Factors promoting and impeding efforts to deprescribe antidepressants among nursing home residents with dementia- a process evaluation guided by normalization process theory.

BACKGROUND: Despite recommendations against psychotropic medication in older nursing homes residents with behavioral and psychological symptoms of dementia (BPSD), antidepressants and other psychotropic drugs are still prescribed. We performed a cluster-randomized controlled trial to evaluate the effect of a complex intervention aiming to promote the deprescribing of antidepressants in institutionalized older persons with dementia. To understand the underlying mechanisms of trial outcomes, we conducted a process evaluation exploring the interventions implementation, areas of impact, and contextual factors. The aim of this study was to explore the implementation process and the key factors that promoted and inhibited intervention implementation in the care home setting (Clinicaltrials.gov: NCT04985305. Registered 30 July 2021). METHODS: Qualitative interviews were conducted between August 2022 and February 2023 with four general practitioners and eight nursing home staff from four associated nursing homes in the Capital Region of Denmark. We coded the interview data according to the four constructs of the Normalization Process Theory (coherence, cognitive participation, collective action, and reflexive monitoring). RESULTS: There was a common understanding of the intervention aim. We observed a raised awareness concerning the deprescription of antidepressants among healthcare professionals with good collaboration (coherence). An overall buy-in to a deprescribing mentality was seen (cognitive participation). There were barriers to the GPs and nursing home staff's use of the intervention elements and how they implemented it, but to some, a common language was created (collective action). Professionals overall valued the idea of deprescribing, but lack of time, high staff turnover, and low education level among nursing home staff hampered the integration (reflexive monitoring). CONCLUSION: Successful implementation seemed to be dependent on the quality of the relationship between the single GP and the single nursing home professional. A common deprescribing mentality promoted the uptake of the intervention. However, several barriers related to lack of resources hindered implementation. It is imperative to adapt complex interventions to the available resources and context.

Polypharmacy and cross-sectoral collaboration.

Medication review is a pillar in the new recommendations from the Danish Health Authorities regarding patients with multimorbidity and polypharmacy. This review finds that general practitioners should be primary in coordinating medication. Medication reviews can be conducted differently with various co-interventions to try to improve cross-sectoral collaboration. It seems imperative that the interventions involve improved communication for optimal sharing and implementation of changes to the medication with primary care in a key role.

Disentangling concepts of inappropriate polypharmacy in old age: a scoping review.

INTRODUCTION: Polypharmacy is a common concern, especially in the older population. In some countries more that 50% of all individuals over 60 receive five or more drugs, most often due to multimorbidity and increased longevity. However, polypharmacy is associated with multiple adverse events, and more medication may not always be the answer. The terms "appropriate" and "inappropriate" are often used to distinguish between "much" and "too much" medications in relation to polypharmacy in research and practice, but no explicit definition exists to describe what these terms encompass. The aim of this review is to unfold the different understandings of and perspectives on (in)appropriate polypharmacy and suggest a framework for further research and practice. METHOD: A scoping review was conducted using the framework of Arksey and O'Malley and Levac et al. Pubmed, Embase, PsycINFO, CINAHL, Cochrane database, Scopus and Web of Science were searched for references in English, Danish, Norwegian and Swedish using the search string "Polypharmacy" AND "Appropriate" OR "Inappropriate". Data was extracted on author information, aims and objectives, methodology, study population and setting, country of origin, main findings and implications, and all text including the words "appropriate," "inappropriate," and "polypharmacy." Qualitative meaning condensation analysis was used and data charted using descriptive and thematic analysis. RESULTS: Of 3982 references, a total of 92 references were included in the review. Most references were from 2016-2021, from fields related to medicine or pharmacy, and occurred within primary and secondary healthcare settings. Based on the qualitative analysis, a framework were assembled consisting of Context, three domains (Standardization, Practices and Values & Concerns) and Patient Perspective. CONCLUSION: Inappropriate polypharmacy is a concept loaded by its heterogeneity and the usefulness of a single definition is doubtful. Instead, the framework suggested in this article representing different dimensions of inappropriate polypharmacy may serve as an initial strategy for focusing research and practice on polypharmacy in old age.

Tailoring a complex intervention to reduce antidepressants in institutionalized older persons with dementia.

INTRODUCTION: First-line treatment for behavioral and psychiatric symptoms of dementia is non-pharmacological. Still, psychotropic medication is widely used, despite its limited effect and harmful side-effects. More than half of all nursing home residents with dementia receive antidepressants, even though deprescribing is safe and feasible. Interventions to promote deprescribing of antidepressants in nursing homes are few and complex. To optimize the deprescribing process through an intervention, transparency for the development of the intervention is needed. We aim to describe the steps in the development and tailoring of an intervention targeting GPs, nursing home staff, and relatives to enhance collaboration on reducing the use of antidepressants in institutionalized older persons with dementia in Denmark. METHOD: A step-wise process guided by the core elements in the Medical Research Council constituted the tailoring process. Five steps were included; 1) a literature search, 2) interviews with stakeholders, 3) drafting the intervention prototype, 4) professionals' assessment of the intervention, and 5) refinement of the intervention. The steps were conducted from June 2020 to June 2022. RESULTS: Based on the literature search, interviews with stakeholders, and professionals' assessment of the intervention, four main themes were identified; 1) focusing on antidepressants, 2) importance of professional qualifications, 3) collaboration and communication, and 4) patient and relative involvement. They guided intervention development and refinement of the final intervention, which included 1) a case-based training course and 2) a dialog tool including a symptom assessment scale to be used in a structured consultation at the nursing home. CONCLUSION: This study presents a detailed account of the tailoring process for a complex intervention to optimize deprescribing of antidepressants for older persons with dementia at nursing homes. By presenting a thorough development process, we expect to achieve increased adherence to the intervention which is currently being tested in an ongoing cluster randomized controlled trial. The transparency of the process will also increase the future development of other similar complex interventions.

A cluster-randomized trial of a complex intervention to encourage deprescribing antidepressants in nursing home residents with dementia: a study protocol.

BACKGROUND: The effectiveness of psychotropic medication on behavioral and psychological symptoms of dementia (BPSD) is limited, while associated with a higher risk of adverse events. Non-pharmacological treatment of BPSD is advocated as treatment of first choice. However, many general practitioners (GPs) find it difficult to initiate deprescribing, and when attempting to discontinue psychotropic medication in nursing home residents, they face many barriers. Therefore, we hypothesize that an intervention aimed at improving communication with and involvement of nursing home staff, relatives, and patients by GPs can optimize the pharmacological treatment of BPSD. The aim is to reduce the use of antidepressants in nursing home residents with dementia without increasing morbidity or mortality. OBJECTIVE: The primary outcome is reduction of antidepressant. Secondary outcomes include difference in use of other psychotropic medication, mortality, morbidity, and severity of BPSD. METHOD: The study is a cluster-randomized controlled trial based in general practices in Denmark. We aim to include 22 practices, each of which will recruit up to 15 patients with dementia living in nursing homes. The intervention period is 3 months, and the total study period is 1 year. Randomization is 1:1 to intervention and control group by computer algorithm. Both groups receive education on BPSD and its evidence-based treatment. The intervention includes three tailored components; (1) teaching material and training to be used by the GP to educate nursing home staff on BPSD, (2) a pre-visit reflection tool to encourage nursing home staff to evaluate symptoms and reflect on relatives involvement in the discontinuation process; and (3) a dialog tool to facilitate shared decision making on optimization of BPSD treatment during the visits at the nursing home. The control group includes enhanced care as usual. The primary and secondary outcomes will be assessed at the end of the study period. A process evaluation will be conducted to assess the implementability. DISCUSSION: We anticipate that the intervention will optimize the treatment of BPSD with antidepressants for nursing homes residents and enhance compliance with reduction of medication. The process evaluation should provide insights into the barriers and facilitators to changing the current practice of deprescribing. TRIAL REGISTRATION: Clinicaltrials.gov NCT04985305 . Registered on 30 July 2021.

What Makes Deprescription of Psychotropic Drugs in Nursing Home Residents with Dementia so Challenging? A Qualitative Systematic Review of Barriers and Facilitators.

BACKGROUND: Behavioral and psychological symptoms of dementia are frequently experienced in the nursing home setting and place a substantial burden on patients, relatives, and nursing home staff. Despite guidelines recommending non-pharmacological treatments, psychotropic drugs are often prescribed to address these symptoms. This is the case despite their effects being limited, and there being a risk of side effects and adverse events for the patient. Several studies have aimed to reduce the use of psychotropic drugs, with varying results. The reasons behind these variations are not well understood. OBJECTIVES: The objective of this systematic review was to investigate which factors nursing home general practitioners and nursing home staff experience as barriers or facilitators when attempting to deprescribe psychotropic drugs in nursing home residents. METHODS: We searched PubMed, EMBASE, psycINFO, Web of Science, and CINAHL between April and September 2020. An inductive method using thematic analysis of the qualitative findings was applied for the derivation of themes. Quantitative studies were included but described descriptively and separately. RESULTS: Of 8204 unique records, 14 studies were included in the review. Of these, nine were interview or focus group studies and five were survey studies. Thematic analysis resulted in five major themes identified as either facilitators or barriers or both: (1) 'Operationality and routines'; (2) 'Lack of resources and qualifications'; (3) 'Patient-related outcomes', which points to a strong belief in negative patient-related outcomes of discontinuation and a downplay of side effects of the medication; (4) 'Policies', including support and buy-in from nursing home leadership; and (5) 'Collaboration' between physicians and nursing home staff. Themes 1 and 4 consist of facilitators. Theme 2 consists of barriers. Theme 3 and 5 consist of both facilitators and barriers. Evaluation of closed-ended questions from the surveys supported the findings. CONCLUSIONS: Deprescribing psychotropic drugs used for behavioral and psychological symptoms of dementia in nursing home residents is challenging. Resources need to be in place for deprescribing, as well as there being a focus on the positive patient-related outcomes of doing so. Managerial support, staff routines, and interprofessional collaboration are some factors facilitating the process, in addition to there being routines and systematic procedures in place allowing for operationality and a common understanding. Addressing these barriers and facilitators is necessary to ensure that deprescribing can be understood as meaningful and pursued among healthcare professionals in the nursing home setting.