Deprescribing Antipsychotics Based on Real-World Evidence to Inform Clinical Practice: Safety Considerations in Managing Older Adults with Dementia

Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review

INTRODUCTION

We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers.

METHODS

We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings.

RESULTS

Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life.

DISCUSSION

Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.

Why psychiatry needs an honest dose of gentle medicine

The pharmaceutical industry's influence on psychiatric research and practice has been profound and has resulted in exaggerated claims of the effectiveness of psychotropic medications and an under-reporting of harms. After the regulatory approval of fluoxetine, the pharmaceutical industry began promoting (and continues to promote) a chemical imbalance theory of emotional distress. In the last decade, there has been an increased awareness about the limits of this theory and the risks of psychotropic medications. Nonetheless, the medicalization of distress, the sedimented belief in "magic bullets," and the push to "scale up" mental health treatment have contributed to the meteoric rise in the prescription of psychiatric drugs and of polypharmacy. A major premise of this paper is that the conceptual framework of medical nihilism can help researchers and clinicians understand and address the harms incurred by inflated claims of the efficacy of psychotropic medications. We propose that psychiatry, and the mental health field more generally, adopt a model of 'gentle medicine' with regard to both the diagnosis of and treatment for mental health conditions and focus greater attention on the upstream causes of distress.

Characteristics of frequent users of emergency departments living with major neurocognitive disorders: a cohort study

Objective: This study aimed to describe and compare the characteristics of community-dwelling older adults living with or without major neurocognitive disorders who made frequent use of emergency departments. Methods: This is a retrospective cohort study based on a secondary analysis of provincial health administrative data in Quebec, Canada. We included community-dwelling older adults from Quebec who were considered frequent emergency department users (a minimum of 4 visits in the year following an index emergency department visit chosen randomly between January 1, 2012, and December 31, 2013) and who had been diagnosed with at least one chronic condition. We compared characteristics of frequent users living with or without major neurocognitive disorders using chi-square and Kruskal-Wallis tests. Results: The study cohort consisted of 21 393 frequent emergency department users, of which 3051 (14.26%) were identified as having a major neurocognitive disorder. The results highlight a higher burden of chronic conditions, polypharmacy, antipsychotic use, and past use of healthcare services among these individuals. The results also reveal a higher proportion of conditions associated with geriatric syndromes such as trauma and injury, malnutrition, orthostatic hypertension, and gait disorders. Conclusion: Frequent emergency department users living with major neurocognitive disorders represent a complex population. Our results highlight the importance of systematically addressing their needs in appropriate settings and through customized interventions.