Rationalising antipsychotic prescribing in dementia: a mixed-methods investigation

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Walsh, Kieran A.
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University College Cork
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Introduction: Antipsychotics are commonly prescribed to people with dementia, especially in nursing homes, despite limited benefits and significant harms. There have been calls to better understand the reasons why antipsychotics continue to be inappropriately prescribed to people with dementia, and to develop sustainable interventions. Hence the overarching aim of this thesis was to develop and assess the feasibility of a theoretically-informed, evidence-based and sustainable intervention to rationalise (or optimise) antipsychotic prescribing in nursing home residents with dementia. Methods: The overarching Medical Research Council (MRC) framework for developing and evaluating complex interventions guided our approach to this mixed-methods research. Firstly, a systematic review was undertaken to determine the effectiveness of pharmacists’ intervention in improving the appropriateness of prescribing in hospitalised older adults, with a particular focus on people with dementia. Secondly, a retrospective cross-sectional study was conducted examining prescribing differences between older adults with and without dementia, on admission to hospital. Next, a systematic review of qualitative evidence was undertaken to explore the influences on decision-making regarding antipsychotic prescribing in nursing home residents with dementia, which subsequently informed a semi-structured interview study exploring antipsychotic prescribing behaviours. The Behaviour Change Wheel (BCW) was then used to develop a complex intervention with Patient and Public Involvement (PPI) throughout. Finally, a feasibility study of the novel intervention was conducted in a nursing home setting. Results: Despite the fact that our cross-sectional study showed that hospitalised adults with dementia were prescribed significantly more antipsychotics, our systematic review found no pharmacist intervention existed which aimed to improve the quality of prescribing in this population. Our qualitative synthesis highlighted the complexity of decision-making with regards antipsychotic prescribing to nursing home residents with dementia. The interview study identified determinants influencing prescribing behaviours. Based on these findings, we developed the ‘Rationalising Antipsychotic Prescribing in Dementia’ (RAPID) complex intervention which consisted of academic detailing with general practitioners, education and training with nursing home staff, and an assessment tool. This intervention was found to be both feasible and acceptable, however limited uptake of the assessment tool compromised intervention implementation. Conclusion: This thesis has made a significant original contribution to knowledge, generating a much needed conceptual understanding of this complex issue and contributing towards intervention development. Further research is required to evaluate the effectiveness and sustainability of our novel intervention through larger scale evaluations.
Dementia , Antipsychotics , Mixed-methods , Inappropriate prescribing , Nursing homes , Behaviour change wheel , Older persons , Systematic reviews
Walsh, K. 2019. Rationalising antipsychotic prescribing in dementia: a mixed-methods investigation. PhD Thesis, University College Cork.