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

Abstract

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.

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

“…Furthermore, neither residents nor relatives were interviewed, which could also have provided important insights. However, since they were not actively part of the intervention in the final form because their mandatory presence was removed in the development process, it was less relevant for the evaluation [ 32 ]. As for the patient’s perspective, a recent study concerning nursing home resident’s thoughts on discussing deprescribing has shown that residents may not know how to talk about their medication [ 56 ].…”

“…Some of these challenges are specific to antipsychotic medication and are very difficult to overcome, while others apply to all medication groups. The difficulties that arise from antidepressants may be a bit less challenging to deal with [ 32 ].…”

“…To address these factors, we developed a complex intervention aiming to reduce antidepressants for nursing home residents with dementia by improving communication and collaboration between GPs, nursing home staff, relatives, and patients [ 32 , 33 ]. The results of the randomized controlled trial (RCT) will not be able to explain why or why not a possible effect was achieved.…”

“…A detailed description of the main trial and the development of the intervention is reported elsewhere [ 32 , 37 ]. To summarize, the trial was conducted as a cluster randomized controlled trial with GPs working as nursing home physicians as the clusters.…”

Person-centred medicine in the care home setting: development of a complex intervention

“…HCPs often perceive care home residents as not being capable of or not wanting to be involved in their care [ 25 ]. Similarly, HCPs sometimes believe that the relatives do not want to be involved, or they perceive relative involvement to be time-consuming, not helpful, and sometimes problematic [ 26 ]. Research indicates that residents and their relatives generally want to be involved [ 27 – 29 ], but many residents are reticent, because they think that their HCPs are not receptive to their perspectives, or they do not know how to be involved [ 30 ].…”