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

Nurses' knowledge, attitude and practice regarding non-pharmacologic interventions for behavioral and psychological symptoms of dementia

BACKGROUND

To evaluate the knowledge, attitude and practice of nurses regarding non-pharmacologic therapies for behavioral and psychological symptoms of dementia (BPSD).

METHODS

This cross-sectional, questionnaire-based study enrolled nurses at Peking Union Medical College Hospital (Beijing, China) between September 2022 and October 2022. Correlations between knowledge, attitude and practice scores were evaluated by Pearson correlation analysis. Factors associated with knowledge, attitude and practice scores were identified by multivariable linear regression. Based on a cross-sectional questionnaire survey, this study designed a questionnaire according to the Guidelines for Diagnosis and Treatment of Dementia in China, and randomly selected nurses from Peking Union Medical College Hospital to fill in the questions through the Wen-Juan-Xing online platform from September 2022 to October 2022.

RESULTS

The analysis included 210 nurses (202 females). The average knowledge, attitude and practice scores were 11.06±2.61 (total score: 18), 53.51±5.81 (total score: 60) and 64.66 ± 10.35 (total score: 80) points, respectively. Knowledge score was positively correlated with attitude score (r = 0.416, P < 0.001) and practice score (r = 0.389, P < 0.001); attitude and practice scores were also positively correlated (r = 0.627, P < 0.001). Multivariable analysis demonstrated that age ≥ 40 years-old (vs. ≤30 years-old) was associated with higher knowledge score (β = 1.48, 95% confidence interval [95%CI] = 0.42-2.54, P = 0.006). Age ≥ 40 years-old (β = 1.43, 95%CI = 0.35-2.51, P = 0.010 vs. ≤30 years-old) and bachelor's degree or higher (β = 1.11, 95%CI = 0.12-2.10, P = 0.028 vs. college degree or lower) were associated with higher practice score.

CONCLUSIONS

Older age and higher education level were associated with higher knowledge, attitude and/or practice scores. The findings of this study may help guide the development and implementation of education and training programs to improve the management of BPSD by nurses in China.

[Evaluation of satisfaction with and relief vs. workload by a general practitioner-centered dementia care project: early information and support in dementia (FIDEM) in Göttingen, Germany]

BACKGROUND

Early information and support in dementia (FIDEM) is a cross-sectoral, general practitioner-centered network model for the improvement of community-based care of people with dementia and their caregivers by systematically assigning them to non-physician healthcare providers.

OBJECTIVE

To describe the implementation of FIDEM in Göttingen, Germany and to exploratorily evaluate satisfaction and relief vs. additional workload.

MATERIAL AND METHODS

FIDEM was established in Göttingen in 2017. Community-based and district-based networks consisted of medical (general practitioners) and non-medical cooperation partners (occupational therapists, care counselling, other non-medical care providers) and were instructed to efficiently share information. During biannual network meetings from August 2017 to October 2019, a self-developed questionnaire for quality management and evaluation of the aspects of the project described above was filled out by participants attending the meetings.

RESULTS

Consecutive recruitment resulted in 7 networks by October 2019, with participation of 29 general practitioners and 46 non-medical care providers, serving as cooperation partners. Quantitative evaluation of 80 FIDEM cooperation partners revealed high satisfaction ratings with all aspects of the model (M from 7.22 to 7.87 out of possible "10"), with partially higher ratings on the part of primary care physicians. Furthermore, all participants reported a reduction in workload due to participation, which was significantly higher for primary care physicians across all scales (all p-values < 0.001).

CONCLUSION

FIDEM has been implemented in Göttingen beyond a funded pilot project phase. High satisfaction ratings and considerable relief in workload suggest the continuation of FIDEM along with a full evaluation and, provided positive results, its consolidation of and transfer to other regions in Germany.

Barriers and facilitators to dementia care in long-term care facilities: protocol for a qualitative systematic review and meta-synthesis

INTRODUCTION

Long-term care needs for people with dementia are predicted to increase due to increased life expectancy and dementia diagnoses. Most published meta- syntheses of dementia care focus on hospitals or home settings. When focusing on long-term care facilities, most reviews about dementia care only focus on a single outcome, such as feeding, behavioural symptoms management, palliative care and others, which is limited. The present study aims to synthesise qualitative data and examine barriers and facilitators to caring for people with dementia in long-term care facilities.

METHODS AND ANALYSIS

This is the protocol for our systematic review and meta-synthesis, which describes the design of this study, and we plan to complete the study from October 2023 to November 2024. The systematic review and meta-synthesis will follow the Joanna Briggs Institute (JBI) guidance for systematic reviews of qualitative evidence. Nine databases (five English and four Chinese) were searched, including Embase, Web of Science, Medline, CINAHL, PsycINFO and Wan Fang Data, China National Knowledge Infrastructure, VIP and Chinese Biomedical Medicine, from inception to August 2023. Qualitative and mixed-approach research about barriers and facilitators to caring for people with dementia in long-term care facilities, which are reported in English or Chinese, will be included. Covidence software will help with study selection, assessment and data extraction. The JBI Critical Appraisal Checklist for Qualitative Research (2020) will be used for included studies' quality assessment. Data extraction will be based on the JBI Qualitative Assessment and Review Instrument Data Extraction Tool for Qualitative Research. The JBI aggregation approach will be used to synthesise data. We will use the JBI ConQual tool to assess the credibility and dependability of each synthesised finding to establish confidence in the synthesised findings. All review steps will be managed by two reviewers independently, and disparities will be discussed. If consensus cannot reach a resolution, a third reviewer will be consulted.

ETHICS AND DISSEMINATION

The present study is a secondary analysis of published qualitative data. So ethical approval is not required. The findings may be disseminated through peer-reviewed publications, conference papers or elsewhere.

PROSPERO REGISTRATION NUMBER

The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) in May 2022, and the registration number is CRD42022326178.

Trends in the use of psychotropics in older people with dementia: interrupted time series of Finnish clinical guidelines of behavioural and psychological symptoms of dementia

BACKGROUND

Up to 90% of people with dementia experience behavioural and psychological symptoms of dementia (BPSD) as part of their illness. Psychotropics are not recommended as the first-line treatment of BPSD because older people are more prone to adverse reactions. In this study, we evaluate the impact of the Finnish clinical guidelines of BPSD (published in 2017) on psychotropic use in people with dementia.

METHODS

This study is based on Finnish Prescription Register data from 2009 to 2020. The data included all community-dwelling Finnish people aged ≥65 and who had anti-dementia medication purchases (n = 217,778). We used three-phased interrupted time series design to evaluate the changes in levels and trends of monthly (n = 144) psychotropic user rates compared with the predicted trends. In addition, we evaluated the changes in levels and trends of monthly new psychotropic user rates.

RESULTS

The level of monthly psychotropic user rate decreased non-significantly during the intervention period (β -0.057, P = 0.853), and during the post-intervention period, there was an increase in the level (β 0.443, P = 0.091) and slope (β 0.199, P = 0.198), but not statistically significant. The level of monthly new psychotropic user rate (β -0.009, P = 0.949) during the intervention period and the level (β 0.044, P = 0.714) and slope (β 0.021, P = 0.705) during the post-intervention period were almost unchanged.

CONCLUSIONS

Results may indicate possible challenges in deprescribing and better adherence to the guidelines at the beginning of BPSD treatment. Further research into the barriers to implement BPSD guidelines and the availability of non-pharmacological treatments is needed.

The longitudinal patterns of psychotropic drug prescriptions for subpopulations of community-dwelling older people with dementia: electronic health records based retrospective study

BACKGROUND

Studies focusing on patterns of psychotropic drug prescriptions (PDPs) for subpopulations of community-dwelling older people with dementia are lacking.

OBJECTIVE

The aim of this study was to identify the longitudinal patterns of PDPs in subpopulations.

METHODS

This retrospective study used electronic health records from general practitioners (GPs) in the Netherlands. People (N = 1278) firstly diagnosed with dementia between 2013 and 2015, aged 65 years or older, were selected and categorized into four subpopulations: community-dwelling (CD) group throughout follow-up, ultimately admitted to nursing homes (NH) group, ultimately died (DIE) group, and ultimately deregistered for unclear reasons (DeR) group. Generalised estimating equations were used to estimate the patterns of psychotropic drug prescriptions, after the diagnosis of dementia for a five-year follow-up, and 0-3 months before institutionalisation or death.

RESULTS

Over the five-year follow-up, antipsychotic prescriptions increased steadily in CD (OR = 1.07 [1.04-1.10]), NH (OR = 1.10 [1.04-1.15]), and DIE (OR = 1.05 [1.02-1.08]) groups. Similarly, prescriptions of antidepressants also showed upward trends in CD (OR = 1.04 [1.02-1.06]), NH (OR = 1.10 [1.02-1.18]), and DIE (OR = 1.04 [1.00-1.08]) groups. The other psychotropic drugs did not show clear changes over time in most of the subpopulations. In the three months before institutionalisation, antipsychotic prescriptions increased (OR = 2.12 [1.26-3.57]) in the NH group compared to prior periods. Likewise, before death, prescriptions of antipsychotics (OR = 1.74 [1.28-2.38]) and hypnotics and sedatives (OR = 2.11 [1.54-2.90]) increased in the DIE group, while anti-dementia drug prescriptions decreased (OR = 0.42 [0.26-0.69]).

CONCLUSIONS

After community-dwelling older people are diagnosed with dementia, all subpopulations' prescriptions of antipsychotics and antidepressants increase continuously during the follow-up. While we cannot judge whether these prescriptions are appropriate, GPs might consider a more reluctant use of psychotropic drugs and use alternative psychosocial interventions. Additionally, antipsychotic prescriptions rise considerably shortly before institutionalisation or death, which might reflect that older people experience more neuropsychiatric symptoms during this period.

Rationalising Antipsychotic Prescribing in Dementia (RAPID) complex intervention: A mixed-methods feasibility intervention study

BACKGROUND

To help address the issue of inappropriate antipsychotic prescribing to nursing home residents with dementia, the 'Rationalising Antipsychotic Prescribing in Dementia' (RAPID) complex intervention was developed, comprising staff education and training, academic detailing and a novel resident assessment tool.

OBJECTIVES

The primary objective was to assess the feasibility and acceptability of the RAPID complex intervention in a nursing home setting. The secondary objective was to describe associated trends in psychotropic prescribing, falls, and behavioural symptoms.

METHODS

A mixed-methods feasibility intervention study in one large nursing home in Ireland was undertaken between 07/2017 and 01/2018. Focus groups and semi-structured interviews were conducted with nursing home staff and GPs at the end of the 3-month follow up period to assess participants' experience of the intervention. Quantitative measurements included pre- and post-course evaluation and psychotropic prescribing rates.

RESULTS

Sixteen nursing home staff members attended the two education and training days (21% attendance rate), and four GPs participated in the academic detailing sessions (100% attendance rate). Participants of the focus groups and interviews (n = 18) found the education and training beneficial for their work and expressed a desire to continue educating new staff after the study's completion. However, there was limited usage of the resident assessment tool. Participants also offered recommendations to enhance the intervention.The proportion of dementia residents prescribed at least one regular antipsychotic was stable over the 3-months pre-intervention at 45% (n = 18), and at baseline at 44% (n = 19) but decreased slightly to 36% (n = 14) at 3-months post-intervention. At the same time the absolute number of 'PRN' psychotropics administered monthly to dementia residents decreased substantially from 90 at baseline to 69 at 3-months post-intervention.

CONCLUSION

The RAPID complex intervention was broadly feasible to conduct and may be acceptable to stakeholders. However, before it can be evaluated in larger scale studies, certain protocol modifications and further exploratory work are required to improve implementation.

How formal caregiver's BPSD knowledge influences positive aspects of caregiving: the mediating role of attitude and the moderating role of self-efficacy

Background

The current study investigated the relationship between behavioural and psychological symptoms of dementia (BPSD) knowledge and positive aspects of caregiving (PAC), in addition, how caregiving attitude and self-efficacy mediate or moderate this relationship.

Methods

Two hundred twenty-nine formal caregivers (51males and 178females) who has worked in nursing homes for more than a month were recruited.With a cross-sectional, face-to-face survey, structural questionnaires were implemented to evaluate formal caregiver’s BPSD knowledge, attitude, self-efficacy and PAC.A 13-item self-developed questionnaire was used to assess caregiver’s BPSD knowledge about disease characteristics, care and risks, and treatment needs. Dementia attitude, self-efficacy and positive aspects of caregiving were measured by dementia attitude scale, the General self-efficacy scale, and Chinese version of positive aspects of caregiving respectively. Model 5 in the PROCESS micro was employed in order to verify the mediating effect of attitude and the moderating effect of self-efficacy on the relationship between BPSD knowledge and PAC.

Results

The results showed that greater BPSD knowledge was associated with increased PAC, and this relationship was fully mediated by increased friendly attitude toward people with dementia. Moreover, direct effect was moderated by self-efficacy, and that only among those with high self-efficacy, the direct effect of BPSD knowledge was found on promoting PAC.

Conclusions

By elucidating the knowledge-attitude-practice pathway in handling patient’s BPSD, the current study extends existing literature and provides insights for developing psychoeducation programs among formal caregivers.

Improving the appropriateness of psychotropic prescribing for nursing home residents with dementia: an overview of reviews

OBJECTIVES

Psychotropic medications are commonly inappropriately prescribed for people with dementia (PwD) residing in nursing homes. This population is often multi-morbid, receiving multiple medications and therefore at an increased risk of mortality. This overview aimed to collate all synthesised quantitative, qualitative, and mixed-method evidence pertaining to the effectiveness of interventions aimed at reducing inappropriate psychotropic prescribing for nursing home residents with dementia; the perceived barriers and facilitators to the implementation of these interventions; and the attitudes and experiences of stakeholders toward prescribing. Method: An overview of reviews was conducted (PROSPERO protocol registration CRD42020187288). Five databases were systematically searched from January 2010 through June 2020, supplemented by grey literature searching. Reviews presenting evidence pertaining to either randomised controlled trials (RCT) aiming to reduce inappropriate prescribing or qualitative/mixed method studies of stakeholder views, were included.

RESULTS

Of 273 records identified, 11 systematic reviews were included. The quality of reviews ranged from critically low to moderate. There was mixed evidence for the use of education-only interventions. Multicomponent interventions (typically staff education combined with organisational and structural components), medication review, and interventions aimed at cultural change were evidenced as effective compared to care as usual. Stakeholders cited the importance of multidisciplinary collaboration and targeting organisational climate in changing psychotropic prescribing behaviours.

CONCLUSIONS

The inappropriate use of psychotropic medications in nursing homes for PwD is a complex issue with many contextual factors. The evidence suggests a comprehensive approach, targeting organisational climate and multidisciplinary collaboration, along with staff education and training, may be an effective strategy.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia

OBJECTIVES

The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia.

DESIGN

A mixed-methods study was performed.

SETTING AND PARTICIPANTS

During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica.

METHODS

Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ² tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports.

RESULTS

Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on PRN psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001).

CONCLUSIONS AND IMPLICATIONS

This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

Identifying behavior change techniques for inclusion in a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia

Nursing home residents with dementia are commonly prescribed antipsychotics despite the associated increased risk of harms. Interventions to optimize prescribing practice have been found to be effective in the short term, but there is a lack of evidence to support sustainability of effects, along with a lack of theory, public involvement, and transparency in the intervention development process. Using theory has been advocated as a means of improving intervention sustainability. The aim of this study was, therefore, to identify behavior change techniques (BCTs) for inclusion in a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia. A comprehensive approach to identifying a long list of all potential BCTs from three different sources was undertaken. The most appropriate BCTs were then selected through a two-round Delphi consensus survey with a broad range of experts (n = 18 panelists). Advisory groups of people with dementia, family carers, and professional stakeholders provided feedback on the final BCTs included. After two Delphi survey rounds, agreement was reached on 22 BCTs. Further refinement of the selected BCTs based on advisory group and panelists' feedback, along with use of the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects/safety, and Equity) resulted in a final list of 16 BCTs. The next step in intervention development will be to identify the most appropriate mode of delivery of the 16 BCTs identified for inclusion. The study provides a case example of a systematic approach to incorporating evidence with stakeholder views in the identification of appropriate BCTs.

Remote primary care consultations for people living with dementia during the COVID-19 pandemic: experiences of people living with dementia and their carers

Background

COVID-19 has accelerated remote healthcare provision in primary care, with changes potentially permanent. The implementation of remote provision of health care needs to be informed by vulnerable populations, such as people living with dementia.

Aim

To understand the remote healthcare experiences of patients living with dementia and their family carers during the COVID-19 pandemic.

Design and setting

Qualitative interviews with community-based patients living with dementia and their carers were carried out between May–August 2020, while the COVID-19 pandemic was ongoing in England.

Method

Semi-structured interviews were conducted remotely by telephone or video call with 30 patients living with dementia and 31 carers. Data were analysed using thematic analysis.

Results

Three main themes were derived relating to: proactive care at the onset of COVID-19 restrictions; avoidance of healthcare settings and services; and difficulties with remote healthcare encounters. People living with dementia and their carers felt check-up calls were reassuring but limited in scope and content. Some avoided healthcare services, wishing to minimise COVID-19 risk or reduce NHS burden, or encountering technological barriers. Difficulties in remote consultations included lack of prompts to remember problems, dealing with new emerging difficulties, rescheduling/missed calls, and inclusion of the voice of the person with dementia.

Conclusion

While remote consultations could be effective, proactive calls could be more structured around needs. Consideration should be given to replace non-verbal prompts to describe problems, particularly for new health concerns. In continuing remote consultations, it is important to facilitate engagement with patients living with dementia and their carers to ensure good practice.

Clinical profiles of people with dementia exhibiting with neuropsychiatric symptoms admitted to mental hospitals: A multicenter prospective survey in Japan

AIMS

Patients with severe behavioral and psychological symptoms of dementia (BPSD) are often admitted to mental hospitals, while, inpatient care could also lead to prolonged hospital stay. The present study aims to survey clinical profiles of patients who required inpatient treatment for BPSD, and then establish the criteria for introducing inpatient treatment through assessment by certified psychiatrists.

METHODS

We performed a prospective survey about clinical characteristics of people with dementia who required treatment of BPSD at 12 mental medical institutions. All patients were assessed by certified psychiatrists to determine the optimal treatment settings: outpatient or inpatient. The multivariate logistic regression analysis was performed to specify factors contributed to the judgement of clinicians. Subsequently, the receiver operating characteristic curve analysis was conducted to explore a score derived from the Neuropsychiatric Inventory to divide patients into outpatient or inpatient groups.

RESULTS

The present study included 386 patients, of which 242 were admitted to mental hospitals. BPSD were classified into four domains, and aggressive BPSD was significantly associated with assessment for inpatient treatment; the adjusted odds ratio was approximately 2 regardless of dementia severity. Furthermore, the composite score of agitation, irritability and aberrant behavior showed the highest area under the curve value (=0.706), which differentiated inpatients from outpatients with a sensitivity of 76% and a specificity of 54%.

CONCLUSIONS

Aggressive BPSD was the risk factor for inpatient treatment. The composite score of the Neuropsychiatric Inventory subdomain-related aggressive BPSD could be a screening tool to introduce inpatient treatment for BPSD. Geriatr Gerontol Int 2021; 21: 825-829.

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.

Nomenclature Used by Family Caregivers to Describe and Characterize Neuropsychiatric Symptoms

BACKGROUND AND OBJECTIVES

Neuropsychiatric symptoms (NPS) are a core feature of Alzheimer's disease and related dementias that are characterized by a fluctuating course. NPS are challenging to manage and contribute to high rates of burden among family caregivers. Successful information exchange between clinicians and family caregivers is critical for facilitating effective management of NPS. However, this communication is often challenging due to inconsistent terminology and classification of symptoms and limited understanding of how family caregivers recognize and describe symptoms. The objective of this study was to examine the language family caregivers' use to describe and contextualize NPS.

RESEARCH DESIGN AND METHODS

Descriptive qualitative study of 20 family caregivers in a mostly urban county in the Midwestern United States using semistructured interviews. Caregiver descriptions of NPS were analyzed using directed content and text analysis to examine terminology, followed by a thematic analysis approach to examine contextualization of NPS.

RESULTS

Caregivers employed shared terminologies to describe NPS that differed substantially from clinical terminology used to classify symptoms. Caregivers frequently engaged sense-making as a strategy to explain NPS. This sense-making served to contextualize patterns in behavior and was characterized by explanatory, situational, and strategy-oriented frameworks for understanding behavior in terms of its purpose and meaning. Caregivers' descriptions of NPS reflected broad overlap between individual NPS (i.e., agitation and care resistance) that would generally be considered clinically distinct symptoms.

DISCUSSION AND IMPLICATIONS

Nomenclature surrounding NPS may vary considerably between family caregivers and clinicians, and should be evaluated in partnership with people with dementia and their caregivers to ensure supportive interventions and resources are responsive to caregivers' interpretation of symptoms and sense-making.

The factors associated with distress a minimum of six months after BRCA1/2 confirmation: A systematic review

PROBLEM IDENTIFICATION

Many BRCA1/2 carriers experience an increase in distress after diagnosis; however, there is a need to review the longer term psychological implications of genetic confirmation and the factors associated with persistent distress.

LITERATURE SEARCH

This article systematically reviewed the literature in line with PRISMA guidelines on distress a minimum of six months after BRCA1/2 confirmation focusing on prevalence rates and factors associated with distress.

DATA EVALUATION AND SYNTHESIS

Fifteen studies were identified for inclusion and a narrative synthesis was conducted. Distress was associated with a range of demographic, clinical and psychological factors. A consistent finding was that although most carriers experience a reduction in distress 6-12 months after BRCA1/2 confirmation, those who experience persistent distress are more likely to have had higher distress levels at time of genetic testing. Risk reducing surgery may also play a role in reducing distress.

CONCLUSION

The review highlights the importance of psychological assessment and the use of specific distress measures. Given the considerable challenges in synthesizing the data there is a need for further prospective studies of high methodological quality.

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.

Pharmacotherapy of Behavioral and Psychological Symptoms of Dementia: State of the Art and Future Progress

The core symptoms of different dementia subtypes are the behavioral and psychological symptoms of dementia (BPSD) and its neuropsychiatric symptoms (NPS). BPSD symptoms may occur at any stage in the case of dementia due to Alzheimer's disease (AD), whereas they tend to occur early on in the case of its behavioral variant frontotemporal dementia or dementia with Lewy bodies and are essential for diagnosis. BPSD treatment consists of non-pharmacological as well as pharmacological interventions, with non-pharmacological interactions being suggested as first-line treatment. Agitation, psychotic features, apathy, depression, and anxiety may not respond to acetylcholinesterase inhibitors or memantine in AD cases; therefore, antipsychotics, antidepressants, sedative drugs or anxiolytics, and antiepileptic drugs are typically prescribed. However, such management of BPSD can be complicated by hypersensitivity to antipsychotic drugs, as observed in DLB, and a lack of effective pro-cognitive treatment in the case of frontotemporal dementia. The present paper reviews current knowledge of the management of BPSD and its limitations and discusses on-going clinical trials and future therapeutic options.

The challenge of pain identification, assessment, and management in people with dementia: a qualitative study

BACKGROUND

Painful conditions are common in older adults, including people with dementia. The symptoms associated with dementia (for example, diminished language capacity, memory impairment, and behavioural changes), however, may lead to the suboptimal identification, assessment, and management of pain. Research has yet to qualitatively explore pain management for community-dwelling people with dementia.

AIM

To explore pain identification, assessment, and management for community-dwelling people with dementia.

DESIGN & SETTING

A qualitative study was undertaken, set in England.

METHOD

Semi-structured interviews took place with people with dementia, family caregivers, GPs, and old-age psychiatrists. Data were analysed thematically.

RESULTS

Interviews were conducted with eight people with dementia, nine family caregivers, nine GPs, and five old-age psychiatrists. Three themes were identified that related to pain identification and assessment: gathering information to identify pain; the importance of knowing the person; and the use of pain assessment tools. A further three themes were identified that related to pain management: non-drug strategies; concerns related to analgesic medications; and responsibility of the caregiver to manage pain.

CONCLUSION

Identifying and assessing the pain experienced by people with dementia was challenging. Most people with dementia, family caregivers, and healthcare professionals supported non-drug strategies to manage pain. The minimal concerns associated with non-drug strategies contrasted the multifactorial concerns associated with analgesic treatment for people with dementia. Given the complexity of pain identification, assessment, and management, primary care should work together with family caregivers and community services, with case finding for pain being considered in all assessment and management plans.

<p>A Scoping Review and Template Analysis of Manual-Based Complex Interventions in Dementia Care</p>

Purpose

In dementia care, the complexity of psychosocial needs and contextual variables often demands nonpharmacological interventions of a complex nature. The purpose of this scoping review was to investigate (1) how manuals published in refereed journals explaining procedures of complex interventions in dementia care are structured and their content disseminated and (2) to provide recommendations for future manuals.

Methods

A systematic search was conducted using four databases (Embase, PsychInfo, CINAHL and Scopus) following PRISMA-ScR and PICo method. The results were analysed using template analysis aiming to describe the possibility of tailoring the intervention, degree of flexibility of the manual and dissemination elements used in the manual.

Results

A total of 882 records were identified, and 86 full-text articles were assessed. Nine articles containing manuals met the inclusion criteria. All of the included manuals allowed the user to tailor actions in the intervention to specific situations. Two-thirds of the manuals showed a medium degree of flexibility. The types of dissemination elements varied. All used written text, and some used various graphical organisers such as headlines and lists. None used illustrations or audio/video material.

Conclusion

Currently, only few manuals for complex interventions in the field of dementia are published in refereed journals, all disseminated as written text. For future manuals, we suggest considering the inclusion of illustrations and/or audio/video material to describe actions, to allow for tailoring of the intervention, and to maintain a medium or low degree of flexibility by structuring the content hierarchically in phases while providing the user with detailed description of what to do, and how to decide what to.

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Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study

BACKGROUND

Persons with dementia use emergency department services at rates greater than other older adults. Despite risks associated with emergency department use, persons with dementia and their caregivers often seek emergency services to address needs and symptoms that could be managed within primary care settings. As emergency departments (EDs) are typically sub-optimal environments for addressing dementia-related health issues, facilitating effective primary care provision is critical to reduce the need for, or decision to seek, emergency services. The aim of this study is to explore how features of primary care practice influence care-seeking decisions by community-dwelling persons with dementia and familial caregivers.

METHODS

Semi-structured qualitative interviews were conducted with 27 key dementia-care stakeholders (10 primary care/geriatrics providers, 5 caregivers, 4 emergency medicine physicians, 5 aging service providers, and 3 community paramedics) from multiple health systems. Transcripts from audio recordings were analyzed using a thematic analysis framework to iteratively code and develop emergent themes. Features of primary care were also synthesized into lists of tangible factors leading to emergency care-seeking and those that help prevent (or decrease the need for) ED use.

FINDINGS

Stakeholders identified eight categories of features of primary care encompassing the clinical environment and provision of care. These collapsed into four major themes: (1) clinic and organizational features-including clinic structure and care team staffing; (2) emphasizing proactive approaches to anticipate needs and avoid acute problems-including establishing goals of care, preparing for the future, developing provider-patient/provider-caregiver relationships, and providing caregiver support, education, and resources to help prevent emergencies; (3) health care provider skills and knowledge of dementia-including training and diagnostic capabilities; and (4) engaging appropriate community services/resources to address evolving needs.

CONCLUSIONS

Features of primary care practice influence decisions to seek emergency department care at the system, organizational/clinic, medical, and interpersonal levels, particularly regarding proactive and reactive approaches to addressing dementia-related needs. Interventions for improving primary care for persons with dementia and their caregivers should consider incorporating features that facilitate proactive family-centered dementia care across the four identified themes, and minimize those leading to caregiver decisions to utilize emergency services.

What happens before, during and after crisis for someone with dementia living at home: A systematic review

BACKGROUND

People living with dementia often experience crisis. Home treatment of crisis is an alternative to hospital admission that can have better outcomes. This systematic review is about people with dementia living at home and in crisis. It identifies modifiable factors in the crisis process that may facilitate crisis resolution.

METHODS

The protocol is registered on PROSPERO. A systematic search of MEDLINE, EMBASE, CINAHL, AHMED, PsycINFO, Cochrane Library and references of retrieved publications, identified empirical research in English language and date range January 2000 to February 2019. Two researchers independently screened abstracts, selected publications and extracted data using a framework based on published guidelines. This is a report of the analysis and narrative synthesis.

RESULTS

The search identified 2755 titles and abstracts, 76 were selected for full-text examination and 13 agreed for inclusion. The included studies evidence that: for a person with dementia, crisis is a process that begins with a problem judged to put them or others at risk of harm. It leads to decision and action to treat this risk, thus resolve the crisis. Such crisis can be predicted or unpredicted and progress quickly or slowly. Medical treatment, community resources and psychosocial support of personal resources, decision making, relationships and social networks, are all modifiable factors that can treat the risk of harm during crisis. Carers' and professionals' knowledge and skills in dementia care are likely to play a key role in crisis resolution in the home.

CONCLUSION

There has been limited investigation of the process and management of crisis at home for people living with dementia. The results of this review provide a foundation for future research. There is no consensus on critical components of home treatment to facilitate crisis resolution. However, education in dementia care for carers and professionals is likely to prove essential to successful home treatment.

Effect of a dementia education intervention on the confidence and attitudes of general practitioners in Australia: a pretest post-test study

OBJECTIVES

This study assessed the impact of a Dementia Education Workshop on the confidence and attitudes of general practitioner (GP) registrars (GPR) and GP supervisors (GPS) in relation to the early diagnosis and management of dementia.

DESIGN

Pretest post-test research design.

SETTING

Continuing medical education in Australia.

PARTICIPANTS

332 GPR and 114 GPS.

INTERVENTIONS

Registrars participated in a 3-hour face-to-face workshop while supervisors participated in a 2-hour-modified version designed to assist with the education and supervision of registrars.

MAIN OUTCOME MEASURES

The General Practitioners Confidence and Attitude Scale for Dementia was used to assess overall confidence, attitude to care and engagement. A t-test for paired samples was used to identify differences from preworkshop (T1) to postworkshop (T2) for each GP group. A t-test for independent samples was undertaken to ascertain differences between each workshop group. A Cohen's d was calculated to measure the effect size of any difference between T1 and T2 scores.

RESULTS

Significant increases in scores were recorded for Confidence in Clinical Abilities, Attitude to Care and Engagement between pretest and post-test periods. GPR exhibited the greatest increase in scores for Confidence in Clinical Abilities and Engagement.

CONCLUSIONS

Targeted educational interventions can improve attitude, increase confidence and reduce negative attitudes towards engagement of participating GPs.

[Challenges in dementia care at home - The situation at home of a married couple]

Challenges in dementia care at home - The situation at home of a married couple Abstract. Background: People with dementia and their relatives are faced with major challenges due to complex dementia symptoms. Families need information and counselling in order to find adequate dementia care services tailored to their needs.

AIM

This case report's objective is to exemplify the domestic situation of a married couple who is faced with significant challenges within the family and the care system due to the husband's dementia and Parkinson's disease.

METHODS

The Dementia Care Nurse project included case monitoring; by means of different assessments relevant information was recorded and the family's situation described.

RESULTS

The family's problems and their need for support were multifaceted and entailed reimbursement of costs, application for care services as well as management of challenging behaviours and reduction of the caregiver's psychosocial burden.

CONCLUSIONS

The family, particularly the spouse caregiver, was effectively supported in meeting the challenges of dementia, e. g. by drawing on professional services and sorting out entitlement to benefits. From the perspective of the experience in the project, independent counselling structures such as a case management approach are indispenable in order to stabilise the domestic situation.

Living with a well-known stranger: Voices of family members to older persons with frontotemporal dementia

AIM

To describe family members' experiences of living with persons with neuropsychiatric symptoms (NPS) related to frontotemporal dementia (FTD).

BACKGROUND

The majority of persons with dementia during the disease trajectory develop NPS. Persons with FTD are likely to develop greater levels of NPS than persons with other types of dementias. Research-based knowledge regarding family members' experiences of living with persons with FTD and NPS is limited.

METHODS

Nine family members of persons with FTD were interviewed. Interviews commenced with completion of the Neuropsychiatric Inventory (NPI). Upon completion of the NPI, questions were posed from an interview guide where study participants provided in-depth information about NPS identified. Interview data were analysed using qualitative content analysis.

RESULTS

Interviewed family members highlighted that persons with FTD had developed between four and eight co-existing NPS. Irritability and disinhibition were the most common NPS, with variations in severity, frequency and distress. From the interview data, two themes emerged: Living with a well-known stranger and Coping and overstepping social norms.

CONCLUSIONS

Living with a well-known stranger depicted a new co-existence with a loved one with changes in personality and behaviour, which were not inherent to the person or predictable any more. The presence of NPS can threaten the safety of the person with FTD and their family in real world and on social media. Support offered should focus on the person's physical and psychological needs, not on a diagnosis.

IMPLICATIONS FOR PRACTICE

From a health care perspective it is important to see the person with FTD and their family as unique individuals with specific needs.

Care preferences of healthy, middle-aged adults in Japan and the USA if they acquired dementia: A cross-sectional observational study

AIM

Japan introduced dementia-friendly initiatives into its national policies to help people with dementia remain involved in society for as long as possible. However, some people might choose to live in a nursing home to avoid care burden on family members. Understanding middle-aged adults' preferences for place of care and identifying factors that influence their preferences would help policy decision-makers promote dementia-friendly initiatives. The present study aimed to investigate the care preferences of middle-aged adults if they acquired dementia in Japan and the USA.

METHODS

We carried out a cross-sectional observational study using an internet-based questionnaire survey of Japanese residents with Japanese ethnicity, Japanese Americans, and non-Asian Americans aged 40-70 years. A total of 301 participants, including 104 Japanese residents, 93 Japanese Americans and 104 non-Asian Americans, completed the survey. Participants were asked to answer the items based on a hypothetical situation in which they had acquired dementia requiring regular care and supervision.

RESULTS

Participants preferred nursing home care (29.9%), followed by professional home care (19.6%), family home care (17.6%) and hospital care (11.3%). Japanese residents had a significantly lower preference for professional home care than did Japanese or non-Asian Americans (adjusted odds ratio 0.28, 95% confidence interval 0.10-0.75). Between-ethnicity difference in care preferences was not observed.

CONCLUSIONS

A low preference for professional home care among the middle-aged adults might be influenced by country-specific long-term and dementia care systems. Policy decision-makers should develop professional home care services that are more available for families of people living with dementia. Geriatr Gerontol Int 2019; 19: 829-833.

A Needs Assessment of Family Physicians to Inform Development of Educational Resources on Antipsychotic Use in Dementia

OBJECTIVES

Objectives of this study were to (1) assess the needs and preferred resources of Iowa physicians to inform the development of educational resources for best practice dementia care and (2) compare the responses of nursing home medical directors with nonmedical directors.

METHODS

Of 498 physicians, 101 (20%) completed and returned the survey. Family physicians were obtained from a list of family physicians from the Iowa Board of Medical Examiners. Respondent answers were summarized and presented as total numbers and percentages in tables. Significant differences between medical directors and nonmedical directors were evaluated using chi-square tests, Fisher exact tests, and Wilcoxon rank-sum tests.

RESULTS

Medical directors and nonmedical directors had similar preferences for resources used and information needs. Online resources, pocket guides, a handbook, consulting pharmacists, and facility in-services were the most commonly preferred sources of new information. Medical directors were significantly more aware of the Food and Drug Administration warning on antipsychotic use in dementia and treated more nursing home patients. No differences were observed between groups related to confidence in and use of nondrug strategies instead of antipsychotics to manage behavioral symptoms of dementia.

CONCLUSION

The results of this survey illustrate physician preferences for information and resources on the management of behavioral and psychological symptoms in dementia. Information was used to inform the development of resources to aid physicians and other health care providers in making decisions about managing these symptoms.

Development of a tool for monitoring the prescribing of antipsychotic medications to people with dementia in general practice: a modified eDelphi consensus study

Background

Despite their adverse effects, antipsychotics are frequently used to manage behavioral and psychological symptoms of dementia. Regular monitoring of antipsychotic prescribing has been shown to improve the appropriateness of prescribing. However, there is currently no consensus on what the components of such a monitoring tool would be.

Aim

The aim of this study was to use an expert consensus process to identify the key components of an antipsychotic repeat prescribing tool for use with people with dementia in a general practice setting.

Methods

A modified eDelphi technique was employed. We invited multidisciplinary experts in antipsychotic prescribing to people with dementia to participate. These experts included general practitioners (GPs), geriatricians and old age psychiatrists. The list of statements for round 1 was developed through a review of existing monitoring tools and international best practice guidelines. In the second round of the Delphi, any statement that had not reached consensus in the first round was presented for re-rating, with personalized feedback on the group and the individual’s response to the specific statement. The final round consisted of a face-to-face expert meeting to resolve any uncertainties from round 2.

Results

A total of 23 items were rated over two eDelphi rounds and one face-to-face consensus meeting to yield a total of 18 endorsed items and five rejected items. The endorsed statements informed the development of a structured, repeat prescribing tool for monitoring antipsychotics in people with dementia in primary care.

Conclusion

The development of repeat prescribing tool provides GPs with practical advice that is lacking in current guidelines and will help to support GPs by providing a structured format to use when reviewing antipsychotic prescriptions for people with dementia, ultimately improving patient care. The feasibility and acceptability of the tool now need to be evaluated in clinical practice.

The knowledge and attitudes of general practitioners to the assessment and management of pain in people with dementia

BACKGROUND

Pain in people with dementia is underdiagnosed and undertreated. General practitioners (GPs) play a pivotal role in dementia care but their perspectives on pain in people with dementia remains under-researched. The aim of this study was to explore GPs' knowledge and attitudes towards pain assessment and management in people with dementia.

METHODS

This was a descriptive cross-sectional study. A questionnaire was adapted from a previous study and piloted with 5 GPs. The questionnaire was posted to a census sample of all GPs in Cork city and county in the southern region of Ireland. The questionnaire collected demographic information, responses to a series of Likert-type statements assessing GPs' knowledge and attitudes, and provided an opportunity for the GP to give qualitative feedback on their experiences of managing pain in dementia. SPSS v25 was used for statistical analysis. Qualitative responses were thematically analysed.

RESULTS

Of the 320 questionnaires posted, 157 completed questionnaires were returned (response rate of 49%). The sample was representative of GPs nationally in terms of years in GP practice and practice location. Over two-thirds (108/157) of respondents had a nursing home commitment. Only 10% of respondents (16/157) were aware of any dementia-specific pain assessment tools. The larger the nursing home commitment of the GP the more likely they were to be familiar with these tools (p = 0.048). The majority of respondents (113/157) believed people with dementia could not self-report pain. Respondents were uncertain about the safety of using opioid medications to treat pain in people with dementia with only 51.6% agreeing that they were safe. The qualitative comments highlighted the importance the GPs placed on surrogate reports of pain, GPs' uncertainty regarding the value of formal pain assessment tools and the challenges caused by under-resourcing in general practice.

CONCLUSION

This study has highlighted aspects of pain assessment and management in dementia that GPs find challenging. Guidance on pain assessment and management in people with dementia do not appear to be translating into clinical practice. The findings will inform educational interventions being developed by our research team as part of the implementation of the Irish national dementia strategy. The knowledge and attitudes of general practitioners to the assessment and management of pain in people with dementia.

Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study

OBJECTIVES

Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions.

DESIGN

Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF).

SETTING AND PARTICIPANTS

A purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland.

MEASURES

Using framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed.

RESULTS

Nine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants' effort to achieve "a fine balance" between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents over-sedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes ("human suffering"; "the interface between resident and nursing home"; and "power and knowledge: complex stakeholder dynamics"), which conceptualize how different nursing homes strike this "fine balance."

CONCLUSIONS

Implementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that "fine balance" and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.

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.