Abstract/Summary

Dementia is a syndrome characterised by damage to the parts of the brain responsible for learning, decision-making, and memory. As dementia progresses, approximately 90% of people begin to exhibit Behavioural and Psychological Symptoms of Dementia (BPSD). Managing these symptoms can pose significant challenges not only for people living with dementia but also for their caregivers. Antipsychotics are sometimes used to manage these symptoms. However, the use of antipsychotics is accompanied by substantial risks of adverse effects. Therefore, caution is advised when requesting and prescribing antipsychotics for people with dementia. Despite the significant warnings regarding adverse effects, antipsychotics continue to be prescribed for the management of BPSD, particularly in care homes. The information provided by staff working within care homes can influence prescribing decisions and how BPSD is managed. Therefore, an evidenced-based and theoretically-informed study exploring the breadth of factors influencing antipsychotic prescribing decisions within care homes is necessary to design a successful intervention aimed at reducing such prescribing practices. Aims The aim was to identify the breadth and complexity of factors influencing decisions of staff in care homes on the use of antipsychotics for residents with dementia, using a theoretical and mixed-methods approach. Methods A systematic review was conducted to identify existing surveys and questionnaires on care home staff views towards the use of antipsychotics in dementia. This review examined questionnaires and surveys against aspects of the Theory of Planned Behaviour (TPB) and employed thematic analysis to meta-synthesise the findings of the studies on staff views regarding antipsychotics for residents with BPSD. Deficiencies identified in the reviewed surveys and questionnaires led to the development of the Antipsychotics in Dementia Attitude Questionnaire (ADAQ), a 50-item online questionnaire in English. The ADAQ was translated, modified, content validated, and pilot tested. It was then distributed online to staff in UK-based care homes to capture their views on antipsychotic use for residents with BPSD, specifically the factors influencing intentions to request antipsychotic prescriptions. Based on the ADAQ findings and the observed increase in antipsychotic prescribing during the COVID-19 pandemic, semi-structured online interviews were conducted with staff to explore the pandemic's impact on the care home environment, residents, and antipsychotic use. Results The systematic review identified 14 studies using surveys or questionnaires to explore care home staff views toward antipsychotic use for residents with BPSD. Analysis of these surveys and questionnaires revealed incomplete reporting of relevant TPB aspects, leading to the development of the ADAQ questionnaire based on the TPB. Thematic analysis of the findings showed that while care home staff generally held positive attitudes towards prescribing antipsychotics, they faced barriers to deprescribing and highlighted the need for education, training, financial, and clinical support to reduce antipsychotic use. The ADAQ was validated (I-CVI > 0.78), and pilot tested (factor loading ≥0.628, KMO ≥ 0.5, α = 0.785). Analysis of 84 completed responses following dissemination of the ADAQ found behavioural, normative and control beliefs, attitude, subjective norm and perceived behavioural control significantly (individual correlation; r ≥ 0.230, p<0.05, variance= 45.6%) associated with staff intentions to ask doctors to prescribe an antipsychotic for a resident with BPSD, and intentions (r =0.395, p<0.01) to determine staff behavioural expectation of an antipsychotic to be prescribed for residents. Qualitative analysis of the interview identified numerous challenges posed by the pandemic and the worsening of BPSD that caused increased antipsychotic use in residents with dementia. The staff justified the use of antipsychotics to cope with inadequate resources and the worsening of BPSD. Healthcare professionals were criticised for prescribing antipsychotics to residents with dementia without adequately considering potential risks and adverse effects, and GPs were primarily blamed for prescribing during the COVID-19 pandemic. Conclusion This study provides a significant contribution to existing knowledge around the inappropriate requesting and prescribing of antipsychotics by shedding light on the involvement of staff and offers impetus for policymakers, researchers, and professionals to develop theoretically-informed interventions to address antipsychotic prescribing in dementia.