Caregiver Perspectives About Using Antipsychotics and Other Medications for Symptoms of Dementia

Kerns, J. William; Winter, Jonathan D.; Winter, Katherine; Kerns, Christine C; Etz, Rebecca

doi:10.1093/geront/gnx042

Cited by 50 publications

(66 citation statements)

References 40 publications

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“…That few families take full advantage of fragmented existing resources is consistent with what community caretakers have previously described. 16 In addition, congruent with this suggestion, dementia "navigators" in Minnesota and "counselors" elsewhere have been shown to be of great benefit to families, optimizing support, personalizing therapies, and improving both patient and caregiver outcomes. 63 When alternative approaches failed or were unavailable, almost all PCPs readily used drugs, including antipsychotics, to address BPSD.…”

Section: Discussionmentioning

confidence: 91%

“…As previously proposed, it may be that it is difficult to perceive rare medication-related effects against the backdrop of severe chronic morbidity. 16 For example, distinguishing a 12-week survivorship rate of 97.7% from 96.5% for patients taking antipsychotics may not be clinically appreciable. 65 The discrepancy between PCPs' perceptions about medication efficacy and safety compared with what is proven may contribute to persistent medication use.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, the amount of autonomy caregivers want in medication decisions varies from actively evaluating pros and cons and being the primary decision maker to deferring all medication decisions to the physician. 16,65 FDA warnings, CMS efforts, and guidelines about antipsychotic use in patients with dementia have had multifaceted consequences for almost all the PCPs we interviewed. In nursing homes, periodic medication reviews overseen by pharmacists seemed to be effective in encouraging dose reductions and weaning.…”

Section: Discussionmentioning

confidence: 99%

“…This is congruent with caregiver stakeholders who also had a palliative perspective for dementia care. 16 While some policies and guidelines would endorse all such prescribing, it is contrary to others, and PCPs resent being characterized as "bad doctors." 45 Ongoing and appropriate medication reduction efforts may need to take these findings into consideration.…”

Section: Discussionmentioning

confidence: 99%

“…7,9,[13][14][15] At times even optimally applied nonpharmacologic therapies simply do not work because of numerous factors, including disease variation and progression. 8,16 Medications used "off label" for BPSD include anxiolytics, antidepressants, cognitive enhancers, antipsychotics, and anticonvulsant mood stabilizers. Benzodiazepines, prescribed for anxiety and agitation, increase risks of sedation, confusion, falls, and fractures.…”

mentioning

confidence: 99%

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Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

Kerns

Winter

et al. 2018

J Am Board Fam Med

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Background: Guidelines, policies, and warnings have been applied to reduce the use of medications for behavioral and psychological symptoms of dementia (BPSD). Because of rare dangerous side effects, antipsychotics have been singled out in these efforts. However, antipsychotics are still prescribed "off label" to hundreds of thousands of seniors residing in nursing homes and communities. Our objective was to evaluate how and why primary-care physicians (PCPs) employ nonpharmacologic strategies and drugs for BPSD.Methods: Semi-structured interviews analyzed via template, immersion and crystallization, and thematic development of 26 PCPs (16 family practice, 10 general internal medicine) in full time primarycare practice for at least 3 years in Northwestern Virginia.Results: PCPs described 4 major themes regarding BPSD management: (1) nonpharmacologic methods have substantial barriers; (2) medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate; (3) pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications; and (4) PCPs need practical evidence-based guidelines for all aspects of BPSD management.Conclusions: PCPs continue to prescribe medications because they meet patient-oriented goals and because PCPs perceive drugs, including antipsychotics and their alternatives, to be more effective and less dangerous than evidence suggests. To optimally treat BPSD, PCPs need supportive verified prescribing guidelines and access to nonpharmacologic modalities that are as affordable, available, and efficacious as drugs; these require and deserve significant additional research and payer support. Community PCPs should be included in BPSD policy and guideline development. (J Am Board Fam Med 2018;31: 9 -21.)

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

Kerns

Winter

et al. 2018

J Am Board Fam Med

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Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis

Anderson,

Ayanian,

Curto

et al. 2023

JAMA Intern Med

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ImportanceDementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.ObjectiveTo examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults.Design, Setting, and ParticipantsIn this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023.ExposureIncident dementia diagnosis.Main Outcomes and MeasuresThe main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)–active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date.ResultsThe study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs −0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, −0.53% vs −0.21%; difference, −0.32% [95% CI, −0.55% to −0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: –0.84% vs –0.40%; difference, –0.44% [95% CI, –0.64% to –0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase).Conclusions and RelevanceIn this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.

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Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults

et al. 2021

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Key Points Question What rationale for deprescribing, the structured process of reducing or stopping unnecessary, potentially harmful, or goal-discordant medicines, do older adults prefer for clinicians to use? Findings In this survey study of 835 older adults, respondents’ preferred phrases to explain deprescribing preventive and symptom-relief medicines focused on the risk of side effects. For preventive medicines, other more preferred phrases included references to using a harmful total number of medicines and benefits not outweighing risks, and for symptom-relief medicines, other more preferred phrases included references to working together to slowly reduce the dose and the medicine causing more harm than good. Meaning These findings suggest that for deprescribing to succeed, it requires effective communication that resonates with patients.

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Caregiver Perspectives About Using Antipsychotics and Other Medications for Symptoms of Dementia

Cited by 50 publications

References 40 publications

Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

Primary Care Physician Perspectives about Antipsychotics and Other Medications for Symptoms of Dementia

Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis

Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults

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