Conceptualizing the Influences on Decision-Making Regarding the Prescription of Antipsychotics to Nursing Home Residents with Dementia: A Meta-Ethnography KA
1,2,3 Walsh ,
R
2 Dennehy ,
C
4 Sinnott ,
JP
2 Browne ,
S
1 Byrne ,
J
5 McSharry ,
E
2 Coughlan ,
S
3 Timmons
1Pharmaceutical
Care Research Group, School of Pharmacy, University College Cork, Ireland. 2Department of Epidemiology and Public Health, University College Cork, Ireland. 3Centre for Gerontology and Rehabilitation, University College Cork, Ireland. 4Cambridge Centre for Health Services Research, Department of Primary Care and Public Health, University of Cambridge, UK. 5School of Psychology, National University of Ireland Galway, Ireland.
[email protected]
BACKGROUND
RESULTS
• Antipsychotics are commonly prescribed to people with dementia for the management of Behavioral and Psychological Symptoms of Dementia (BPSD), despite limited effectiveness and associated harms1 • The majority of antipsychotic prescribing in people with dementia occurs in the nursing home setting, where the prevalence of antipsychotic prescribing often exceeds 40%2 • Qualitative studies have attempted to explore the reasons behind the ongoing high levels of prescribing, but to date these have not been the subject of a systematic review • Our aim was to synthesize the findings from individual qualitative studies on decision-making and prescribing behaviors for antipsychotics in nursing home residents with dementia, with a view to informing intervention development and quality improvement in this field
METHODS • We undertook a systematic review of qualitative evidence and utilized the seven-step meta-ethnographic approach to qualitative synthesis3 • An electronic literature search was conducted using the following databases from inception up to and including July 2016; Medline, PubMed, EMBASE, CINAHL, PsycINFO and Academic Search Complete, supplemented by a grey literature search (Fig. 1) • Search terms: ‘dementia’ AND ‘prescription’ AND ‘antipsychotic agents’ • We included primary qualitative (or mixed-methods) studies exploring the prescribing of antipsychotics to nursing home residents with dementia for the purpose of managing BPSD • Two reviewers independently selected papers for inclusion, extracted data and conducted quality appraisal using the Critical Appraisal Skills Programme (CASP) tool • Key concepts were developed drawing on first- (research participants’), second- (primary authors’) and third-order (review team’s) interpretations • A ‘line of argument’ was synthesized and a conceptual model constructed (Fig. 2) • PROSPERO registration number: CRD42015029141 (See QR Code on bottom right of this poster for link)
@KieranWalshMPSI @PharmCareUCC
DISCUSSION
Records identified through database searching (n = 3369)
Additional records identified through other sources (n = 54)
Records after duplicates removed (n = 1534)
Duplicates Removed (n = 1889)
Titles screened (n = 1534)
Records excluded (n = 631)
Title and Abstracts assessed for eligibility (n = 903)
Records Excluded
Full Texts assessed for eligibility (n = 103)
Records Excluded
Line of argument: The conceptual model in Figure 2 describes the process of a dysfunctional negative feedback loop where any ‘challenging behavior’ promotes either antipsychotic prescribing or a non-pharmacological intervention, or sometimes both, all with the goal of suppressing the behavior. Decision-making may be pushed towards an exclusively pharmacological solution, especially if staff feel overwhelmed. Once the behavior is suppressed, the need for an intervention is reduced. However, the fear that these behaviors may return at any time, or confusion surrounding roles and responsibilities facilitates maintenance of antipsychotic prescribing, breaking the feedback loop. The five key concepts act as the overarching influences on this decision-making process.
(n = 800)
(n = 85)
Studies included in metaethnography (n = 18)
Fig. 1. PRISMA flow diagram of search strategy results. “By jointly looking at the problems and by learning from each other…we gained more clarity, much more peace, and also had a significant decrease in prescribed medication.’’ (Physician, Smeets et al., 2014)
“[We need to] educate physicians that the use of antipsychotics are not the answers for residents with dementia.”(Risk Manager, Ellis et al., 2015)
Fear of recurrence of behaviors
Legend: Promote
Confusion surrounding roles and responsibilities
Suppress Antipsychotic Prescribing
• Antipsychotic prescribing in nursing home residents with dementia occurs in a complex environment involving the interplay of various stakeholders, the nursing home organization and external influences • Five key concepts emerged as influencing decisionmaking: Organizational Capacity; Individual Professional Capability; Communication and Collaboration; Attitudes and Regulations and Guidelines • The conceptualization of decision-making as a dysfunctional negative feedback loop with the ultimate aim of controlling residents, challenges us in the way we perceive dementia and behaviors • Our synthesis indicates that when all stakeholders come together to communicate and collaborate as equal and empowered partners, this can result in a successful reduction in inappropriate antipsychotic prescribing • We argue that a holistic, person-centered approach to behavior change is required, involving both the prescribers and requesters of antipsychotics • More research is required, focusing on how best to sustainably change the prescribing behaviors identified
REFERENCES: “Regulations and expectations around culture change are driving forces in the nursing home, setting the standard for quality of care.” (Authors, Kolanowski et al., 2009)
1. Barnes TR, Banerjee S, Collins N, Treloar A, McIntyre SM, Paton C. Antipsychotics in dementia: prevalence and quality of antipsychotic drug prescribing in UK mental health services. The British Journal of Psychiatry 2012; 201: 221-6. 2. Janus SI, van Manen JG, IJzerman MJ, Zuidema SU. Psychotropic drug prescriptions in Western European nursing homes. International Psychogeriatrics 2016; 1-16. 3. Noblit GW, Hare RD. Meta-ethnography: Synthesizing qualitative studies. Sage, 1988 References for papers included in the systematic review are available on request
“Challenging Behavior”
The manuscript for this research has been accepted for publication in Journal of the American Medical Directors Association (JAMDA) as of June 30th 2017
ACKNOWLEDGEMENTS:
NonPharmacological Intervention
“We [nurses] are pro medicine, we are very medicine prone. Take a pill that makes it [agitation] better.’’ (Nurse, Janzen et al., 2013)
Stimulus (Resident)
Response Behaviors (Staff)
ORGANIZATIONAL CAPACITY
“If you go to do some work with proper challenging behaviour then it’s a lot of man power… and in some ways when resources are limited it’s actually cheaper to just get me in, prescribe some medication for somebody.” (Psychiatrist, Wood-Mitchell et al., 2008)
(Resources and access to services; Coping with the severity of behaviors)
Fig.2. Conceptual Model of the Influences on Decision-Making Regarding Antipsychotic Prescribing in Nursing Home Residents with Dementia. Key concepts are in shown in CAPITALS; sub-themes are in (italics) beneath the relevant key concept; and specific factors influencing response behaviors are in blue circles. Illustrative first- and second-order interpretations are shown in green speech bubbles.
This research was funded by the Health Research Board and the Atlantic Philanthropies, and was conducted as part of the SPHeRE Programme under Grant No. SPHeRE/2013/1. CS is funded, through a clinical lectureship, by the National Institute for Health Research, School for Primary Care Research (NIHR SPCR).
