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Watt JA, Porter J, Tavilsup P, Chowdhury M, Hatch S, Ismail Z, Kumar S, Kirkham J, Goodarzi Z, Seitz D. Guideline Recommendations on Behavioral and Psychological Symptoms of Dementia: A Systematic Review. J Am Med Dir Assoc 2024; 25:837-846.e21. [PMID: 38640961 DOI: 10.1016/j.jamda.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/20/2024] [Accepted: 03/12/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To synthesize recommendations on assessing and managing behavioral and psychological symptoms of dementia (BPSDs) in existing clinical practice guidelines on dementia care to learn from and adapt recommendations to a Canadian context and language for describing BPSDs. DESIGN Systematic review. SETTING AND PARTICIPANTS Moderate to high-quality clinical practice guidelines on dementia care that made 1 or more recommendations on BPSD assessment or management. METHODS We searched MEDLINE, Embase, JBI EBM, PsycINFO, AgeLine, and gray literature for clinical practice guidelines on dementia care making recommendations on BPSD, published between January 1, 2011, and October 13, 2022. Two independent reviewers conducted study screening and data abstraction. Four independent reviewers completed quality appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool; included guidelines had a mean overall AGREE II score ≥4. RESULTS Our systematic review identified 23 moderate to high-quality clinical practice guidelines (264 recommendations). The mean overall quality score on the AGREE II tool ranged from 4 to 6.5. Recommendations were clearly presented (mean clarity of presentation score 73.5%), but guideline applicability was not consistently addressed (mean applicability score 39.3%). BPSD was the most prevalent term describing neuropsychiatric symptoms (number of guidelines [n] = 14). People with lived experience contributed to 6 guidelines (26.1%). Ten guidelines (43.5%) described 1 or more health equity considerations. Guidelines made recommendations for assessing and managing agitation (n = 12), aggression (n = 10), psychosis (n = 11), depression (n = 9), anxiety (n = 5), apathy (n = 6), inappropriate sexual behavior (n = 3), nighttime behavior (n = 5), and eating disturbances (n = 3). There was substantial variability in recommendation statements, evidence quality assigned to each statement, and strength of recommendations. CONCLUSIONS AND IMPLICATIONS There are several moderate to high-quality clinical practice guidelines making recommendations on BPSD assessment and management, but variability in recommendation statements across guidelines and insufficient consideration of guideline applicability may hamper guideline dissemination and implementation in clinical practice.
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Affiliation(s)
- Jennifer A Watt
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Jennifer Porter
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pattara Tavilsup
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohammad Chowdhury
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stacey Hatch
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zahinoor Ismail
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjeev Kumar
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Julia Kirkham
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zahra Goodarzi
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dallas Seitz
- Department of Psychiatry and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Paulamäki J, Jyrkkä J, Hyttinen V, Huhtala H, Jämsen E. Regional variation of potentially inappropriate medication use and associated factors among older adults: A nationwide register study. Res Social Adm Pharm 2023; 19:1372-1379. [PMID: 37355437 DOI: 10.1016/j.sapharm.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Certain medications should be used with caution in older persons, which challenges rational prescribing. Potentially inappropriate medications (PIMs) are defined as medicines whose potential risk of harm typically outweighs the clinical benefits in geriatric population. Earlier studies have found regional differences in PIM use, but the factors underlying this phenomenon are unclear. OBJECTIVE To compare prescription PIM prevalence among Finnish hospital districts and determine which population characteristics and factors related to social and health care are associated with regional variation. METHODS This nationwide register study was based on the Prescription Centre data on all people aged ≥75 years in 2017-2019. Hospital district (n = 20) characteristics were drawn from the Finnish Institute for Health and Welfare's, Finnish Medical Association's, and Finnish Medicines Agency's publicly open data. PIMs were defined according to the Finnish Meds75+ database. A linear mixed-effect model was used to analyze potential associations of regional characteristics with PIM prevalence. RESULTS Prevalence of PIMs varied between 16.4% and 24.8% across regions. The highest prevalence was observed in the southern regions, while the lowest prevalence was on the west coast. Hospital district characteristics associated with higher PIM prevalence were higher share of population living alone, with excessive polypharmacy, or assessed using the Resident Assessment Instrument, shortage of general practitioners in municipal health centers, and low share of home care personnel. Waiting time in health care or share of population with morbidities were not associated with PIM use. Of the total variance in PIM prevalence, 86% was explained by group-level factors related to hospital districts. The regional variables explained 75% of this hospital-district-level variation. CONCLUSIONS PIM prevalence varied significantly across hospital districts. Findings suggest that higher PIM prevalence may be related to challenges in the continuity of care rather than differences in health care accessibility or share of the population with morbidities.
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Affiliation(s)
- Jasmin Paulamäki
- Faculty of Medicine and Health Technology, Clinical Medicine, Tampere University, FI-33014, Tampere University, Finland; Development and Information Services, Finnish Medicines Agency Fimea, P.O. Box 55, FI-00034, FIMEA, Finland.
| | - Johanna Jyrkkä
- Development and Information Services, Finnish Medicines Agency Fimea, P.O. Box 55, FI-00034, FIMEA, Finland.
| | - Virva Hyttinen
- Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland.
| | - Heini Huhtala
- Faculty of Social Sciences, Health Sciences, Tampere University, FI-33014, Tampere University, Finland.
| | - Esa Jämsen
- Faculty of Medicine (Clinicum), University of Helsinki, P.O. Box 63, FI-00014, University of Helsinki, Finland; Department of Geriatrics, Helsinki University Hospital, P.O. Box 340, FI-00029, Helsinki, HUS, Finland.
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Raza A, Piekarz H, Jawad S, Langran T, Donyai P. A systematic review of quantitative studies exploring staff views on antipsychotic use in residents with dementia in care homes. Int J Clin Pharm 2023; 45:1050-1061. [PMID: 37773304 PMCID: PMC10600045 DOI: 10.1007/s11096-023-01645-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/26/2023] [Indexed: 10/01/2023]
Abstract
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.
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Affiliation(s)
- Amna Raza
- Reading School of Pharmacy, University of Reading, Reading, UK.
| | - Hannah Piekarz
- Reading School of Pharmacy, University of Reading, Reading, UK
| | - Sundus Jawad
- NHS Frimley, King Edward VII Hospital, Windsor, UK
| | - Tim Langran
- NHS Frimley, King Edward VII Hospital, Windsor, UK
| | - Parastou Donyai
- Department of Pharmacy and Forensic Science, King's College London, London, UK
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Yoon JM, Trinkoff AM, Kim M, Kim E. State-level nursing home in-service dementia training requirements and inappropriate psychotropic medication use. Geriatr Nurs 2023; 51:209-214. [PMID: 37011493 DOI: 10.1016/j.gerinurse.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/07/2023] [Accepted: 03/07/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Although non-pharmacological interventions, which are staff intensive, are recommended for behavioral symptoms of dementia, psychotropics are often prescribed in nursing homes (NHs), with insufficient nurse staffing levels and dementia care training. Since 2017, deficiency citations can be assigned for inappropriate psychotropics use (F-758 tag). Some states require in-service dementia training above federal minimums, but it is unknown whether extra dementia training requirements were related to fewer F-758 citations for residents with dementia and whether nurse staffing influenced the relationship between receiving F-758 citations and having additional state-level dementia training requirements. PURPOSE To relate F-758 citation occurrence to extra in-service dementia training regulations and to explore how the relationships are affected by nurse staffing levels. METHOD Generalized linear mixed models were used to examine F-758 citation occurrence in relation to state-level in-service dementia training regulations. Stratification was also conducted to compare the effects in NHs with low versus high nurse staffing. FINDINGS Requiring in-service dementia training with extra hours was inversely related to receiving F-758 tags. That relationship was also noted in NHs with lower registered nurse and certified nurse assistant staffing. DISCUSSION In-service dementia training may be helpful in reducing inappropriate psychotropics use, particularly in facilities with lower nurse staffing.
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Affiliation(s)
- Jung Min Yoon
- Ewha Womans University, College of Nursing, Seoul, South Korea.
| | | | - Miyoung Kim
- Ewha Womans University, College of Nursing, Seoul, South Korea.
| | - Eunjin Kim
- Ewha Womans University, College of Nursing, Seoul, South Korea.
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Timmons S, Bracken-Scally M, Chakraborty S, Gallagher P, Hamilton V, Begley E, O'Shea E. Psychotropic Medication Prescribing to Patients with Dementia Admitted to Acute Hospitals in Ireland. Drugs Aging 2023; 40:461-472. [PMID: 36995582 DOI: 10.1007/s40266-023-01020-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Psychotropic medications are commonly prescribed to people with dementia (PwD) for non-cognitive symptoms of dementia (NCSD), but have significant risks. A national audit was performed in acute hospitals in the Republic of Ireland (ROI) to establish baseline practice prior to the launch and implementation of a National Clinical Guideline on the appropriate prescribing of psychotropic medications for NCSD. The objective of this study was to analyse psychotropic prescribing patterns and compare these with international data and with existing (limited) data from a previous audit round. METHODS The pooled anonymous dataset from the second round of the Irish National Audit of Dementia Care (INAD-2) was analysed. The audit had collected retrospective data from 30 random healthcare records from each of 30 acute hospitals in 2019. Inclusion criteria were a clinical diagnosis of dementia of any type, hospital stay of 72 hours or more, and discharge or death within the audit period. Most hospitals (87%) self-audited their healthcare records, but a random sample of six healthcare records (20%) from each hospital were re-audited by a highly trained healthcare auditor. The audit tool was based on a tool used in the England and Wales National Audit of Dementia audit rounds (Royal College of Psychiatrists), adapted to the Irish healthcare setting and national priorities. RESULTS In total, 893 cases were included, as one hospital could not retrieve 30 cases even within a more prolonged audit period. The sample comprised 55% females and 45% males; the median age was 84 years (interquartile range 79-88 years) and the majority (89.6%) were >75 years of age. Only 52% of healthcare records specified the type of dementia; within these, the most common diagnosis was Alzheimer's disease (45%). Most PwD (83%) were receiving psychotropic medication on admission; 40% were prescribed new or increased psychotropic medication during admission, mainly for medical indications, including end-of-life care and delirium. Anticonvulsants or cognitive enhancers were rarely prescribed for NCSD in hospital. However, new/increased antipsychotic medication was prescribed for NCSD in 11.8-17.6% of the total cohort, while 4.5-7.7% were prescribed a benzodiazepine for anxiety or NCSD. Overall, there was poor documentation of risk/benefit, or of discussion with the patient/family, and apparently inadequate review for efficacy and tolerability. Concurrently, acetylcholinesterase inhibitors appeared to be underused for cognitive impairment in the community. CONCLUSION This audit provides baseline data on psychotropic medication prescription for NCSD in Irish hospitals prior to a specific Irish guideline on this topic. Reflecting this, most PwD were receiving psychotropic medications on admission, and many were prescribed new/increased psychotropic medication in hospital, often without evidence of appropriate decision making and prescribing processes.
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Affiliation(s)
- Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | | | - Shelly Chakraborty
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland
| | | | | | - Emer Begley
- National Dementia Office, Health Service Executive, Tullamore, Ireland
| | - Emma O'Shea
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, Ireland.
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Watt JA, Bronskill SE, Lin M, Youngson E, Ho J, Hemmelgarn B, Straus SE, Gruneir A. Comparative Risk of Harm Associated with Zopiclone or Trazodone Use in Nursing Home Residents: a Retrospective Cohort Study in Alberta, Canada. Can Geriatr J 2023; 26:9-22. [PMID: 36865408 PMCID: PMC9953503 DOI: 10.5770/cgj.26.622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Background There is growing evidence of harm associated with trazodone and nonbenzodiazepine sedative hypnotics (e.g., zopiclone); however, their comparative risk of harm is unknown. Methods We conducted a retrospective cohort study with linked health administrative data, which enrolled older (≥66 years old) nursing home residents living in Alberta, Canada, between December 1, 2009, and December 31, 2018; the last follow-up date was June 30, 2019. We compared the rate of injurious falls and major osteoporotic fractures (primary outcome) and all-cause mortality (secondary outcome) within 180 days of first prescription of zopiclone or trazodone with cause-specific hazard models and inverse probability of treatment weights to control for confounding; primary analysis was intention-to-treat and secondary analysis was per-protocol (i.e., residents censored if dispensed the other exposure drug). Results Our cohort included 1,403 residents newly dispensed trazodone and 1,599 residents newly dispensed zopiclone. At cohort entry, the mean resident age was 85.7 (standard deviation [SD] 7.4), 61.6% were female, and 81.2% had dementia. New zopiclone use was associated with similar rates of injurious falls and major osteoporotic fractures (intention-to-treat-weighted hazard ratio 1.15, 95% confidence interval [CI] 0.90-1.48; per-protocol-weighted hazard ratio 0.85, 95% CI 0.60-1.21) and all-cause mortality (intention-to-treat-weighted hazard ratio 0.96, 95% CI 0.79-1.16; per-protocol-weighted hazard ratio 0.90, 95% CI 0.66-1.23) compared to trazodone. Conclusions Zopiclone was associated with a similar rate of injurious falls, major osteoporotic fractures, and all-cause mortality compared to trazodone-suggesting one medication should not be used in lieu of the other. Appropriate prescribing initiatives should also target zopiclone and trazodone.
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Affiliation(s)
- Jennifer A. Watt
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital-Unity Health Toronto, Toronto, ON,Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON,ICES, Toronto, ON,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Susan E. Bronskill
- ICES, Toronto, ON,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Meng Lin
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, AB
| | - Erik Youngson
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, AB
| | - Joanne Ho
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Kitchener, ON,Schlegel Research Institute for Aging, University of Waterloo, Waterloo, ON
| | - Brenda Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, WC Mackenzie Health Sciences Centre, Edmonton, AB
| | - Sharon E. Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital-Unity Health Toronto, Toronto, ON,Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Andrea Gruneir
- Department of Family Medicine, University of Alberta, Edmonton, AB
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Perrine E, Damiaens A, Patey AM, Grimshaw JM, Spinewine A. Barriers and enablers towards benzodiazepine-receptor agonists deprescribing in nursing homes: A qualitative study of stakeholder groups. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 9:100258. [PMID: 37124470 PMCID: PMC10130691 DOI: 10.1016/j.rcsop.2023.100258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/08/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Background Despite recommendations to deprescribe chronic benzodiazepine receptor agonists (BZRA) among older adults, the prevalence of their use in Belgian nursing homes (NHs) remains above 50%. The use of a behavioral science approach, starting with the evaluation of barriers and enablers for BZRA deprescribing, has the potential to decrease BZRA prescribing. Objectives To identify barriers and enablers for BZRA deprescribing perceived by the different stakeholders involved in nursing home care in Belgium. Methods In a purposive sample of 6 NHs, we conducted face-to-face interviews with general practitioners (GPs), and focus groups with other healthcare providers (HCPs), including nurses, pharmacists, occupational therapists, physical therapists, and with NH residents and relatives. All interviews with HCPs were analyzed through deductive thematic analysis, using the theoretical domains framework (TDF) as the coding framework. Residents' and relatives' interviews were analyzed using an inductive thematic approach. Results We interviewed 13 GPs, 35 other HCPs, 22 nursing home residents, and 5 relatives. Overall, 9 TDF domains were identified as most relevant among HCPs interviewed: Skills, Beliefs about capabilities, Goals, Memory attention and decision processes, Environmental context and resources, Social influences, Knowledge, Social/professional role and identity, and Beliefs about consequences. Five additional themes emerged from residents' and relatives' interviews: knowledge on medications used, communication with NH staff and GPs, perceived efficacy and necessity of BZRA, influence of the environment, and reluctance towards BZRA deprescribing. Some domains and themes differ between stakeholders (e.g., knowledge), while others match between groups (e.g., environmental aspects). Conclusion BZRA deprescribing is influenced by knowledge and skills gaps, automatic BZRA refilling, competing priorities, social challenges, environmental factors and poor nursing home residents involvement. Targeting these barriers will be a key step for implementation of BZRA deprescribing.
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Chappell V, Kirkham J, Seitz DP. Association Between Long-Term Care Facility Staffing Levels and Antipsychotic Use in US Long-Term Care Facilities. J Am Med Dir Assoc 2022; 23:1787-1792.e1. [PMID: 35926573 DOI: 10.1016/j.jamda.2022.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 05/31/2022] [Accepted: 06/25/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Inappropriate use of antipsychotics is an indicator of quality of care in long-term care (LTC) facilities. There is evidence to suggest that staffing levels in LTC may be associated with the rates of inappropriate antipsychotic use. This study sought to examine the association between staffing and antipsychotic prescribing in LTC facilities. DESIGN Cross-sectional study investigated the association between reported staffing levels and the frequency of inappropriate antipsychotic prescribing at US LTC facilities between 2016 and 2018. SETTING AND PARTICIPANTS Data from the Nursing Home Compare and LTCFocus datasets were linked, which contain information from the Minimum Data Set database on facility characteristics and staffing measures from the Payroll-Based Journal system. A final sample set of 10,436 facilities was used. METHODS Descriptive statistics were calculated for all variables of interest. An unadjusted linear correlation analysis and linear regression were performed. Potential confounders were investigated by comparison across low-vs high-staffing facilities where adjusted for in regression analyses. RESULTS The mean staff level for the facilities was identified as 3.69 (SD = 0.67) staffing hours per patient per day, and the mean antipsychotic use rate across all facilities was 15.24% (SD = 8.62%). There was a 0.75% decrease in inappropriate antipsychotic prescribing per unit increase in overall staff-to-patient ratio. When looking at staffing types, a 3.09% decrease in inappropriate antipsychotic prescribing per unit increase in licensed staff hours. More specifically, we saw a 2.25% decrease per unit increase in RN staffing hours, a 1.83% decrease per unit increase in LPN staffing hours, and nursing aide staffing hours were not associated with antipsychotic use. CONCLUSIONS AND IMPLICATIONS These findings provide support for policy-based interventions to decrease antipsychotic use in LTC facilities by improving staffing skill mix and staffing levels. The results may also inform nursing staff education and training on antipsychotic prescribing practices.
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Affiliation(s)
- Victoria Chappell
- Department of Psychiatry, Queen's University, Providence Care-Mental Health Services, Kingston, ON, Canada
| | - Julia Kirkham
- Department of Psychiatry, Hotchkiss Brain Institute, and O'Brien Institute for Public Health, Calgary, AB, Canada; Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dallas P Seitz
- Department of Psychiatry, Queen's University, Providence Care-Mental Health Services, Kingston, ON, Canada; Department of Psychiatry, Hotchkiss Brain Institute, and O'Brien Institute for Public Health, Calgary, AB, Canada; Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Yoon JM, Trinkoff AM, Galik E, Storr CL, Lerner NB, Brandt N, Zhu S. Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia. J Am Med Dir Assoc 2022; 23:1772-1779. [PMID: 35568094 DOI: 10.1016/j.jamda.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/14/2022] [Accepted: 04/02/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Jung Min Yoon
- Stony Brook University School of Nursing, Stony Brook, NY, USA.
| | | | - Elizabeth Galik
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Carla L Storr
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Nancy B Lerner
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Nicole Brandt
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Shijun Zhu
- University of Maryland School of Nursing, Baltimore, MD, USA
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O’Donnell E, Holland C, Swarbrick C. Strategies used by care home staff to manage behaviour that challenges in dementia: a systematic review of qualitative studies. Int J Nurs Stud 2022; 133:104260. [DOI: 10.1016/j.ijnurstu.2022.104260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 02/14/2022] [Accepted: 04/17/2022] [Indexed: 11/24/2022]
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Bednarczyk E, Cook S, Brauer R, Garfield S. Stakeholders' views on the use of psychotropic medication in older people: a systematic review. Age Ageing 2022; 51:6550831. [PMID: 35305087 PMCID: PMC8934150 DOI: 10.1093/ageing/afac060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Indexed: 12/24/2022] Open
Abstract
Background psychotropic medication use has been shown to increase with age and has been associated with increased risk of falls, strokes and mortality. Various guidelines, regulations and tools have been developed to reduce inappropriate prescribing, but this remains high. In order to understand the reasons for this, we aimed to systematically review healthcare professionals’, patients’ and family caregivers’ attitudes towards the use of psychotropic medication in older people. Methods a systematic literature search was carried out from inception to September 2020 using PUBMED, EMBASE, PsycINFO and CINAHL and hand-searching of reference lists. Included studies investigated stakeholder views on psychotropic in adults over the age of 65. Findings were thematically synthesised. Results overall, there was an acceptance of long-term psychotropic medication for older people both living in the community and in residential care. While healthcare professionals were aware of guidelines for the use of benzodiazepines and psychotropic medicines, they identified barriers to following them on individual, team and organisational levels. Alternative non-pharmacological approaches were not always available or accepted by patients. Conclusion psychotropic medicine use in older adults remains a complex issue, which needs to be addressed on a broad level. Attitudes of older people and healthcare professionals encourage long-term use. Meanwhile, various internal and external factors act as barriers to the use of non-drug alternatives in this population. In order to reduce overprescribing of psychotropics, there is a need to increase the acceptability and accessibility of alternative interventions in both care homes and the community.
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Affiliation(s)
- Eliza Bednarczyk
- Research Department of Practice and Policy, School of Pharmacy, University College London (UCL), London, UK
| | - Sarah Cook
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Ruth Brauer
- Research Department of Practice and Policy, School of Pharmacy, University College London (UCL), London, UK
| | - Sara Garfield
- Research Department of Practice and Policy, School of Pharmacy, University College London (UCL), London, UK
- Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, London, UK
- NIHR Imperial Patient Safety Translational Research Centre, London, UK
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12
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Affiliation(s)
- Jennifer A Watt
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto
| | - Wade Thompson
- Women's College Research Institute, Toronto
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | | | - Deborah Brown
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto
| | - Barbara Liu
- Division of Geriatric Medicine, Department of Medicine, University of Toronto
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13
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Hosie A, Agar M, Caplan GA, Draper B, Hedger S, Rowett D, Tuffin P, Cheah SL, Phillips JL, Brown L, Sidhu M, Currow DC. Clinicians' delirium treatment practice, practice change, and influences: A national online survey. Palliat Med 2021; 35:1553-1563. [PMID: 34096396 DOI: 10.1177/02692163211022183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Recent studies cast doubt on the net effect of antipsychotics for delirium. AIM To investigate the influence of these studies and other factors on clinicians' delirium treatment practice and practice change in palliative care and other specialties using the Theoretical Domains Framework. DESIGN Australia-wide online survey of relevant clinicians. SETTING/PARTICIPANTS Registered nurses (72%), doctors (16%), nurse practitioners (6%) and pharmacists (5%) who cared for patients with delirium in diverse settings, recruited through health professionals' organisations. RESULTS Most of the sample (n = 475): worked in geriatrics/aged (31%) or palliative care (30%); in hospitals (64%); and saw a new patient with delirium at least weekly (61%). More (59%) reported delirium practice change since 2016, mostly by increased non-pharmacological interventions (53%). Fifty-five percent reported current antipsychotic use for delirium, primarily for patient distress (79%) and unsafe behaviour (67%). Common Theoretical Domains Framework categories of influences on respondents' delirium practice were: emotion (54%); knowledge (53%) and physical (43%) and social (21%) opportunities. Palliative care respondents more often reported: awareness of any named key study of antipsychotics for delirium (73% vs 39%, p < 0.001); changed delirium treatment (73% vs 53%, p = 0.017); decreased pharmacological interventions (60% vs 15%, p < 0.001); off-label medication use (86% vs 51%, p < 0.001: antipsychotics 79% vs 44%, p < 0.001; benzodiazepines 61% vs 26%, p < 0.001) and emotion as an influence (82% vs 39%, p < 0.001). CONCLUSION Clinicians' use of antipsychotic during delirium remains common and is primarily motivated by distress and safety concerns for the patient and others nearby. Supporting clinicians to achieve evidence-based delirium practice requires further work.
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Affiliation(s)
- Annmarie Hosie
- The University of Notre Dame Australia, School of Nursing and Midwifery, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, The Cunningham Centre for Palliative Care, Darlinghurst, NSW, Australia
| | - Meera Agar
- University of Technology Sydney, Faculty of Health, Improving Palliative, Aged and Chronic Care through Research and Translation, Ultimo, NSW, Australia
| | - Gideon A Caplan
- Prince of Wales Hospital, Prince of Wales Clinical School, Randwick, NSW, Australia.,University of New South Wales, Department of Geriatric Medicine, Randwick, NSW Australia
| | - Brian Draper
- University of New South Wales, School of Psychiatry, Randwick, NSW Australia
| | - Stephen Hedger
- Flinders University, College of Medicine and Public Health, Adelaide, SA, Australia
| | - Debra Rowett
- University of South Australia, Clinical and Heath Sciences, Adelaide, SA, Australia
| | - Penny Tuffin
- Royal Perth Hospital, Palliative Care Department and Pain Service, Perth, WA, Australia.,Curtin University, Perth, WA, Australia
| | - Seong Leang Cheah
- University of Technology Sydney, Faculty of Health, Improving Palliative, Aged and Chronic Care through Research and Translation, Ultimo, NSW, Australia
| | - Jane L Phillips
- University of Technology Sydney, Faculty of Health, Improving Palliative, Aged and Chronic Care through Research and Translation, Ultimo, NSW, Australia.,Queensland University of Technology, School of Nursing, Brisbane, QLD, Australia
| | - Linda Brown
- University of Technology Sydney, Faculty of Health, Improving Palliative, Aged and Chronic Care through Research and Translation, Ultimo, NSW, Australia
| | - Manraaj Sidhu
- University of Technology Sydney, Faculty of Health, Improving Palliative, Aged and Chronic Care through Research and Translation, Ultimo, NSW, Australia
| | - David C Currow
- University of Technology Sydney, Faculty of Health, Improving Palliative, Aged and Chronic Care through Research and Translation, Ultimo, NSW, Australia
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14
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Moth AE, Hølmkjær P, Holm A, Rozing MP, Overbeck G. What Makes Deprescription of Psychotropic Drugs in Nursing Home Residents with Dementia so Challenging? A Qualitative Systematic Review of Barriers and Facilitators. Drugs Aging 2021; 38:671-685. [PMID: 34231182 PMCID: PMC8342345 DOI: 10.1007/s40266-021-00875-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 12/03/2022]
Abstract
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.
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Affiliation(s)
| | - Pernille Hølmkjær
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark.
| | - Anne Holm
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark
| | | | - Gritt Overbeck
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark
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15
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Tomlinson EJ, Rawson H, Manias E, Phillips NNM, Darzins P, Hutchinson AM. Factors associated with the decision to prescribe and administer antipsychotics for older people with delirium: a qualitative descriptive study. BMJ Open 2021; 11:e047247. [PMID: 34233988 PMCID: PMC8264916 DOI: 10.1136/bmjopen-2020-047247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To explore factors associated with decision-making of nurses and doctors in prescribing and administering as required antipsychotic medications to older people with delirium. DESIGN Qualitative descriptive. SETTING Two acute care hospital organisations in Melbourne, Australia. PARTICIPANTS Nurses and doctors were invited to participate. Semi-structured focus groups and individual interviews were conducted between May 2019 and March 2020. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis. RESULTS Participants were 42 health professionals; n=25 nurses and n=17 doctors. Themes relating to decisions to use antipsychotic medication were: safety; a last resort; nursing workload; a dilemma to medicate; and anticipating worsening behaviours. Nurses and doctors described experiencing pressures when trying to manage hyperactive behaviours. Safety was a major concern leading to the decision to use antipsychotics. Antipsychotics were often used as chemical restraints to 'sedate' a patient with delirium because nurses 'can't do their job'. Results also indicated that nurses had influence over doctors' decisions despite nurses being unaware of this influence. Health professionals' descriptions are illustrated in a decision-making flowchart that identifies how nurses and doctors navigated decisions regarding prescription and administration of antipsychotic medications. CONCLUSIONS The decision to prescribe and administer antipsychotic medications for people with delirium is complex as nurses and doctors must navigate multiple factors before making the decision. Collaborative support and multidisciplinary teamwork are required by both nurses and doctors to optimally care for people with delirium. Decision-making support for nurses and doctors may also help to navigate the multiple factors that influence the decision to prescribe antipsychotics.
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Affiliation(s)
- Emily J Tomlinson
- Quality and Safety Patient Research Centre, Deakin University, Geelong, Victoria, Australia
- Institute of Health Transformation, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Helen Rawson
- Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Elizabeth Manias
- Quality and Safety Patient Research Centre, Deakin University, Geelong, Victoria, Australia
- Institute of Health Transformation, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Nicole Nikki M Phillips
- Quality and Safety Patient Research Centre, Deakin University, Geelong, Victoria, Australia
- Institute of Health Transformation, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Peteris Darzins
- Eastern Health Clinical School, Monash University, Clayton, Victoria, Australia
| | - Alison M Hutchinson
- Quality and Safety Patient Research Centre, Deakin University, Geelong, Victoria, Australia
- Institute of Health Transformation, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
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16
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Walsh KA, Byrne S, McSharry J, Browne J, Irving K, Hurley E, Rochford-Brennan H, Geoghegan C, Presseau J, Timmons S. Developing a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia. HRB Open Res 2021; 4:23. [PMID: 34136749 PMCID: PMC8185579 DOI: 10.12688/hrbopenres.13228.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 01/23/2023] Open
Abstract
Background: Antipsychotics are commonly prescribed to people living with dementia in nursing home settings, despite strong guideline recommendations against their use except in limited circumstances. We aimed to transparently describe the development process for a complex intervention targeting appropriate requesting and prescribing of antipsychotics to nursing home residents with dementia in Ireland, by nurses and general practitioners (GPs) respectively. Methods: We report the development process for the ‘Rationalising Antipsychotic Prescribing in Dementia’ (RAPID) complex intervention, in accordance with the ‘Guidance for reporting intervention development studies in health research’ (GUIDED) checklist. The UK Medical Research Council framework for developing and evaluating complex interventions guided our overall approach, incorporating evidence and theory into the intervention development process. To unpack the intervention development process in greater detail, we followed the Behaviour Change Wheel approach. Guided by our stakeholders, we conducted three sequential studies (systematic review and qualitative evidence synthesis, primary qualitative study and expert consensus study), to inform the intervention development. Results: The RAPID complex intervention was developed in collaboration with a broad range of stakeholders, including people living with dementia and family carers, between 2015 and 2017. The finalised RAPID complex intervention was comprised of the following three components; 1) Education and training sessions with nursing home staff; 2) Academic detailing with GPs; 3) Introduction of an assessment tool to the nursing home. Conclusions: This paper describes the steps used by the researchers to develop a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia in Ireland, according to the GUIDED checklist. We found that the GUIDED checklist provided a useful way of reporting all elements in a cohesive manner and complemented the other tools and frameworks used. Transparency in the intervention development processes can help in the translation of evidence into practice.
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Affiliation(s)
- Kieran A Walsh
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12XH60, Ireland.,Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, T12YN60, Ireland.,School of Public Health, University College Cork, Cork, T12K8AF, Ireland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, T12YN60, Ireland
| | - Jenny McSharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Galway, H91TK33, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, T12K8AF, Ireland
| | - Kate Irving
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland
| | - Eimir Hurley
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Helen Rochford-Brennan
- Expert by Experience, N/A, N/A, Ireland.,Irish Dementia Working Group, The Alzheimer Society of Ireland, Dublin, Ireland
| | | | - Justin Presseau
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, K1H 8L6, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, K1G 5Z3, Canada
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12XH60, Ireland
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17
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Ma D, Zhao Y, Wan Z, Sun D, Li H, Xie Z, Sun J. Nurses' attitudes and views on the application of antipsychotics in patients with dementia: A systematic review of qualitative studies. Geriatr Nurs 2020; 41:669-676. [DOI: 10.1016/j.gerinurse.2019.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/19/2019] [Accepted: 10/23/2019] [Indexed: 11/25/2022]
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18
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Rosenthal M, Poling J, Wec A, Connolly E, Angell B, Crystal S. "Medication Is Just One Piece of the Whole Puzzle": How Nursing Homes Change Their Use of Antipsychotic Medications. J Appl Gerontol 2020; 41:62-72. [PMID: 32996374 DOI: 10.1177/0733464820958919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Antipsychotic medication use for nursing home residents with dementia poses major patient safety challenges. This article investigates health professionals' experiences with decision-making during changes under the National Partnership to Improve Dementia Care in Nursing Homes (National Partnership) and its companion state coalitions. These programs were introduced in 2012 to encourage reductions in antipsychotic use and increased use of nonpharmacological treatments for dementia. Interviews with 40 nursing home physicians and staff in seven states found that reducing antipsychotics is more time and resource-intensive than relying on medication, because it requires a person-centered approach. However, respondents supported reductions in antipsychotic use, and indicated that with sufficient staffing, effective communications, and training, they could create or implement individualized treatments. Their positive attitudes suggest that the National Partnership has been a catalyst in reducing antipsychotic medications, and their perspectives can inform further research, policy and practice in nursing homes toward achieving quality dementia care.
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19
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Dhuny S, Foley T, Jennings A. General practitioners' knowledge of and attitudes towards prescribing psychoactive drugs in dementia care: a cross-sectional questionnaire study. Ir J Med Sci 2020; 190:667-675. [PMID: 32897448 PMCID: PMC7477732 DOI: 10.1007/s11845-020-02356-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/31/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Sheefah Dhuny
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland.
| | - Tony Foley
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
| | - Aisling Jennings
- Department of General Practice, Western Gateway Building, University College Cork, Cork, Ireland
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20
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Paksaite P, Crosskey J, Sula E, West C, Watson M. A systematic review using the Theoretical Domains Framework to identify barriers and facilitators to the adoption of prescribing guidelines. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2020; 29:3-11. [DOI: 10.1111/ijpp.12654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/30/2020] [Accepted: 06/13/2020] [Indexed: 11/28/2022]
Abstract
Abstract
Objectives
Evidence-based guidelines have the potential to reduce variation and increase prescribing quality. Identifying the key determinants to their uptake, using a theory-based approach, may assist in the design of successful interventions to increase their adoption into practice. This systematic review investigated barriers and facilitators identified using the Theoretical Domains Framework (TDF) to the implementation of prescribing guidelines.
Methods
Electronic databases (EMBASE, PubMed) were searched. Studies were included if they used the TDF to identify key determinants of guideline implementation. Only studies published in English were included.
Key findings
Of the 407 studies identified, 15 were included. A range of patient populations and therapeutic categories were represented. Multiple determinants were identified that affected guideline implementation, with similarities and differences identified across studies. Barriers to guideline adoption included time restriction, lack of awareness, guideline complexity, lack of clinical evidence, social influences and disagreement. Facilitators included peer influence, guideline simplicity, confidence and belief about the positive consequences derived from guideline adoption, for examples improved care and patient outcomes.
Conclusions
Multiple behavioural factors affect the adoption of prescribing guidelines. The results aided the understanding of factors that may be targeted to increase guideline compliance. However, barriers and facilitators can vary significantly in different environments; therefore, research that targets particular healthcare settings and patient populations may provide further evidence to increase the specificity and credibility of intervention strategies.
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Affiliation(s)
- Paulina Paksaite
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Joel Crosskey
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Eni Sula
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Celine West
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Margaret Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
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21
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Barry HE, Bedford LE, McGrattan M, Ryan C, Passmore AP, Robinson AL, Molloy GJ, Darcy CM, Buchanan H, Hughes CM. Improving medicines management for people with dementia in primary care: a qualitative study of healthcare professionals to develop a theory-informed intervention. BMC Health Serv Res 2020; 20:120. [PMID: 32059718 PMCID: PMC7023803 DOI: 10.1186/s12913-020-4971-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 02/11/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND People with dementia (PwD) face unique challenges with medicines management, yet little is known about these challenges from the perspectives of primary healthcare professionals, particularly general practitioners (GPs) and community pharmacists. Few medicines management interventions have been developed which are aimed at community-dwelling PwD. This study sought to develop an intervention to improve medicines management for PwD in primary care using a theory-informed approach. METHODS Semi-structured interviews were conducted with GPs (n = 15) and community pharmacists (n = 15) to explore participants' views and experiences of medicines management for PwD, and their perceptions of barriers and facilitators to successful medicines management for PwD. The 14-domain Theoretical Domains Framework was the underpinning theoretical guide, allowing key theoretical domains to be identified and mapped to behaviour change techniques (BCTs) which are considered the 'active ingredients' of an intervention. Draft interventions were developed to operationalise selected BCTs and were presented to GPs and community pharmacists during task groups. Final selection of an intervention for feasibility testing was guided by feedback provided during these task groups and through application of the APEASE (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity) criteria. RESULTS Participants expressed a number of concerns about medicines management for PwD, particularly monitoring adherence to medication regimens and conducting medication review. Two draft interventions comprising selected BCTs ('Modelling or demonstration of behaviour'; 'Salience of consequences'; 'Health consequences'; 'Social and environmental consequences'; 'Action planning'; Social support or encouragement', 'Self-monitoring of behaviour') were developed, each targeting GPs and community pharmacists. Following the task groups and discussions within the research team, the community pharmacy-based intervention was selected for future feasibility testing. The intervention will target community pharmacists to conduct a medication review (incorporating an adherence check) with a PwD, delivered as an online video demonstrating key behaviours. The video will include feedback emphasising positive outcomes of performing the behaviours. Action planning and a quick reference guide will be used as complementary intervention components. CONCLUSIONS A community pharmacist-based intervention has been developed targeting medicines management for PwD in primary care using a systematic, theory-informed approach. Future work will determine the usability and acceptability of implementing this intervention in clinical practice.
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Affiliation(s)
- Heather E Barry
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Laura E Bedford
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Máiréad McGrattan
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Cristín Ryan
- The School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - A Peter Passmore
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK.,Belfast Health & Social Care Trust, Belfast City Hospital, Belfast, Northern Ireland, UK
| | - A Louise Robinson
- Institute for Ageing and Institute for Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Gerard J Molloy
- School of Psychology, National University of Ireland, Galway, Ireland
| | | | | | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK.
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22
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Deprescribing in Geriatric Medicine: Challenges and Opportunities. J Am Med Dir Assoc 2018; 19:919-922. [DOI: 10.1016/j.jamda.2018.09.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/18/2022]
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