial to enhance medication safety by reducing polypharmacy and minimizing related adverse events. Nurses as the member of the multidisciplinary healthcare team can support deprescription initiatives, but there is a gap in comprehensive knowledge about their roles.

Objectives

To investigate the role and contribution of nurses in deprescribing medications within the multidisciplinary pharmaceutical care context of long-term healthcare for older people.

Design

A systematic review utilizing an integrative approach was performed.

Methods

Multiple databases were searched, including PubMed (covering MEDLINE), Scopus, CINAHL, ProQuest and Embase, focusing on studies published in English from 2014 to 2024. The preliminary search yielded 4872 studies, which were then refined to 32 qualitative and quantitative studies chosen for data analysis and narrative synthesis. Thematic comparisons and analysis led to the creation of meaningful categories integrating the studies' findings to meet the review's objective.

Results

The review findings were classified into categories: 'necessity and benefits of deprescribing', 'multidisciplinary collaboration for deprescribing', 'nurse role in deprescribing', 'identified challenges to deprescribing', 'involvement of older people and families in deprescribing'. They illustrated and exemplified various aspects of nurses' roles and contributions in deprescription initiatives within the multidisciplinary pharmaceutical care team, such as support for reducing doses, discontinuing medications or transitioning to safer alternatives, as well as factors influencing this process.

Conclusion

The main dimensions of nurses' roles and contributions in deprescription initiatives encompass monitoring, communicating and educating. Challenges to nurses' active participation in deprescribing, such as the need for increased knowledge, confidence and inclusion in team discussions, should be addressed through education, training and changing attitudes. These steps are essential for improving the safety of medication deprescribing in long-term care settings.

Trial registration

The review was registered under PROSPERO ID: CRD42023486484, and can be accessed at crd.york.ac.uk/PROSPERO/display_record.php?RecordID=486484.

A systematic review of quantitative studies exploring staff views on antipsychotic use in residents with dementia in care homes

BACKGROUND

Despite significant warnings of adverse effects, antipsychotics continue to be prescribed for managing the behavioural and psychological symptoms of dementia (BPSD) in care homes. Information provided by staff working within care homes is a factor that can influence prescribing decisions in residents with BPSD.

AIM

The review aimed to capture care home staff views towards antipsychotics for residents with BPSD and separately analyse tools utilized in the studies, mapping them onto the theory of planned behaviour (TPB).

METHOD

A comprehensive literature search published in ten databases was conducted between May and July 2020 and updated in July 2021. Studies published in full with no date restriction were included and quality assessed using CROSS checklist. A thematic framework approach was applied to extract data and study tools which were then mapped onto the TPB.

RESULTS

Fourteen studies (2059 participants) were included. Findings identified four overarching themes: attitudes toward antipsychotics (e.g. antipsychotics as an appropriate strategy and effectiveness); barriers to deprescribing (e.g. lower staff education, lack of resources and time, poor medication reviews); measures implemented (e.g. nonpharmacological interventions, medication reviews); and perceived needs of staff (e.g. need for training, financial or clinical support). Identified tools addressed seven but not all components of TPB namely, behavioural, normative and control beliefs, attitude, perceived behavioural control, intention and behaviour.

CONCLUSION

The positive attitudes toward antipsychotics, the identified barriers to deprescribing and the existing tools not addressing all components of the TPB provide the impetus for further research.

STOP Signs: A Population-based Interrupted Time Series Analysis of Antibiotic Duration for Complicated Intraabdominal Infection Before and After the Publication of a Landmark RCT

OBJECTIVE

To determine if the STOP-IT randomized controlled trial changed antibiotic prescribing in patients with Complicated Intraabdominal Infection (CIAI).

SUMMARY OF BACKGROUND DATA

CIAI is common and causes significant morbidity. In May 2015, the STOP-IT randomized controlled trial showed equivalent outcomes between four-day and clinically determined antibiotic duration.

METHODS

This was a population-based retrospective cohort study using interrupted time series methods. The STOP-IT publication date was the exposure. Median duration of inpatient antibiotic prescription was the outcome. All adult patients admitted to four hospitals in Calgary, Canada between July 2012 and December 2018 with CIAI who survived at least four days following source control were included. Analysis was stratified by infectious source as appendix or biliary tract (group A) versus other (group B).

RESULTS

Among 4384 included patients, clinical and demographic attributes were similar before vs after publication. In Group A, median inpatient antibiotic duration was 3 days and unchanged from the beginning to the end of the study period [adjusted median difference -0.00 days, 95% confidence interval (CI) -0.37 - 0.37 days]. In Group B, antibiotic duration was shorter at the end of the study period (7.87 vs 6.73 days; -1.14 days, CI-2.37 - 0.09 days), however there was no change in trend following publication (-0.03 days, CI -0.16 - 0.09).

CONCLUSIONS

For appendiceal or biliary sources of CIAI, antibiotic duration was commensurate with the experimental arm of STOP-IT. For other sources, antibiotic duration was long and did not change in response to trial publication. Additional implementation science is needed to improve antibiotic stewardship.

Determine the impact of a structured pharmacist-led medication review - a controlled intervention study to optimise medication safety for residents in long-term care facilities

Background

Medication reviews contribute to protecting long-term care (LTC) residents from drug related problems (DRPs). However, few controlled studies have examined the impact on patient-relevant outcomes so far.

Objective

We examined the impact of a one-time, pharmacist-led medication review on medication changes (primary endpoint) including discontinued medication, the number of chronic medications, hospital admissions, falls, and deaths (secondary endpoints).

Methods

A prospective, controlled intervention study was performed in three LTC facilities. In the intervention group (IG), after performing a medication review, a pharmacist gave recommendations for resolving DRPs to physicians, nurses and community pharmacists. The control group (CG) received usual care without a medication review. (i) We assessed the number of medication changes and the secondary endpoints in both groups before (t0) and after (t1, t2) the intervention. (ii) Additionally, the medication review was evaluated in the IG with regard to identified DRPs, the healthcare professional’s feedback on the forwarded pharmacist recommendations and whether DRPs were finally resolved.

Results

107 (IG) and 104 (CG) residents were enrolled. (i) More medication changes were identified in the IG than in the CG at t1 (p = 0.001). However, no significant difference was identified at t2 (p = 0.680). Mainly, medication was discontinued in those medication changes. Chronic medications increased in the CG (p = 0.005) at t2 while hospital admissions, falls, and deaths showed no differences. (ii) Overall, 1252 DRPs (median: 10; minimum-maximum: 2–39) were identified. Recommendations for 82% of relevant DRPs were forwarded to healthcare professionals, of which 61% were accepted or clarified. 22% were not accepted, 12% required further review and 6% remained without feedback. 51% of forwarded DRPs were finally resolved.

Conclusions

We found more medication changes in the IG compared to controls. Mostly, medication was discontinued. This suggests that our intervention was successful in discontinuing unnecessary medication. Other clinical outcomes such as falls, hospitalisations, and deaths were not improved due to the one-time intervention. The medication review further identified a high prevalence of DRPs in the IG, half of which were finally resolved.

Trial registration

German Clinical Trials Register, DRKS00026120 (www.drks.de, retrospectively registered 07/09/2021).

De-implementing and sustaining an intervention to eliminate nursing home resident bed and chair alarms: interviews on leadership and staff perspectives

Background

Improving nursing home quality of care relies partly on reducing or stopping ineffective or harmful practices, a process known as de-implementation. We know little about de-implementation in this setting. Relatively recent policy changes reclassified resident position-change (bed and chair) alarms, which monitor resident movement, as restraints. This created an optimal environment in which to study impressions of an alarm de-implementation and sustainment intervention.

Methods

This cross-sectional interview study focused on understanding participants’ experience of a quality improvement program in the Department of Veterans Affairs Community Living Centers (nursing homes). The program’s goal was to improve resident outcomes and staff communication and teamwork through, among other foci, eliminating resident position-change alarms. The Community Living Centers were located in geographically dispersed areas of the continental United States. Interview participants were leadership and staff members from seven Community Living Centers. We conducted in-depth, semi-structured qualitative interviews using a convenience sample and used a thematic analytic approach.

Results

We conducted seventeen interviews. We identified five main themes: Initiating De-implementation (compelling participants with evidence, engaging local leadership, and site-level education and training), Changing Expectations (educating staff and family members), Using Contrasting Approaches (gradual or abrupt elimination of alarms), Witnessing Positive Effects of De-implementation (reduction in resident falls, improved resident sleep, reduction in distressing behaviors, and increased resident engagement), and Staying the Course (sustainment of the initiative).

Conclusions

Findings highlight how participants overcame barriers and successfully eliminated resident position-change alarms and sustained the de-implementation through using convincing evidence for the initiative, local leadership involvement and support, and staff and family member education and engagement. These findings and the resulting three-phase process to support nursing homes' de-implementation efforts expand the de-implementation science knowledge base and provide a promising framework for other nursing home-based de-implementation initiatives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00195-w.

What Makes Deprescription of Psychotropic Drugs in Nursing Home Residents with Dementia so Challenging? A Qualitative Systematic Review of Barriers and Facilitators

Background

Behavioral and psychological symptoms of dementia are frequently experienced in the nursing home setting and place a substantial burden on patients, relatives, and nursing home staff. Despite guidelines recommending non-pharmacological treatments, psychotropic drugs are often prescribed to address these symptoms. This is the case despite their effects being limited, and there being a risk of side effects and adverse events for the patient. Several studies have aimed to reduce the use of psychotropic drugs, with varying results. The reasons behind these variations are not well understood.

Objectives

The objective of this systematic review was to investigate which factors nursing home general practitioners and nursing home staff experience as barriers or facilitators when attempting to deprescribe psychotropic drugs in nursing home residents.

Methods

We searched PubMed, EMBASE, psycINFO, Web of Science, and CINAHL between April and September 2020. An inductive method using thematic analysis of the qualitative findings was applied for the derivation of themes. Quantitative studies were included but described descriptively and separately.

Results

Of 8204 unique records, 14 studies were included in the review. Of these, nine were interview or focus group studies and five were survey studies. Thematic analysis resulted in five major themes identified as either facilitators or barriers or both: (1) ‘Operationality and routines’; (2) ‘Lack of resources and qualifications’; (3) ‘Patient-related outcomes’, which points to a strong belief in negative patient-related outcomes of discontinuation and a downplay of side effects of the medication; (4) ‘Policies’, including support and buy-in from nursing home leadership; and (5) ‘Collaboration’ between physicians and nursing home staff. Themes 1 and 4 consist of facilitators. Theme 2 consists of barriers. Theme 3 and 5 consist of both facilitators and barriers. Evaluation of closed-ended questions from the surveys supported the findings.

Conclusions

Deprescribing psychotropic drugs used for behavioral and psychological symptoms of dementia in nursing home residents is challenging. Resources need to be in place for deprescribing, as well as there being a focus on the positive patient-related outcomes of doing so. Managerial support, staff routines, and interprofessional collaboration are some factors facilitating the process, in addition to there being routines and systematic procedures in place allowing for operationality and a common understanding. Addressing these barriers and facilitators is necessary to ensure that deprescribing can be understood as meaningful and pursued among healthcare professionals in the nursing home setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00875-1.

Low continuation of antipsychotic therapy in Parkinson disease - intolerance, ineffectiveness, or inertia?

Background

Antipsychotics are used in Parkinson disease (PD) to treat psychosis, mood, and behavioral disturbances. Commonly used antipsychotics differ substantially in their potential to worsen motor symptoms through dopaminergic receptor blockade. Recent real-world data on the use and continuation of antipsychotic therapy in PD are lacking. The objectives of this study are to (1) examine the continuation of overall and initial antipsychotic therapy in individuals with PD and (2) determine whether continuation varies by drug dopamine receptor blocking activity.

Methods

We conducted a retrospective cohort study using U.S. commercially insured individuals in Optum 2001–2019. Adults aged 40 years or older with PD initiating antipsychotic therapy, with continuous insurance coverage for at least 6 months following drug initiation, were included. Exposure to pimavanserin, quetiapine, clozapine, aripiprazole, risperidone, or olanzapine was identified based on pharmacy claims. Six-month continuation of overall and initial antipsychotic therapy was estimated by time to complete discontinuation or switching to a different antipsychotic. Cox proportional hazards models evaluated factors associated with discontinuation.

Results

Overall, 38.6% of 3566 PD patients in our sample discontinued antipsychotic therapy after the first prescription, 61.4% continued with overall treatment within 6 months of initiation. Clozapine use was too rare to include in statistical analyses. Overall therapy discontinuation was more likely for those who initiated medications with known dopamine-receptor blocking activity (adjusted hazard ratios 1.76 [95% confidence interval 1.40–2.20] for quetiapine, 2.15 [1.61–2.86] for aripiprazole, 2.12 [1.66–2.72] for risperidone, and 2.07 [1.60–2.67] for olanzapine), compared with serotonin receptor-specific pimavanserin. Initial antipsychotic therapy discontinuation also associated with greater dopamine-receptor blocking activity medication use – adjusted hazard ratios 1.57 (1.28–1.94), 1.88 (1.43–2.46), 2.00 (1.59–2.52) and 2.03 (1.60–2.58) for quetiapine, aripiprazole, risperidone, and olanzapine, respectively, compared with pimavanserin. Similar results were observed in sensitivity analyses.

Conclusions

Over one-third of individuals with PD discontinued antipsychotic therapy, especially if the initial drug has greater dopamine-receptor blocking activity. Understanding the drivers of antipsychotic discontinuation, including ineffectiveness, potentially inappropriate use, clinician inertia, patient adherence and adverse effects, is needed to inform clinical management of psychosis in PD and appropriate antipsychotic use in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02265-x.

Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care

OBJECTIVES

To explore the relationships between dose changes to antipsychotic and/or benzodiazepine medications and resident outcomes, including variations in neuropsychiatric symptoms, quality of life (QoL), and social withdrawal, within a multicomponent, interdisciplinary antipsychotic and benzodiazepine dose reduction program.

DESIGN

Prospective, observational, longitudinal study.

INTERVENTION

The Reducing Use of Sedatives (RedUSe) project involved 150 Australian Long-Term Care Facilities (LTCFs) incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews.

SETTING

A convenience sample of LTCFs (n = 28) involved in RedUSe between January 2015 and March 2016.

PARTICIPANTS

Permanent residents (n = 206) of LTCFs involved in RedUSe taking an antipsychotic and/or benzodiazepine daily. Residents were excluded if they had a severe psychiatric condition where antipsychotic therapy should generally be maintained long-term (e.g., bipolar disorder, schizophrenia) or were considered end-stage palliative.

MEASUREMENTS

Neuropsychiatric symptoms (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), QoL (Assessment of Quality of Life-4D), and social withdrawal (Multidimensional Observation Scale for Elderly Subjects-withdrawal subscale) were measured at baseline and 4 months where nursing staff completed psychometric tests as proxy raters.

RESULTS

There was no evidence that psychometric measures were worsened following dose reductions. In fact, dose reduction was associated with small, albeit non-statistically significant, improvements in behavior, particularly less physically non-aggressive behavior with both drug groups (-0.36 points per 10% reduction in antipsychotic dose, -0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behavior with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with non-statistically significant improvements in QoL and social withdrawal.

CONCLUSIONS

Antipsychotic and benzodiazepine dose reduction in LTCFs was not associated with deterioration in neuropsychiatric symptoms, QoL, or social withdrawal. Trends toward improved agitation with antipsychotic and benzodiazepine dose reduction require further evaluation in larger, prospective, controlled studies.

Psychotropic drug use in community-dwelling people with young-onset dementia: two-year course and determinants

OBJECTIVES

The aim of this study was to describe the course of psychotropic drug use in people with young-onset dementia and to explore possible associations with age, sex, dementia severity, dementia subtype and neuropsychiatric symptoms.

METHODS

Psychotropic drug use was studied in 198 community-dwelling persons participating in the Needs in Young-onset Dementia study. Data about psychotropic drug use were retrieved at baseline, as well as at 6, 12, 18 and 24 months and was classified into five groups (antiepileptics, antipsychotics, anxiolytics, hypnotics/sedatives and antidepressants) and quantified as 'present' or 'absent'. Generalized Estimating Equation modeling and chi-square tests were used to study associations between the determinants and psychotropic drug use.

RESULTS

There was a statistically significant increase in the prevalence of psychotropic drug use from 52.3% to 62.6% during the course of the study. Almost three-quarters (72.4%) of the participants were treated with any psychotropic drug during the study, and more than one-third (37.4%) received psychotropic drugs continuously. Antipsychotics were used continuously in more than 10% of the participants and antidepressants in more than 25%. Increasing age was positively associated (p = .018) with psychotropic drug use at baseline, while apathy symptoms were negatively associated (p = .018).

CONCLUSIONS

Despite the recommendations of various guidelines, the prolonged use of psychotropic drugs in community-dwelling people with young-onset dementia is high. Therefore, more attention is needed to timely evaluate psychotropic drug use and the introduction of self-management programs for caregivers should be encouraged to support caregivers in dealing with the neuropsychiatric symptoms caused by the dementia.

Factors influencing management of agitation in aged care facilities: A qualitative study of staff perceptions

BACKGROUND

Agitation in older people is commonly associated with cognitive decline, complex medical diagnoses and polypharmacy. Impaired communication and comprehension within a dementia trajectory adds complexity to assessment and management. Despite high prevalence, agitated behaviours remain challenging to manage in residential aged care settings.

AIM

To explore staff perceptions of agitation in residents of aged care facilities, including the influence of dementia, when selecting management strategies to reduce agitated behaviour.

DESIGN

Qualitative descriptive.

METHODS

Semi-structured interviews with 11 aged care staff were conducted at two aged care sites. Transcripts were examined using content analysis to identify common issues and categories. The study complied with COREQ guidelines (see. Appendix S1).

RESULTS

Participants reported managing resident agitation at least once per shift; most frequently manifesting as wandering, restlessness or aggression. Management strategies included distraction, providing space, knowing the resident, identifying causative factors, spending individual time and if necessary medication administration. Agitation management was more challenging for residents with dementia due to impaired communication or comprehension of instruction.

CONCLUSIONS

While participants strived to deliver individualized person-centred care, this was difficult given time and resource constraints. Contemporary management of agitation therefore remains variable in everyday practice, with resident preference used when causative factors were known. Conversely, for residents with impaired communication and/or comprehension, distraction and chemical restraint were commonly used. Nuanced education for assessment and management is recommended to better address this unmet need for some residents.

RELEVANCE TO CLINICAL PRACTICE

For optimal care, appropriate allocation of time and resources is necessary to identify causative and contextual factors for individual residents. Recommendations are for additional staff training in communication and attitude, and collaborating with frontline staff to develop a practical guide for management of agitation in aged care. These simple initiatives may help to improve consistency of care delivery and resident outcomes.

General practitioners' knowledge of and attitudes towards prescribing psychoactive drugs in dementia care: a cross-sectional questionnaire study

Background

Despite their adverse effects, antipsychotics are frequently prescribed to manage behavioural and psychological symptoms of dementia (BPSD). At present, we do not have a good understanding of general practitioners’ (GPs) current management of BPSD.

Aims

To explore the knowledge, attitudes, and opinions of GPs regarding the prescribing of psychoactive drugs in managing BPSD.

Methods

This was a descriptive cross-sectional study. A questionnaire was adapted from a previous study and piloted with three GPs and was posted to a census sample of all GPs working in counties Cork and Kerry, Ireland. We collected and analysed both quantitative and qualitative data.

Results

Of the 456 eligible GPs who received the questionnaire, 168 GPs returned completed questionnaires (response rate 36.8%). All respondents (100%, 168/168) believed that antipsychotics did not benefit all patients with BPSD. The majority of GPs (69%, 116/168) routinely recommended non-pharmacological interventions before medication to manage BPSD. Most GPs (60.7%, 102/168) welcomed more training and experience to improve their management of BPSD. The qualitative comments provided by GPs described a pressure to prescribe from nursing home staff. GPs highlighted that the management of BPSD is difficult in daily practice and felt that antipsychotics still have a role to play.

Conclusions

This study identified several factors influencing the prescription of antipsychotics for patients with BPSD as well as the prescribing dilemmas faced by GPs in their daily practice. These findings can be used to guide future interventions aimed at reducing inappropriate prescribing in dementia care.

Electronic supplementary material

The online version of this article (10.1007/s11845-020-02356-7) contains supplementary material, which is available to authorized users.

A Canadian Cohort Study to Evaluate the Outcomes Associated with a Multicenter Initiative to Reduce Antipsychotic Use in Long-Term Care Homes

OBJECTIVES

To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels.

DESIGN

Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories.

SETTING AND PARTICIPANTS

Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study.

MEASURES

Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use.

INTERVENTION

Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis.

RESULTS

At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms.

CONCLUSIONS/IMPLICATIONS

The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

Association between changes in the use of psychotropic drugs and behavioural and psychological symptoms of dementia over 1 year among long-term care facility residents

AIM

Pharmacological treatments are often used in treating the behavioural and psychological symptoms of dementia (BPSD) in nursing homes, despite the fact that non-pharmacological treatments are recommended as a first-line treatment and can provide a suitable alternative. Because the course of BPSD is known to fluctuate depending on individual symptoms over time, the frequencies of drug use and BPSD, as well as their association, should be observed over a longer period. We investigated the association between the changes in psychotropic drug (PD) use and BPSD, focusing on the number of symptoms, severity, and care burden over 1 year among long-term care facility residents.

METHODS

A 1-year follow-up study was conducted among older residents with dementia or similar symptoms (n = 312 at baseline; n = 237 at follow-up) by using a care staff questionnaire in 10 long-term care facilities in Hokkaido, Japan. Medication use was determined based on prescription information. The brief questionnaire form of the Neuropsychiatric Inventory was used to assess BPSD.

RESULTS

Among residents followed up for 1 year, new users of PD-particularly anxiolytics and hypnotics-had a significantly increased number and severity of BPSD, compared with non-PD users. Continuing PDs was also related to increased severity over the year. Among residents with any persistent BPSD for 1 year, new use of PDs-particularly anxiolytics and hypnotics-was significantly associated with an increased care burden of BPSD, compared with the non-use of PDs. The discontinuation of PDs was significantly associated with a decreased care burden, compared with the non-use of PDs.

CONCLUSIONS

Our study suggests that PDs, particularly anxiolytics and hypnotics, may be prescribed carefully in response to exacerbation of BPSD in terms of the number of symptoms, severity, and care burden in long-term care facilities. Continuous monitoring of PDs use and BPSD is important to effectively address BPSD.

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review

OBJECTIVES

To synthesise the existing published literature on general practitioners (GP)'s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions.

METHODS

We conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs' experiences of managing BPSD (PROSPERO protocol registration CRD42017054916). Seven electronic databases were searched from inception to October 2017. Each stage of the review process involved at least 2 authors working independently. The meta-ethnographic approach was used to synthesise the findings of the included studies while preserving the context of the primary data. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to assess the confidence in our individual review findings.

RESULTS

Of the 1638 articles identified, 76 full texts were reviewed and 11 were included. Three main concepts specific to GPs' experiences of managing BPSD emerged: unmet primary care resource needs, justification of antipsychotic prescribing, and the pivotal role of families. A "line of argument" was drawn, which described how in the context of resource limitations a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached.

CONCLUSION

This systematic review offers new insights into GPs' perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.

Exploring nursing staff views of responsive behaviours of people with dementia in long-stay facilities

WHAT IS KNOWN ON THE SUBJECT?: Caring for people with dementia and responsive behaviours is challenging; however, little is known of nurses' experiences of responsive behaviours. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: To demonstrate understanding nurses need to be aware of their own actions, thoughts, attitudes and reactions. Time, education and management support are essential in enabling a person-centred approach. A decision regarding the place of care is difficult to come to, and given the drive to a person-centred approach, there is a need to consider the views of people with dementia. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nursing staff supporting people with dementia should engage more frequently in reflective practice, ongoing education and decision-making. Service providers/managers need to have an understanding of the complexities of caring for a person with dementia and responsive behaviours and provide their staff with relevant supports and education that is accessible to all staff.

ABSTRACT

Introduction Caring for people with dementia and responsive behaviours can challenge nurses, and little is known of their experiences. Aims To explore nurses' views of supporting people with dementia and responsive behaviours in long-stay facilities. Methods A qualitative descriptive study utilizing in-depth audio-recorded interviews of nine nurses, recruited from private and public care facilities. Qualitative content analyses conducted involving iterative comparisons of transcripts, summaries and memos, where coding, key quotes and tables were developed to determine themes. Results Four themes emerged: recognizing and understanding responsive behaviour, resources and interventions to support people with dementia and responsive behaviour, the impact of education on nursing practice and the care environment. Discussion Availability of staff, adequate time and financial restraints hinder nurses' ability to provide care. Access to ongoing education and being able to provide one-to-one care was valued as dementia-specific education changed nursing practice. Implications for practice Place of care was seen as dependent on the type of responsive behaviour in question, the duration of the behaviour and the impact of the behaviour on the person, other residents and staff. Dementia education needs to be accessible to all staff, and a collaborative approach is necessary in order to develop management guidelines and support strategies.

Reasons for (not) discontinuing antipsychotics in dementia

BACKGROUND

The gap between high antipsychotic prescription rates for patients with dementia and the guidelines' advice to prescribe cautiously indicates that barriers to discontinuation exist. This exploratory study used the theory of planned behaviour to give a first overview of the factors that influence physicians to discontinue antipsychotics in nursing home patients with dementia.

METHODS

Forty-one physicians in the Netherlands completed an online survey based on the theory of planned behaviour.

RESULTS

Half of the respondents agreed that antipsychotics have positive consequences for patients, such as calming effects. Physicians who indicated that they tend not to discontinue antipsychotics believe that antipsychotics are associated with positive consequences for nursing home staff. Physicians who tend to discontinue antipsychotics had a higher perceived behavioural control than those who indicated having a low intention.

CONCLUSION

To enhance discontinuation of antipsychotics, interventions should focus on both patient-related factors and staff-related factors. Prescribing decisions are influenced by staff-related factors that need to be addressed as well.

The use of psychotropic drugs for behavioral and psychological symptoms of dementia among residents in long-term care facilities in Japan

OBJECTIVE

To examine whether the use of psychotropic drugs (PDs) was related to behavioral and psychological symptoms of dementia (BPSD) focusing on the prevalence, numbers of symptoms, severity, and care burden among the elderly with BPSD living in long-term care facilities in Japan.

METHOD

We conducted a cross-sectional survey among older people with dementia or similar symptoms (n = 312) using a questionnaire for care staff in 10 selected long-term care facilities. A brief questionnaire form of the Neuropsychiatric Inventory was used to assess BPSD.

RESULTS

PDs were used in 45% among all participants and 47.5% among those exhibiting at least one BPSD. We found that use of PDs was associated with greater numbers, severity, and care burden of BPSD. Also, there was significantly more use of PDs among people who had specific BPSD symptoms, such as delusions, anxiety, and disinhibition, compared with those who did not.

CONCLUSION

The use of PDs among residents in long-term care facilities with dementia or similar symptoms was relatively low compared with previous reports from other countries. Nonetheless, the greater numbers, severity, and care burden of BPSD were associated with the use of PDs.

Prescribing of psychotropic medication for nursing home residents with dementia: a general practitioner survey

Objective

The aim of this study was to identify factors influencing the prescribing of psychotropic medication by general practitioners (GPs) to nursing home residents with dementia.

Subjects and methods

GPs with experience in nursing homes were recruited through professional body newsletter advertising, while 1,000 randomly selected GPs from southeastern Australia were invited to participate, along with a targeted group of GPs in Tasmania. An anonymous survey was used to collect GPs’ opinions.

Results

A lack of nursing staff and resources was cited as the major barrier to GPs recommending non-pharmacological techniques for behavioral and psychological symptoms of dementia (BPSD; cited by 55%; 78/141), and increasing staff levels at the nursing home ranked as the most important factor to reduce the usage of psychotropic agents (cited by 60%; 76/126).

Conclusion

According to GPs, strategies to reduce the reliance on psychotropic medication by nursing home residents should be directed toward improved staffing and resources at the facilities.

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background

Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.

Objectives

To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.

Review methods

Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.

Design

ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.

Settings

ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.

Participants

ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.

Intervention

An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.

Main outcome measures

ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.

Results

ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.

Limitations

Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.

Conclusions

A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.

Future work

There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.

Trial registration

Current Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

Time-to-First Discontinuation, Adherence and Persistence in New Users of Second-Generation Antipsychotics

Consensus guidelines which are applicable in New Zealand and worldwide recommend that the duration of exposure to antipsychotics not exceed 12 weeks, unless justified for mental illnesses like schizophrenia and severe psychotic symptoms which require longer treatment. There has been limited information on time-to-first discontinuation (TTFD) for second-generation antipsychotics (SGAs) in a real world population setting in older people. The study objective was to compare TTFD, adherence, and persistence for individual SGA new users among people 65 years and older. A cohort of 30,297 SGA new users was followed up for antipsychotic discontinuation from January 1, 2006, to December 31, 2012. Data for oral formulations were extracted using health care databases from the New Zealand Ministry of Health. The TTFD, adherence, and persistence were defined using (dispensing gap ≥ 91 days, variable medication possession ratio ≥ 0.8, and gap duration < 91 days between refills), respectively. Kaplan-Meier curves and Cox regression analysis were used to estimate and adjust for outcomes. The overall TTFD in SGA new users was 192.3 days (95% confidence interval [CI], 177.6-206.9), mean age at dispensing was 80.9 years (SD, 8.1 years), and 60.3% were women. The TTFD for was shortest for risperidone, 101.3 days (95% CI, 85.0-117.7; P = 0.03) compared with clozapine, 68.3 days (95% CI: 43.7, 92.9). The adjusted all-cause TTFD risk for risperidone, olanzapine, quetiapine, or ziprasidone (hazard ratios, 0.54, 0.29, 0.22, and 0.08, respectively) was significantly lower than clozapine. The TTFD risk in the nonadherent compared with the adherent group was more than 3 times.

Towards understanding the de-adoption of low-value clinical practices: a scoping review

BACKGROUND

Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed 'related articles' function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate.

RESULTS

From 26,608 citations, 109 were included in the final review. Most citations (65%) were original research with the majority (59%) published since 2010. There were 43 unique terms referring to the process of de-adoption-the most frequently cited was "disinvest" (39% of citations). The focus of most citations was evaluating the outcomes of de-adoption (50%), followed by identifying low-value practices (47%), and/or facilitating de-adoption (40%). The prevalence of low-value practices ranged from 16% to 46%, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption.

CONCLUSIONS

This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.

Dealing with behavioral and psychological symptoms of dementia: a general overview

Dealing with the behavioral and psychological symptoms of dementia (BPSD) is often complex. Given the controversy with regard to antipsychotics for behavioral problems in people with dementia, there has been a renewed emphasis on nonpharmacological interventions, with progress in the design of the relevant studies. Potential nonpharmacological interventions for BPSD are: cognitive training/stimulation, rehabilitative care, activities of daily living, music therapy, massage/touch, physical activity, education/training of professionals, and education and psychosocial support of informal caregivers. Use of antipsychotics in the management of BPSD is controversial due to limited efficacy and the risk of serious adverse effects, but credible alternatives remain scarce. The problem of chronic use of antipsychotics in nursing homes should be tackled. Discontinuation of antipsychotic medication in older individuals with BPSD appears to be feasible. Discontinuation efforts are needed to differentiate between patients for whom antipsychotics have no added value and patients for whom the benefits outweigh the risks.

Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis

OBJECTIVE

To synthesise qualitative studies that explore prescribers' perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults.

DESIGN

A qualitative systematic review was undertaken by searching PubMed, EMBASE, Scopus, PsycINFO, CINAHL and INFORMIT from inception to March 2014, combined with an extensive manual search of reference lists and related citations. A quality checklist was used to assess the transparency of the reporting of included studies and the potential for bias. Thematic synthesis identified common subthemes and descriptive themes across studies from which an analytical construct was developed. Study characteristics were examined to explain differences in findings.

SETTING

All healthcare settings.

PARTICIPANTS

Medical and non-medical prescribers of medicines to adults.

OUTCOMES

Prescribers' perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults.

RESULTS

21 studies were included; most explored primary care physicians' perspectives on managing older, community-based adults. Barriers and enablers to minimising PIMs emerged within four analytical themes: problem awareness; inertia secondary to lower perceived value proposition for ceasing versus continuing PIMs; self-efficacy in regard to personal ability to alter prescribing; and feasibility of altering prescribing in routine care environments given external constraints. The first three themes are intrinsic to the prescriber (eg, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (eg, patient, work setting, health system and cultural factors). The PIMs examined and practice setting influenced the themes reported.

CONCLUSIONS

A multitude of highly interdependent factors shape prescribers' behaviour towards continuing or discontinuing PIMs. A full understanding of prescriber barriers and enablers to changing prescribing behaviour is critical to the development of targeted interventions aimed at deprescribing PIMs and reducing the risk of iatrogenic harm.