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Chenoweth L. Supporting shared decision-making in medicines use with people living with dementia and their carers. Nurs Older People 2024:e1458. [PMID: 38263893 DOI: 10.7748/nop.2024.e1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 01/25/2024]
Abstract
Polypharmacy and inappropriate prescribing of psychotropic medicines are common among people living with dementia and pose considerable health risks. One way of addressing these issues is by involving the person and their carer in shared decision-making. This article discusses some of the issues related to polypharmacy and inappropriate prescribing in people living with dementia and examines the concept of shared decision-making in this context. The author details some practical aids that nurses and other healthcare professionals can use to engage people living with dementia and their carers in shared decision-making about medicines use.
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Affiliation(s)
- Lynn Chenoweth
- School of Clinical Medicine, Centre for Healthy Brain Ageing, University of New South Wales, Kennington, NSW, Australia
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Mattos MK, Gibson JS, Wilson D, Jepson L, Ahn S, Williams IC. Shared decision-making in persons living with dementia: A scoping review. DEMENTIA 2023; 22:875-909. [PMID: 36802973 PMCID: PMC10866150 DOI: 10.1177/14713012231156976] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Evidence supports that older adults with cognitive impairment can reliably communicate their values and choices, even as cognition may decline. Shared decision-making, including the patient, family members, and healthcare providers, is critical to patient-centered care. The aim of this scoping review was to synthesize what is known about shared decision-making in persons living with dementia. A scoping review was completed in PubMed, CINAHL, and Web of Science. Keywords included content areas of dementia and shared decision-making. Inclusion criteria were as follows: description of shared or cooperative decision making, cognitively impaired patient population, adult patient, and original research. Review articles were excluded, as well as those for which the formal healthcare provider was the only team member involved in the decision-making (e.g., physician), and/or the patient sample was not cognitively impaired. Systematically extracted data were organized in a table, compared, and synthesized. The search yielded 263 non-duplicate articles that were screened by title and abstract. Ninety-three articles remained, and the full text was reviewed; 32 articles were eligible for this review. Studies were from across Europe (n = 23), North America (n = 7), and Australia (n = 2). The majority of the articles used a qualitative study design, and 10 used a quantitative study design. Categories of similar shared decision-making topics emerged, including health promotion, end-of-life, advanced care planning, and housing decisions. The majority of articles focused on shared decision-making regarding health promotion for the patient (n = 16). Findings illustrate that shared decision-making requires deliberate effort and is preferred among family members, healthcare providers, and patients with dementia. Future research should include more robust efficacy testing of decision-making tools, incorporation of evidence-based shared decisionmaking approaches based on cognitive status/diagnosis, and consideration of geographical/cultural differences in healthcare delivery systems.
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Affiliation(s)
| | | | - Dan Wilson
- Health Sciences Library, 2358University of Virginia, USA
| | - Laura Jepson
- School of Nursing, 2358University of Virginia, USA
| | - Soojung Ahn
- School of Nursing, Vanderbilt University, USA
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Kurmyshev MV, Pak MV, Savilov VB. [Dynamics of cognitive functions in elderly and old people after completing a comprehensive neurocognitive rehabilitation program]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:113-116. [PMID: 34874665 DOI: 10.17116/jnevro2021121101113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the differences in the dynamics of cognitive functions in the elderly and old people during a comprehensive neurocognitive rehabilitation program with- and without drug therapy. MATERIAL AND METHODS Ninety-six patients, aged 53-88 years, with cognitive impairment of varying degrees are divided into two groups depending on the presence/absence of drug therapy during the neurocognitive rehabilitation program. Assessment of cognitive functions was carried out twice: at the beginning and at the end of the rehabilitation program using international cognitive status assessment scales (MMSE and MoCA). RESULTS The analysis of the dynamics of cognitive functions revealed the high efficiency of the neurocognitive rehabilitation program in both groups. The results of the study demonstrate insignificant differences in the dynamics of cognitive functions in the two groups, however, a clear direct effect of drug therapy on changes in cognitive functions has not been established. An analysis of the statistical significance of the data did not reveal differences. CONCLUSIONS The study confirmed the positive dynamics of cognitive functions in the elderly and old people who underwent the neurocognitive rehabilitation program both with the use of drug therapy and without its use. The issue of the need to use drugs in the framework of this program requires further study. The results of the study can be used in planning programs of psychological, medical and social support for the elderly and old people.
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Affiliation(s)
- M V Kurmyshev
- Alexeev Clinical Psychiatric Hospital No. 1 Moscow City Health Department, Moscow, Russia
| | - M V Pak
- Alexeev Clinical Psychiatric Hospital No. 1 Moscow City Health Department, Moscow, Russia
| | - V B Savilov
- Alexeev Clinical Psychiatric Hospital No. 1 Moscow City Health Department, Moscow, Russia
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Barry HE, Hughes CM. An Update on Medication Use in Older Adults: a Narrative Review. CURR EPIDEMIOL REP 2021; 8:108-115. [PMID: 34306966 PMCID: PMC8294219 DOI: 10.1007/s40471-021-00274-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The global phenomenon of population aging is impacting the health and care needs of society. The use of medications by older adults is acknowledged to be the most common form of medical intervention for many acute and chronic conditions and prescribing in this population continues to increase. In this narrative review, we summarise the age-related factors that should be considered when prescribing for older adults, address some of the perennial challenges related to medicine use in older people, and highlight important emerging research in this area. RECENT FINDINGS A range of age-related factors should be considered when prescribing for older adults. However, the evidence base still lacks data pertaining to older adults due to their continued under-representation in clinical trials. Multimorbidity, polypharmacy, and inappropriate prescribing continue to remain prevalent among older adults, although recent research has been focused on the development and evaluation of complex interventions to address these challenges. SUMMARY Further high-quality studies of interventions to improve and support medication use in older adults are needed, ensuring that older adults are well represented in such trials and consideration is given to the measurement of patient- and provider-focused outcomes.
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Affiliation(s)
- Heather E. Barry
- Primary Care Research Group, School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL UK
| | - Carmel M. Hughes
- Primary Care Research Group, School of Pharmacy, Queen’s University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL UK
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Ford J, Thomas F, Byng R, McCabe R. Asking about self-harm and suicide in primary care: Moral and practical dimensions. PATIENT EDUCATION AND COUNSELING 2021; 104:826-835. [PMID: 33162274 DOI: 10.1016/j.pec.2020.09.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 09/23/2020] [Accepted: 09/30/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Self-harm and suicide are important topics to discuss with people experiencing mental health conditions. This study explores how such discussions unfold in practice, and how their moral and practical repercussions manifest for patients and doctors. METHODS Conversation analysis (CA) was used to examine 20 recorded examples of doctors' questions about self-harm and suicide and their ensuing discussions with patients. RESULTS A tendency to frame questions about self-harm towards a 'no' response, to amalgamate questions around self-harm and suicide, and to limit dialogue around the protective factors offered by family and friends restricted discussion of patients' experiences and concerns. Closed questions about thoughts and actions in the context of risk assessment resulted in missed opportunities to validate distressing thoughts. Patients responding affirmatively often did so in a way that distanced themselves from the negative stigma associated with suicide. CONCLUSION The wording of questions, along with negative stigma, can make it difficult for patients to talk about self-harm. PRACTICE IMPLICATIONS Discussions could be improved by asking about self-harm and suicide separately, encouraging discussion when responses are ambiguous and validating distressing thoughts. Negative stigma could be countered by exploring patients' positive reasons for wanting to stay alive.
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Affiliation(s)
- Joseph Ford
- College of Medicine and Health, University of Exeter, UK.
| | | | | | - Rose McCabe
- School of Health Sciences, City University of London, UK.
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Dooley J, Booker M, Barnes R, Xanthopoulou P. Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences. BMJ Open 2020; 10:e037673. [PMID: 32938596 PMCID: PMC7497532 DOI: 10.1136/bmjopen-2020-037673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/22/2020] [Accepted: 07/08/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals. DESIGN Scoping review. The search strategy and data synthesis were informed by people with dementia and carers. DATA SOURCES Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019. ELIGIBILITY CRITERIA Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion. DATA EXTRACTION AND SYNTHESIS Data were extracted using charting techniques and findings were synthesised according to content and themes. RESULTS Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress. CONCLUSIONS The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.
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Affiliation(s)
- Jemima Dooley
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Matthew Booker
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
| | - Rebecca Barnes
- Centre for Academic Primary Care, School for Social and Community Medicine, Bristol University, Bristol, UK
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Sheehan R, Hassiotis A, Strydom A, Morant N. Experiences of psychotropic medication use and decision-making for adults with intellectual disability: a multistakeholder qualitative study in the UK. BMJ Open 2019; 9:e032861. [PMID: 31780594 PMCID: PMC6887070 DOI: 10.1136/bmjopen-2019-032861] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Understanding patient and carer perspectives is essential to improving the quality of medication prescribing. This study aimed to explore experiences of psychotropic medication use among people with intellectual disability (ID) and their carers, with a focus on how medication decisions are made. DESIGN Thematic analysis of data collected in individual semistructured interviews. PARTICIPANTS AND SETTING Fourteen adults with ID, 12 family carers and 12 paid carers were recruited from specialist psychiatry services, community groups, care providers and training organisations in the UK. RESULTS People with ID reported being highly compliant with psychotropic medication, based on a largely unquestioned view of medication as important and necessary, and belief in the authority of the psychiatrist. Though they sometimes experienced medication negatively, they were generally not aware of their right to be involved in medication decisions. Paid and family carers reported undertaking a number of medication-related activities. Their 'front-line' status and longevity of relationships meant that carers felt they possessed important forms of knowledge relevant to medication decisions. Both groups of carers valued decision-making in which they felt they had a voice and a genuine role. While some in each group described making joint decisions about medication with psychiatrists, lack of involvement was often described. This took three forms in participants' accounts: being uninformed of important facts, insufficiently included in discussions and lacking influence to shape decisions. Participants described efforts to democratise the decision-making process by gathering information, acting to disrupt perceived power asymmetries and attempting to prove their credibility as valid decision-making partners. CONCLUSIONS Stakeholder involvement is a key element of medication optimisation that is not always experienced in decisions about psychotropic medication for people with ID. Forms of shared decision-making could be developed to promote collaboration and offer people with ID and their carers greater involvement in medication decisions.
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Affiliation(s)
- Rory Sheehan
- Division of Psychiatry, University College London, London, UK
| | | | - André Strydom
- Department of Forensic and Neurodevelopmental Science, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Nicola Morant
- Division of Psychiatry, University College London, London, UK
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Ford J, Thomas F, Byng R, McCabe R. Exploring how patients respond to GP recommendations for mental health treatment: an analysis of communication in primary care consultations. BJGP Open 2019; 3:bjgpopen19X101670. [PMID: 31662317 PMCID: PMC6995855 DOI: 10.3399/bjgpopen19x101670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Patient take-up and adherence to antidepressants and talking therapy is low. However, little is known about how GPs recommend these treatments and whether patients accept them. AIM To examine how GPs recommend antidepressants and talking therapy, and how patients respond. DESIGN & SETTING A total of 52 recorded primary care consultations for depression, anxiety, and stress were analysed. METHOD Using a standardised coding scheme, five ways doctors recommend treatment were coded, conveying varying authority and endorsement. The treatment recommendation types were as follows: more directive pronouncements (I'll start you on X); proposals (How about we start X?); less directive suggestions (Would you like to try X?); offers (Do you want me to give you X?); and assertions (There are medications that might help). It was also coded whether patients accepted, passively resisted (for example, withholding response), or actively resisted (for example, I've tried that before). RESULTS A total of 33 recommendations occurred in 23 consultations. In two-thirds of cases, GPs treated the patient as primary decision-maker by using suggestions, offers, or assertions. In one-third of cases, they used more directive pronouncements or proposals. GPs endorsed treatment moderately (67%), weakly (18%), or strongly (15%). Only one-quarter of recommendations were accepted immediately. Patients cited fears about medication side effects and/or dependency, group therapy, and doubts about treatment efficacy. Despite three-quarters of patients resisting, 76% got prescriptions or self-referral information for talking therapy. CONCLUSION Initially, GPs treat patients as the decision-maker. However, although patients resist, most end up with treatment. This may impact negatively on treatment uptake and success. Social prescribing may fill a treatment gap for some patients.
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Affiliation(s)
- Joseph Ford
- Postdoctoral Research Associate, College of Medicine and Health, University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Felicity Thomas
- Senior Research Fellow, College of Medicine and Health, University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Richard Byng
- Professor of Primary Care Research, Community and Primary Care Research Group, University of Plymouth, Faculty of Medicine and Dentistry, Plymouth Science Park, Plymouth, UK
| | - Rose McCabe
- Professor of Clinical Communication, School of Health Sciences, City, University of London, London, UK
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