Conceptualizing the Influences on Decision-Making Regarding the Prescription of Antipsychotics to Nursing Home Residents with Dementia: A Meta-Ethnography

Background Antipsychotic medication (APM) prescribing is prevalent in nursing home (NH) residents for the management of behavioral and psychological symptoms of dementia (BPSD), despite the known risks and limited effectiveness.1 Studies have attempted to understand the reasons behind this continuing phenomenon utilizing qualitative research methods. However no study has systematically collated and synthesized this qualitative evidence. Therefore the aim of this study was to conceptualize the influences on decision-making regarding the prescribing of APM to NH residents with dementia, drawing on the existing qualitative evidence. Methods A systematic review and synthesis of qualitative evidence was conducted (PROSPERO protocol registration CRD42015029141). Six electronic databases were searched from inception through July 2016, supplemented by a gray literature search. Studies were included if they utilized qualitative methods of both data collection and analysis, and explored APM prescribing in NHs for the purpose of managing BPSD. The Critical Appraisal Skills Programme (CASP) assessment tool for qualitative research was utilized for quality appraisal.2 The seven-step meta-ethnographic approach,3 was utilized to synthesize included studies. All stages were conducted by at least two independent reviewers, and consensus reached by discussion. Results Of 1534 unique articles identified, 18 met the inclusion criteria and were included in the review. Overall, “the aim of improving care” for residents was a priority, but there was tension as to how this was best achieved. The choice between APM and non-pharmacological interventions was often perceived to be binary, with the former option considered a “quick-fix”. Pressure was commonly exerted on prescribers to make prescribing decisions, as doing nothing was not considered to be a viable option. Five key concepts emerged as influencing decision-making: Organizational Capacity; Individual Professional Capacity; Communication and Collaboration; Attitudes; Regulations and Guidelines. A conceptual model was constructed describing this decision-making process as a negative feedback loop, whereby the overarching aim of BPSD management was to negate the “challenging behavior” (Figure 1). Conclusions APM prescribing in NH residents with dementia occurs in a complex environment involving the interplay of various stakeholders, the NH organization and external influences. A paradigm shift is required in the management of BPSD in the NH setting.