Influences on Decision-Making Regarding Antipsychotic Prescribing in Nursing Home Residents With Dementia: A Systematic Review and Synthesis of Qualitative Evidence

Walsh, Kieran; Dennehy, Rebecca; Sinnott, Carol; Browne, John; Byrne, Stephen; McSharry, Jennifer; Coughlan, Eoin; Timmons, Suzanne

doi:10.1016/j.jamda.2017.06.032

Cited by 40 publications

(57 citation statements)

References 63 publications

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“…They were perceived to improve the quality of life of people with BPSD and enabled everyone, including the GP, to cope with the constraints imposed by insufficient resources. A recent systematic review examined the influences on decision‐making on antipsychotic prescribing in nursing home residents and found that that to circumvent the problems of inadequate resourcing antipsychotics were “used” as cheap, fast, and effective staff members . In this current review, the benefits of antipsychotics were often over‐estimated and their potential harmful side‐effects were sometimes overlooked because these side effects were perceived to relate to longevity of life rather than quality of life.…”

Section: Discussionmentioning

confidence: 99%

“…In this current review, the benefits of antipsychotics were often over‐estimated and their potential harmful side‐effects were sometimes overlooked because these side effects were perceived to relate to longevity of life rather than quality of life. Similarly, the systematic review on prescribing influences in nursing home residents found that inadequate knowledge of the risks and benefits of antipsychotic prescribing in dementia enabled inappropriate prescribing . However, the benefit of antipsychotics in BPSD is minimal and many of the side effects, such as extrapyramidal symptoms and sedation, occur in the short term.…”

Section: Discussionmentioning

confidence: 99%

“…A recent systematic review examined the influences on decision-making on antipsychotic prescribing in nursing home residents and found that that to circumvent the problems of inadequate resourcing antipsychotics were "used" as cheap, fast, and effective staff members. 65 In this current review, the benefits of antipsychotics were often over-estimated and their potential harmful side-effects were sometimes overlooked because these side effects were perceived to relate to longevity of life Low confidence Substantial concerns regarding adequacy and minor concerns regarding methodological limitations and relevance.…”

Section: Comparison With Previous Researchmentioning

confidence: 99%

“…Similarly, the systematic review on prescribing influences in nursing home residents found that inadequate knowledge of the risks and benefits of antipsychotic prescribing in dementia enabled inappropriate prescribing. 65 However, the benefit of antipsychotics in BPSD is minimal 26 and many of the side effects, such as extrapyramidal symptoms and sedation, occur in the short term. General practitioners' concern that discontinuation of antipsychotics will lead to a re-emergence of BPSD is also challenged by current evidence that suggests that for most people with Alzheimer's type dementia, antipsychotic discontinuation has no detrimental effect on cognition or functional status.…”

Section: Comparison With Previous Researchmentioning

confidence: 99%

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General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed‐methods systematic review

Jennings

Foley

Walsh

et al. 2018

Int J Geriat Psychiatry

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ObjectivesTo synthesise the existing published literature on general practitioners (GP)'s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions.MethodsWe conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs' experiences of managing BPSD (PROSPERO protocol registration CRD42017054916). Seven electronic databases were searched from inception to October 2017. Each stage of the review process involved at least 2 authors working independently. The meta‐ethnographic approach was used to synthesise the findings of the included studies while preserving the context of the primary data. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to assess the confidence in our individual review findings.ResultsOf the 1638 articles identified, 76 full texts were reviewed and 11 were included. Three main concepts specific to GPs' experiences of managing BPSD emerged: unmet primary care resource needs, justification of antipsychotic prescribing, and the pivotal role of families. A “line of argument” was drawn, which described how in the context of resource limitations a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached.ConclusionThis systematic review offers new insights into GPs' perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Comparison With Previous Researchmentioning

confidence: 99%

Section: Comparison With Previous Researchmentioning

confidence: 99%

See 2 more Smart Citations

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed‐methods systematic review

Jennings

Foley

Walsh

et al. 2018

Int J Geriat Psychiatry

Self Cite

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“…On the other hand, non-pharmacologic treatment strategies have shown to improve NPS without the complicated side effect profile of medications. It is important to recognize that lack of training of caregivers, poor person-centered care, understaffing of healthcare centers, and lack of understanding of the natural progression of dementia can lead to inadequate assessment of NPS, poor implementation of non-pharmacologic strategies, as well as the overuse of pharmacologic agents (especially antipsychotics) [90]. In addition to increased availability and easy implementation of non-pharmacologic measures, consideration of deprescribing can result in improvement of NPS in elderly patients with dementia.…”

Section: Deprescribingmentioning

confidence: 99%

Management of Neuropsychiatric Symptoms of Dementia: A Comprehensive Review of the Current Literature

Suarez¹,

Shafi²,

Lapid³

2019

obm geriatr

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Background: Dementia is a progressive and debilitating condition that affects millions of patients in the United States with an enormous impact on healthcare costs, caregivers, and society. Patients with dementia often experience dementia-related neuropsychiatric disturbances, commonly known as Behavioral and Psychological Symptoms of Dementia (BPSD) and more recently Neuropsychiatric symptoms (NPS) in dementia. These symptoms include verbal and physical agitation, aggression, disinhibition, affect lability, apathy, psychosis, depression, and anxiety. Symptom management is important to optimize quality of life, minimize further functional decline, and delay institutionalization. We aim to review the existing published literature on pharmacologic and non-pharmacologic management of NPS. Methods: PubMed, Google Scholar, and Cochrane were searched for available reviews, systematic reviews, meta-analysis, and randomized controlled trials on diagnostic tools and treatment strategies for NPS. Some of the searched terms used included, "neuropsychiatric symptoms of dementia treatment," "NPS treatment," "pharmacologic treatment NPS," "non-pharmacologic treatment NPS," "scales NPS." We also searched for the term "BPSD" instead of "NPS" and "neurocognitive disorder" instead of "dementia." Recent Findings: There are different treatment modalities to address NPS, including pharmacologic and non-pharmacologic approaches, but the evidence throughout the years has been controversial and mostly studied in Alzheimer's disease population making less generalizable to other dementia populations. Summary: NPS continues to be a prevalent and debilitating condition in the elderly population with dementia. Non-pharmacologic strategies continue to be the first-line treatment for NPS despite lack of strong evidence because of their potential benefit and absence of side effects. Conversely, pharmacologic strategies have a potential risk for side effects in addition to the lack of strong evidence about their benefits in NPS; therefore, deprescribing is an important consideration in the management of these patients.

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Physician Antipsychotic Overprescribing Letters and Cognitive, Behavioral, and Physical Health Outcomes Among People With Dementia

Harnisch,

Barnett,

Coussens

et al. 2024

JAMA Netw Open

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ImportanceAntipsychotics, such as quetiapine, are frequently prescribed to people with dementia to address behavioral symptoms but can also cause harm in this population.ObjectiveTo determine whether warning letters to high prescribers of quetiapine can successfully reduce its use among patients with dementia and to investigate the impacts on patients’ health outcomes.Design, Setting, and ParticipantsThis is a secondary analysis of a randomized clinical trial of overprescribing letters that began in April 2015 and included the highest-volume primary care physician (PCP) prescribers of quetiapine in original Medicare. Outcomes of patients with dementia were analyzed in repeated 90-day cross-sections through December 2018. Analyses were conducted from September 2021 to February 2024.InterventionsPCPs were randomized to a placebo letter or 3 overprescribing warning letters stating that their prescribing of quetiapine was high and under review by Medicare.Main Outcomes and MeasuresThe primary outcome of this analysis was patients’ total quetiapine use in days per 90-day period (the original trial primary outcome was total quetiapine prescribing by study PCPs). Prespecified secondary outcomes included measures of cognitive function and behavioral symptoms from nursing home assessments, indicators of depression from screening questionnaires in assessments and diagnoses in claims, metabolic diagnoses derived from assessments and claims, indicators of use of the hospital and other health care services, and death. Outcomes were analyzed separately for patients living in nursing homes and in the community.ResultsOf the 5055 study PCPs, 2528 were randomized to the placebo letter, and 2527 were randomized to the 3 warning letters. A total of 84 881 patients with dementia living in nursing homes and 261 288 community-dwelling patients with dementia were attributed to these PCPs. There were 92 874 baseline patients (mean [SD] age, 81.5 [10.5] years; 64 242 female [69.2%]). The intervention reduced quetiapine use among both nursing home patients (adjusted difference, –0.7 days; 95% CI, −1.3 to −0.1 days; P = .02) and community-dwelling patients (adjusted difference, −1.5 days; 95% CI, −1.8 to −1.1 days; P &lt; .001). There were no detected adverse effects on cognitive function (cognitive function scale adjusted difference, 0.01; 95% CI, −0.01 to 0.03; P = .19), behavioral symptoms (agitated or reactive behavior adjusted difference, −0.2%; 95% CI −1.2% to 0.8% percentage points; P = .72), depression, metabolic diagnoses, or more severe outcomes, including hospitalization and death.Conclusions and RelevanceThis study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia. This intervention and others like it may be useful for future efforts to promote guideline-concordant care.Trial RegistrationClinicalTrials.gov Identifier: NCT05172687

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Influences on Decision-Making Regarding Antipsychotic Prescribing in Nursing Home Residents With Dementia: A Systematic Review and Synthesis of Qualitative Evidence

Cited by 40 publications

References 63 publications

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed‐methods systematic review

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed‐methods systematic review

Management of Neuropsychiatric Symptoms of Dementia: A Comprehensive Review of the Current Literature

Physician Antipsychotic Overprescribing Letters and Cognitive, Behavioral, and Physical Health Outcomes Among People With Dementia

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