A qualitative exploration of proxy decision makers' expectations of prescribed medications for people with advanced dementia

Medication management information priorities of people living with dementia and their carers: a scoping review

BACKGROUND

People living with dementia and their carers often experience difficulties in effectively managing medications and have indicated they lack necessary support, information and guidance. Recognising the medication management information needs of this population is an important first step in addressing these issues.

OBJECTIVES

To identify the priorities for information on medication management expressed by people living with dementia and their carers.

METHODS

A scoping review with systematic search was conducted from inception to 12 May 2023 for any original studies that reported the information needs of people living with dementia and their carers (informal, i.e. unpaid or within an existing relationship) regarding medication management. Two authors independently screened the abstracts, full-texts and extracted data. Study characteristics were described descriptively, and themes of information need were extracted using an iterative approach.

RESULTS

Of the 11 367 records screened, 35 full-texts were included. All studies (n = 35) involved carers, with 17 also including people living with dementia. Most studies (n = 30) were conducted in the community and used qualitative methods (n = 32). Five major themes of information need were identified: critical medication information; medication effects; medication indication(s); disease progression and impact on medications; and safe and appropriate administration of medications. People living with dementia and their carers indicated they need more medication management information generally and want it simple, tailored and relevant.

CONCLUSIONS

This review highlights the key medication information priorities for people living with dementia and their carers and will help guide the provision of medication management guidance and development of new information resources.

Anti-dementia drugs: what is the evidence in advanced stages?

Dementia is a major public health concern due to its increasing prevalence, substantial caregiver burden, and high financial costs. Currently, the anti-dementia drugs aim only at a symptomatic effect. The subject of prescribing these drugs in advanced stages is a matter of considerable debate, with different countries making distinct recommendations. In this review article, we analyzed the evidence regarding cognitive and functional outcomes, adverse events, health-related costs, and caregiver burden in patients with advanced Alzheimer disease (AD) and mixed dementia. We included 35 studies. Most studies are heterogeneous, focus exclusively on AD, and show small benefits in terms of cognitive and functional scales. The overall evidence seems to suggest a benefit in introducing or maintaining anti-dementia drugs in patients with advanced dementia, but clinical meaningfulness is difficult to ascertain. The issue of costs and caregiver burden is significantly underexplored in this field but also seems to favor treatment continuation, despite a reduced overall effect. The decision of introducing or withdrawing anti-dementia drugs in advanced stages of dementia should be individualized. Future studies with homogeneous designs and outcomes are warranted.

Optimising Medication Use along Dementia Progression: Recommendations from a Qualitative Study

Medicines management is known to be an integral part of the role of family caregivers; it also contributes to the burden and stress of caregivers’ experience. As dementia progresses, new challenges arise as a consequence, which negatively affects the ability of people living with dementia (PLWD) regarding practical decision making and may lead to a change of setting. The aim of this study is to identify and explore changes in medicines management and associated caregiver burden as dementia progresses. To examine medicines management and related issues across severities, a qualitative approach utilising face-to-face and telephone interviews with PLWD and their family caregivers in both the community and care-home setting in London was used. Follow-up interviews with family caregivers were also conducted to gain additional insight into change over time. Eleven family caregivers, ten PLWD, and eight care-home staff were interviewed in 2016. Findings identified how key changes along dementia progression affect medication use. These include changes to caregiver burden, respecting the PLWD’s autonomy and decline in capacity, scheduling and administration, choice of formulation, interactions with and between providers, and information needs. The findings assist in informing recommendations to optimise medication use and alleviate caregiver burden.

Exploring stakeholder roles in medication management for people living with dementia

BACKGROUND

Therapeutic decision making, prescribing, administering and managing medications can be difficult for people with dementia.

OBJECTIVES

To explore stakeholder roles in medication management for people with dementia, including barriers and enablers to achieving those roles.

METHODS

Focus groups were held with stakeholders (consumers, general practitioners, nurses and pharmacists) from both rural and metropolitan communities in two Australian states. Focus groups were audio-recorded, transcribed and thematically analysed using an inductive approach.

RESULTS

Nine focus groups were held with 55 participants. Four major themes were identified: supporting the role of the person with dementia, carer roles and challenges, health professional roles, and process and structure barriers to medication management. Stakeholders discussed the importance of advance care planning, and the potential benefits of early implementation of dose administration aids to support patients in self-managing their medication. Carers were seen to have a vital role as patient advocates, but carer burden and changes in the patient-carer roles acted as barriers to this role. General practitioners were perceived as the main care coordinator for a person with dementia, with effective interprofessional collaboration and communication with allied health professionals and specialists further enabling optimisation of medication use. A lack of evidence, guidelines and practitioner training to guide prescribing and deprescribing decisions in people with dementia were mentioned as barriers to medication management.

CONCLUSION

Medication management is increasingly challenging for people with dementia and each stakeholder perceives that they have a different role and faces different barriers and enablers. Future research should focus on improving the evidence base to guide prescribing, facilitating stakeholder communication and ensuring early documentation of patient wishes for the future.

Does Palliative Care Utilization Facilitate Conversion to Hospice Care? A Qualitative Study of the "Soft No"

BACKGROUND

Facilitating patient conversion to hospice at end of life is a prominent clinical concern. Enrollment in outpatient palliative care services is often assumed to encourage seamless transition to hospice care, but this has not been demonstrated. Moreover, decisions to convert from palliative care to hospice are generally treated as dichotomous, thus hampering our ability to understand decision processes.

OBJECTIVE

To examine medical decision-making among patients who are prospectively evaluating whether to convert from palliative care to hospice.

DESIGN

Qualitative case study, using in-depth interviews and constant comparative method.

SETTING/PATIENTS

Terminally ill patients currently enrolled in outpatient palliative care services (N = 26) and their caregivers (N = 16), selected purposely for maximum variation in condition and personal background.

MEASUREMENTS

Themes identified in qualitative in-depth interviews.

RESULTS

Patients rarely refused hospice outright but more often postponed using a "soft no," in which they neither accepted nor overtly refused hospice. Justifications patients and caregivers offered for why hospice was not needed (yet) appeared in these themes: (1) not seeing the value added of hospice, (2) assuming the timing is premature, and (3) relying on extensive health-related support networks that justify or endorse continuation of active care.

CONCLUSIONS

Despite assumptions to the contrary, benefits associated with utilization of outpatient palliative care services have the potential to incentivize the delay of hospice in some cases. Clinical interactions with outpatient palliative care patients should consider the influence of these broad social support systems when discussing hospice options.

Caregivers' perspectives and experiences of withdrawing acetylcholinesterase inhibitors and memantine in advanced dementia: a qualitative analysis of an online discussion forum

BACKGROUND

There is considerable uncertainty surrounding the medications used to delay the progression of dementia, especially their long-term efficacy and when to withdraw treatment with these agents. Current research regarding the optimal use of antidementia medication is limited, contributing to variability in practice guidelines and in clinicians' prescribing practices. Little is currently known about the experiences encountered by caregivers of people with dementia after antidementia medication is withdrawn.

AIM

To investigate the experiences and perspectives of carers and family members when antidementia medications (cholinesterase inhibitors and/or memantine) are stopped, by analysing archived threads and posts of an online discussion forum for people affected by dementia.

METHODS

Archived discussions from Talking Point, an online discussion forum hosted by the Alzheimer's Society UK, were searched for threads discussing antidementia medication withdrawal and relevant threads were analysed thematically using the Framework method. Participant demographics were not established due to usernames which ensured anonymity.

RESULTS

Four key themes emerged: (1) expectations about withdrawal, (2) method of withdrawal, (3) clinical condition on withdrawal, and (4) the effect of withdrawal on caregivers.

CONCLUSIONS

Online discussion forums such as Talking Point provide dementia carers with an outlet to seek help, offer advice and share experiences with other members. The study findings highlight the complexity surrounding optimising dementia pharmacotherapy and antidementia medication withdrawal, highlighting the need for treatment to be person-centred and highly individualised.