Clinicians' Perspectives on Barriers and Enablers of Optimal Prescribing in Patients with Dementia and Coexisting Conditions

Abstract

Patients with dementia experience high rates of polypharmacy, potentially inappropriate medication use, and adverse drug events. There is little guidance for clinicians on how to optimize prescribing for this population. Our objective was to investigate clinician-perceived barriers to and facilitators of optimizing prescribing for people with dementia. Methods: Qualitative study involving semistructured interviews of primary care and specialist clinicians in urban, suburban, and rural settings. Transcripts were analyzed using qualitative content analysis. Results: Interviews were conducted with 12 primary care and 9 specialist clinicians, with a mean (SD) age of 47 (9) and mean (SD) of 14 (10) years in practice. Clinicians cited decisions regarding the following drug classes as particularly challenging: oral anticoagulants, antidiabetic agents, statins, bladder antimuscarinics, and antipsychotics. Perceived enablers of optimizing prescribing included access to interdisciplinary services and guidelines for nondementia illnesses (eg, diabetes) addressing the care of people with dementia. Barriers included the lack of data on efficacy and safety of most medications in people with dementia, difficulty assessing medication effects in an individual patient, and the perception that stopping medications is seen as "giving up." Clinicians used a variety of strategies to discuss risks and benefits of medications with patients and caregivers. Conclusions: Clinicians identified numerous barriers to and some facilitators of optimizing prescribing in people with dementia. More data are needed on the benefits and harms of stopping medications in this population. Research should also test different approaches for supporting informed decision making about medications by people with dementia and caregivers.

Barriers and facilitators to deprescribing in primary care: a systematic review

“…' 39 Studies described a trend towards the prescribing of medication for asymptomatic patients to prevent future morbidity and mortality, 40 and a continuation of unnecessary preventive medicine in older patients. 41,42 There was a lack of financial incentives for primary healthcare practitioners to address polypharmacy: Patients in some countries with free prescriptions (or discount cards for the costs of medications) were less likely to cease medications. 44…”

“…60 Opportunities for deprescribing were sometimes lost due to GPs' lack of direct contact with patients who receive repeat prescriptions. 57,61 GPs were reluctant to stop a medication started by another specialist in a different healthcare setting: 41,51,56 'GPs outlined challenges in terms of professional boundaries with hospital prescribers and some GPs were reportedly unwilling to challenge recommendations from secondary care ... ' 43 Uncertainties gave rise to GPs' fears over adverse effects from stopping medications, legal repercussions, and of being perceived by their patients as disengaging or not caring about them if they broached the subject of stopping medications. 41,42,47,50,56,62…”

“…39,58,69 Better continuity between primary care and other healthcare settings, and protected time were needed. 41,62 Studies also highlighted the need for access to alternative non-pharmacological options. 39,40,48 Interpersonal facilitators Improved communication between primary healthcare practitioners and their patients was a key facilitator to deprescribing.…”

Patterns of Potentially Inappropriate Bladder Antimuscarinic Use in People with Dementia: A Retrospective Cohort Study

“…Thus, they may not recognize that the patient's ED visit or hospitalization could have been due to an anticholinergicinduced adverse event. In addition, clinicians are often hesitant to discontinue medications that are being prescribed by other providers involved in the patient's care [38], or they may have incomplete information about patient drug regimens, particularly after patients transition from the hospital to the outpatient setting. For example, a previous study that found that 96% of primary-care provider medication lists contained discrepancies compared with what the patient was actually taking [39].…”

“…For example, a previous study that found that 96% of primary-care provider medication lists contained discrepancies compared with what the patient was actually taking [39]. This problem may be magnified for patients with dementia, who are often unable to give clear medication histories and may not attend visits with caregivers who are knowledgeable about their drug regimens [38]. Clinicians may also assume that serious falls and delirium are unavoidable consequences of dementia and may not connect these events to medications.…”