Primary care physician perspectives about antipsychotics and other medications symptoms of dementia

J William Kerns, Jonathan D Winter, Katherine M Winter, Terry Boyd, Rebecca S Etz 

Abstract

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 primary-care 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.

This article was featured in the April 21, 2022, Lunch and Learn discussion

Behavioral and psychological symptoms of dementia like agitation, paranoia and combativeness are common in all forms of dementia. These behaviors are often the most intrusive, hardest to manage, and most associated with institutionalization. We currently over rely on risky medications to treat them, namely antipsychotics. If we know these drugs have severe risks, why do we see clinicians continue to use them at such a high level?

The research revealed several barriers to using non-medication treatments for symptoms of dementia: 1. non-medication efforts were hard to use because getting caretakers trained and informed was challenging, 2. barriers exist for non-pharmacologic treatments that just don't exist for drugs. Drugs are cheap, easy to prescribe and readily available, 3. the guidelines for non-medication procedures were often not very helpful.

Recommendations:

• Clinicians should be educated about non-medical treatments and know how and when to use medicines when they are necessary.
• We need better guidelines and primary care physicians should be involved in guideline development.
• Non-pharmacologic treatments need to be affordable, widely available, and supported by evidence.
• primary care clinicians and their teams need more training, education, and resources on non-medication options.
• Alzheimer’s Association Reflections
  • Non medication interventions can be effective if the primary care team are trained and have access to the resources needed, agree about the potential side effects and dangers of anti psychotic medications and also agree that sometimes they are needed and can be effective in certain situations.
  • Alzheimer’s Association generally recommends trying non-medication interventions as the first line of defense, while antipsychotic medications considered only after trying non-medication options.
  • Advocating for payment models that appropriately considers the full spectrum of dementia care.
• Alzheimer’s Association Resources:
  • Alzheimer's and Dementia Care ECHO program for case-based, interactive learning for primary care practice teams:
  • Alzheimer’s Association cognitive impairment care planning toolkit:
  • Kezia Scales, PhD, Sheryl Zimmerman, PhD, Stephanie J Miller, MSW, Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S88–S102, https://doi.org/10.1093/geront/gnx167
  • Mary Guerriero Austrom, PhD, Malaz Boustani, MD, MPH, Michael A LaMantia, MD, MPH, Ongoing Medical Management to Maximize Health and Well-being for Persons Living With Dementia, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S48–S57, https://doi.org/10.1093/geront/gnx147