Barriers and enablers for deprescribing benzodiazepine receptor agonists in older adults: a systematic review of qualitative and quantitative studies using the theoretical domains framework

Abstract

Background Many strategies aimed at deprescribing benzodiazepine receptor agonists (BZRA) in older adults have already been evaluated with various success rates. There is so far no consensus on which strategy components increase deprescribing the most. Yet, despite an unfavourable benefit-to-risk ratio, BZRA use among older adults remains high. We systematically reviewed barriers and enablers for BZRA deprescribing in older adults. Methods Two reviewers independently screened records identified from five electronic databases—Medline, Embase, PsycINFO, CINAHL and the Cochrane library—and published before October 2020. They searched for grey literature using Google Scholar. Qualitative and quantitative records reporting data on the attitudes of older adults, caregivers and healthcare providers towards BZRA deprescribing were included. Populations at the end of life or with specific psychiatric illness, except for dementia, were excluded. The two reviewers independently assessed the quality of the included studies using the mixed-methods appraisal tool. Barriers and enablers were identified and then coded into domains of the theoretical domains framework (TDF) using a combination of deductive and inductive qualitative analysis. The most relevant TDF domains for BZRA deprescribing were then identified. Results Twenty-three studies were included 13 quantitative, 8 qualitative and 2 mixed-method studies. The points of view of older adults, general practitioners and nurses were reported in 19, 9 and 3 records, respectively. We identified barriers and enablers in the majority of TDF domains and in two additional themes: “patient characteristics” and “BZRA prescribing patterns”. Overall, the most relevant TDF domains were “beliefs about capabilities”, “beliefs about consequences”, “environmental context and resources”, “intention”, “goals”, “social influences”, “memory, attention and decision processes”. Perceived barriers and enablers within domains differed across settings and across stakeholders. Conclusion The relevant TDF domains we identified can now be linked to behavioural change techniques to help in the design of future strategies and health policies. Future studies should also assess barriers and enablers perceived by under-evaluated stakeholders (such as pharmacists, psychiatrists and health care professionals in the hospital setting). Trial registration This work was registered on PROSPERO under the title “Barriers and enablers to benzodiazepine receptor agonists deprescribing”. Registration number: CRD42020213035

Prescribing and deprescribing trends in schizophrenia: An overview of inpatients in Belgium and in the Canadian province of Québec

“…However, some clinicians believe that APP can speed up effect, increase adherence or further reduce psychotic symptoms, 4,33 making them more reluctant to deprescribe, especially during the acute psychotic state 33 . The barrier to deprescribing thus appears to be more related to psychiatrists than patients, which is different from what is observed for benzodiazepines, where the barriers come from both sides 34 . However, the patient or family barrier to deprescribing cannot be excluded, and as it has never been specifically addressed in schizophrenia, further studies are needed.…”

“…33 The barrier to deprescribing thus appears to be more related to psychiatrists than patients, which is different from what is observed for benzodiazepines, where the barriers come from both sides. 34 However, the patient or family barrier to deprescribing cannot be excluded, and as it has never been specifically addressed in schizophrenia, further studies are needed. Nevertheless, this result may help convince clinicians that deprescribing is a possible option, even for the more severely affected patients.…”

Barriers and enablers towards benzodiazepine-receptor agonists deprescribing in nursing homes: A qualitative study of stakeholder groups

“…Two recent systematic reviews reported barriers and enablers for BZRA deprescribing among older adults, with most studies included coming from the ambulatory setting, and fewer studies from the NH setting. 14 , 15 One of these systematic reviews, also used the TDF, 15 and found common relevant TDF domains: Beliefs about capabilities, Beliefs about consequences, Environmental context and resources, Goals, Social influences , and Memory attention and decision process . Intention was also highlighted as relevant.…”

“…This is particularly important, as a previous systematic review reported the views of some healthcare providers', including pharmacists, had not been elicited. 15 Importantly, data saturation was reached for all interview groups. Finally, the trustworthiness of our results was also strengthened by investigator and data source triangulation.…”

“… 11 , 12 , 13 Two recent systematic reviews analyzed barriers and enablers of BZRA deprescribing in older adults, and reported more barriers than enablers, including a lack of knowledge, expected patients' resistance and interprofessional conflicts. 14 , 15 However, the majority of studies were undertaken in outpatient settings and their results may not be applicable to other contexts (for example nursing homes). In addition, these studies did not involve the full range of HCPs involved in prescribing BZRAs.…”