Abstract
Objectives
Caution is advised when prescribing antipsychotics to people with dementia. This study
explored the determinants of appropriate, evidence-based antipsychotic prescribing
behaviors for nursing home residents with dementia, with a view to informing future
quality improvement efforts and behavior change interventions.
Design
Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF).
Setting and Participants
A purposive sample of 27 participants from 4 nursing homes, involved in the care of
nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare
assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant
psychiatrists of old age) in a Southern region of Ireland.
Measures
Using framework analysis, the predominant TDF domains and determinants influencing
these behaviors were identified, and explanatory themes developed.
Results
Nine predominant TDF domains were identified as influencing appropriate antipsychotic
prescribing behaviors. Participants’ effort to achieve “a fine balance” between the
risks and benefits of antipsychotics was identified as the cross-cutting theme that
underpinned many of the behavioral determinants. On one hand, neither healthcare workers
nor family members wanted to see residents over-sedated and without a quality of life.
Conversely, the reality of needing to protect staff, family members, and residents
from potentially dangerous behavioral symptoms, in a resource-poor environment, was
emphasized. The implementation of best-practice guidelines was illustrated through
3 explanatory themes (“human suffering”; “the interface between resident and nursing
home”; and “power and knowledge: complex stakeholder dynamics”), which conceptualize
how different nursing homes strike this “fine balance.”
Conclusions
Implementing evidence-based antipsychotic prescribing practices for nursing home residents
with dementia remains a significant challenge. Greater policy and institutional support
is required to help stakeholders strike that “fine balance” and ultimately make better
prescribing decisions. This study has generated a deeper understanding of this complex
issue and will inform the development of an evidence-based intervention.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia.Am J Psychiatry. 2016; 173: 543-546
- Dementia: Assessment, management and support for people living with dementia and their carers.(2018. Available at:)
- Antipsychotics, other psychotropics, and the risk of death in patients with dementia: Number needed to harm.JAMA Psychiatry. 2015; 72: 438-445
- Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials.JAMA. 2005; 294: 1934-1943
- Antipsychotics and the risk of cerebrovascular accident: A systematic review and meta-analysis of observational studies.J Am Med Dir Assoc. 2017; 18: 692-699
- Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: An observational study in English institutions over a 4-year period.BMJ Open. 2016; 6: e009882
- Psychotropic drug prescriptions in Western European nursing homes.Int Psychogeriatr. 2016; 28: 1775-1790
- More action needed: Psychotropic prescribing in Australian residential aged care.Aust N Z J Psychiatry. 2018; (0004867418758919)
- Reducing excessive use of antipsychotic agents in nursing homes.JAMA. 2017; 318: 118-119
- Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: A systematic review.J Am Med Dir Assoc. 2014; 15: 706-718
- A 12-month follow-up study of “RedUSe”: A trial aimed at reducing antipsychotic and benzodiazepine use in nursing homes.Int Psychogeriatr. 2011; 23: 1260-1269
- Effect of an interdisciplinary educational program on antipsychotic prescribing among residents with dementia in two long-term care centers.J Appl Gerontol. 2013; 32: 833-854
- The Behaviour Change Wheel: A Guide to Designing Interventions.Silverback Publishing, London, United Kingdom2014
- Influences on decision-making regarding antipsychotic prescribing in nursing home residents with dementia: A systematic review and synthesis of qualitative evidence.J Am Med Dir Assoc. 2017; 18: 897.e
- Validation of the theoretical domains framework for use in behaviour change and implementation research.Implement Sci. 2012; 7: 37
- A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems.Implement Sci. 2017; 12: 77
- Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups.Int J Qual Health care. 2007; 19: 349-357
- Patterns of psychotropic prescribing and polypharmacy in older hospitalized patients in Ireland: The influence of dementia on prescribing.Int Psychogeriatr. 2016; 28: 1807-1820
- Where are antipsychotics prescribed in nursing homes initiated?.J Am Geriatr Soc. 2018; 66: 1082-1088
- Health Information and Quality Authority (HIQA).(2016. Available at:)
- Nursing Home Ireland.(2016. Available at:)
- What is an adequate sample size? Operationalising data saturation for theory-based interview studies.Psychol Health. 2010; 25: 1229-1245
- Carrying out qualitative analysis.in: Ritchie J. Lewis J. Qualitative research practice: A guide for social science students and researchers. Sage, London, United Kingdom2003: 219-262
QSR International Pty Ltd. NVivo Qualitative Data Analysis Software version 11. 2017.
Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013, Irish Statute Book, 2013.
- Antipsychotic drug prescribing in nursing homes.JAMA. 2017; 318: 1829
- Antibiotic prescribing in long-term care facilities: A qualitative, multidisciplinary investigation.BMJ Open. 2014; 4: e006442
- Improving appropriate polypharmacy for older people in primary care: Selecting components of an evidence-based intervention to target prescribing and dispensing.Implementation Science. 2015; 10: 161
- Doctors' perspectives on the barriers to appropriate prescribing in older hospitalized patients: A qualitative study.Br J Clin Pharmacol. 2015; 79: 860-869
- GPs' perspectives on prescribing for older people in primary care: A qualitative study.Br J Clini Pharmacol. 2017; 83: 1521-1531
- Using theory to explore facilitators and barriers to delayed prescribing in Australia: A qualitative study using the theoretical domains framework and the behaviour change wheel.BMC Fam Pract. 2017; 18: 20
- Behavioural and psychological symptoms in dementia and the challenges for family carers: Systematic review.Br J Psychiatry. 2016; 208: 429-439
- Nursing home staff attitudes towards residents with dementia: Strain and satisfaction with work.J Adv Nurs. 2003; 44: 583-590
- Power/Knowledge: Selected Interviews and Other Writings, 1972-1977.Pantheon, New York, NY1980
- Oral medicine modification for older adults: A qualitative study of nurses.BMJ Open. 2017; 7: e018151
- Having a voice and being heard: Nursing home residents and in-house advocacy.J Gerontol Nurs. 2008; 34: 34-42
- ‘Working away in that Grey Area…’A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia.Age Ageing. 2018; 47: 295-303
- “We’re certainly not in our comfort zone”: A qualitative study of GPs’ dementia-care educational needs.BMC Fam Pract. 2017; 18: 66
- General practitioners’ knowledge, attitudes and experiences of managing behavioural and psychological symptoms of dementia: A mixed methods systematic review.Int J Geriatr Psychiatry. 2018; 33: 1163-1176
- The Irish national dementia strategy 2014.(Available at:)http://health.gov.ie/blog/publications/the-irish-national-dementia-strategy/Date accessed: June 18, 2018
- Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review.BMC Geriatr. 2017; 17: 32
- Is dementia special care really special? A new look at an old question.J Am Geriatr Soc. 2008; 56: 199-205
- Relationship between organizational culture and the use of psychotropic medicines in nursing homes: A systematic integrative review.Drugs Aging. 2018; 35: 189-211
- Impact of antipsychotic review and non-pharmacological intervention on health-related quality of life in people with dementia living in care homes: WHELD—a factorial cluster randomised controlled trial.Int J Geriatr Psychiatry. 2017; 32: 1094-1103
- Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel.J Am Geriatr Soc. 2014; 62: 762-769
- Assessment and management of behavioral and psychological symptoms of dementia.BMJ. 2015; 350: h369
- Association of a communication training program with use of antipsychotics in nursing homes.JAMA Intern Med. 2017; 177: 846-853
- Antipsychotic deprescription for older adults in long-term care: The HALT study.J Am Med Dir Assoc. 2018; 19: 592-600.e7
- Strategies for ensuring trustworthiness in qualitative research projects.Educ Iinform. 2004; 22: 63-75
- Pain in care home residents with dementia: An exploration of frequency, prescribing and relatives' perspectives.Int J Geriatr Psychiatry. 2015; 30: 55-63
References
- Carrying out qualitative analysis.in: Ritchie J. Lewis J. Qualitative Research Practice: A Guide for Social Science Students and Researchers. Sage, Los Angeles, CA2003: 219-262
QSR International Pty Ltd. NVivo Qualitative Data Analysis Software version 11, 2017.
- A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems.Implementation Sci. 2017; 12: 77
- What is an adequate sample size? Operationalising data saturation for theory-based interview studies.Psychol Health. 2010; 25: 1229-1245
Article info
Publication history
Published online: September 18, 2018
Footnotes
KW is funded by the Health Research Board (Ireland) and Atlantic Philanthropies, a limited life foundation, and this research was conducted as part of the SPHeRE Program under Grant No. SPHeRE/2013/1. CS is funded, through a clinical lectureship, by the National Institute for Health Research UK, School for Primary Care Research (NIHR SPCR).
The investigators were solely responsible for the design, methods, subject recruitment, data collections, analysis and preparation of paper and the funding sources did not participate in this process.
The authors declare no conflicts of interest.
Identification
Copyright
© 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
