Development of an intervention to improve the management of behavioural and psychological symptoms of dementia in general practice in Ireland
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Date
2018-12-01
Authors
Jennings, Aisling A.
Journal Title
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Publisher
University College Cork
Published Version
Abstract
Background
General practitioners (GPs) play a pivotal and increasing role in the care of people with dementia. However, GPs are challenged by the complexities of dementia care. A triangulated educational needs analysis conducted by the PREPARED project identified that GPs find the management of behavioural and psychological symptoms of dementia (BPSD) a particularly challenging aspect of dementia care. BPSD encompasses a wide range of non-cognitive symptoms such as anxiety and hallucinations that affect people with dementia. Although BPSD has been identified as a challenging area for GPs, an area in which they lack confidence, we do not have a good understanding of why this is a challenging area for GPs or the root causes of their lack of confidence. Furthermore, evidence suggests that current management of BPSD is sub-optimal. In BPSD non-pharmacological strategies are recommended first-line but uptake of these strategies is low. Despite their adverse effects, potentially harmful pharmacological treatments, such as antipsychotics, are frequently employed. Interventions are needed to improve the management of BPSD. It is apposite that these interventions should target GPs. However, interventions to date to improve the management of BPSD have either not targeted GPs or not effectively involved GPs in intervention development, a notable gap in the literature.
Aim
To enhance our understanding of the management of BPSD in general practice with a view to informing a theoretically-based, behaviour change intervention to improve the management of BPSD.
Methods
This was a mixed methods study underpinned by the UK Medical Research Council (MRC) guidance on the development of complex interventions in health care. Existing evidence on GPs’ knowledge of, attitudes towards and experiences with BPSD was systematically reviewed using a mixed methods approach and synthesised using meta-ethnography. Findings of this review were supplemented with new evidence from three studies. A descriptive interpretive qualitative study which explored GPs experiences of managing BPSD. The data collected from 16 semi-structured interviews with a purposively selected sample of GPs were then thematically analysed. The second study was a cross-sectional descriptive study which assessed GPs’ knowledge of and attitudes towards pain in dementia, a key trigger for BPSD. In this study, a postal questionnaire was sent to a census sample of all GPs in Cork. The results were statistically analysed to explore associations between demographic data and responses. To further investigate the findings of the qualitative study a descriptive cross-sectional study was conducted that aimed to explore the knowledge and attitudes of GPs to the prescribing of antipsychotics in people with dementia. The study used an anonymous postal questionnaires that was sent to a census sample of all GPs based in Cork and Kerry. To develop the intervention, results from the systematic review, the qualitative and the two cross-sectional studies were integrated, using the behavioural change theoretical approach outlined in the Behaviour Change Wheel (BCW). In addition, a modified eDelphi study was conducted with multidisciplinary experts on antipsychotic prescribing in dementia. The eDelphi study helped to achieve consensus on the clinical components of the intervention.
Findings
The over-arching finding from the systematic review was that a lack of practical, implementable non-pharmacological treatment strategies created a therapeutic void for GPs, which led to over-reliance on family caregivers and on psychotropic medications. In the qualitative study some GPs described the challenges of managing BPSD as insurmountable and many struggled at an ethical level with the decision to prescribe potentially harmful psychotropic medication but felt they had little else to offer. Key challenges identified by GPs were; stretched resources, unrealistic expectations and a lack of implementable clinical guidelines. The cross-sectional descriptive study of GPs’ knowledge of and attitudes towards the management of pain identified aspects of GPs’ management of pain in dementia that could be improved upon and highlighted the importance of good relationships between GP and nursing home staff when managing dementia. The descriptive cross-sectional study of GPs’ attitudes towards antipsychotic prescribing in dementia found that the majority of GPs recommended non-pharmacological strategies first line when managing BPSD. The GPs reported that the main influencers of prescribing antipsychotics in BPSD were nursing staff and family. Of note the majority of respondents did not routinely monitor antipsychotic prescribing in people with dementia
Using the approach outlined in the Behaviour Change Wheel the findings of these four studies were used to select an aspect of GPs’ behaviour in the management of BPSD to target with an intervention: ‘GPs to systematically monitor their prescribing of antipsychotic medication to people with dementia in nursing home settings’. To address this behaviour, a three-component intervention was developed, consisting of: an interprofessional educational session with GPs and nursing home staff; a repeat prescribing monitoring tool and the facilitation of a self-audit.
Conclusion
The research presented in this thesis adds depth to existing literature and advances our knowledge of the management of BPSD in general practice. Prior to this research it was known that GPs found BPSD challenging but the reasons for why GPs found BPSD to be challenging had not been explored. This research offers new insights into GPs’ perspectives on the management of BPSD. This new insight helps to explain apparent discrepancies between best practice recommendations in BPSD and real-life clinical practice. This deeper understanding of GPs’ management of BPSD informed the development of an intervention to improve an aspect of BPSD management that was identified as being sub-optimal. The intervention developed focuses on GP self-monitoring of their prescribing of antipsychotic medication to people with BPSD in nursing home settings. This intervention has the potential to improve GPs’ management of BPSD.
Description
Keywords
Dementia , General practice , General practitioners , Behaviour change , Behavioural and psychological symptoms of dementia
Citation
Jennings, A. A. 2018. Development of an intervention to improve the management of behavioural and psychological symptoms of dementia in general practice in Ireland. PhD Thesis, University College Cork.