A systematic review of quantitative studies exploring staff attitudes to antipsychotic use in residents with dementia in care homes
Authors: Raza A , Piekarz H , Jawad S , Langran T , Donyai P 
Published: April 2022

Abstract

Introduction
Despite significant warnings of adverse effects associated with giving antipsychotics to patients with dementia, these medicines continue to be prescribed for managing the Behavioural and Psychological Symptoms of Dementia (BPSD) in care homes. Information provided by staff working within care homes is a factor that can influence prescribing decisions and how BPSD is managed (1). This provides the rationale for the current study to understand staff attitudes towards antipsychotic prescribing in dementia within care home settings.

Aim
This quantitative systematic review of survey and questionnaire studies aims to explore the attitudes of staff within care homes towards giving antipsychotics to residents with BPSD.

Methods
A comprehensive search of the literature published in ten databases was conducted between 26-05-2020 and 19-07-2020 and updated in July 2021. The review protocol was registered and has been published on PROSPERO (CRD42021256879). No time limit was imposed on publication dates. Two reviewers (AR & HP) independently performed the systematic search of the electronic databases and assessed the reporting quality of the papers, again independently, using ‘A Consensus-Based Checklist for Reporting of Survey Studies’ (CROSS) (2). All the identified papers were read in detail, and a structured summary was produced for each according to the following four themes: attitudes toward antipsychotics; barriers to reduced usage; measures implemented within the settings; perceived needs of staff. These summarized data were then formulated as a table to allow comparison of each study and consolidation of the findings.

Results
14 papers with 2059 participants, all published in the last decade, were identified for inclusion in the review. Where measured, staff appeared to hold positive beliefs about the effectiveness of antipsychotics in BPSD (n=5). GPs were held responsible for reluctance to complete medication reviews and discontinue antipsychotics in residents (n=1). Antipsychotics were thought to be mainly prescribed for the management of behavioural problems such as agitation, aggression, resistance to care, wandering, hallucination (n=5). Risperidone was stated as a commonly prescribed antipsychotic (n=1). The most frequently reported adverse effects of antipsychotics were increased risk of falls and sedation (n=3). Lower staff education, lack of training, poor antipsychotic medication reviews, lack of resources to implement nonpharmacological methods, and longer working hours/lack of time were viewed as barriers to deprescribing of antipsychotics (n=6). Time was a constraint in managing behavioural problems (n=1). Measures used by the staff to reduce antipsychotic usage included medication reviews, staff education about dementia and its management, dose adjustment of antipsychotics, behavioural assessment tools and nonpharmacological interventions (n=5). Some staff highlighted the need for education, training, resources, and financial and clinical support to reduce the use of antipsychotics (n=4).

Conclusion
This is the first systematic review which synthesizes quantitative data exploring staff attitudes towards giving antipsychotics to care home residents with BPSD. The positive beliefs about the effectiveness of antipsychotics and the barriers to deprescribing identified provide the impetus for further research. This study was limited by excluding non-English papers. Another limitation was that some domains were rarely explored, e.g. commonly-prescribed medicines, meaning medication preferences could not be summarised.

References
(1) Janus SI, van Manen JG, IJzerman MJ, Bisseling M, Drossaert CH, Zuidema SU. Determinants of the nurses’ and nursing assistants’ request for antipsychotics for people with dementia. Int Psychogeriatr. 2017 Nov 21;29(3):475-84.
(2) Sharma A, Duc NT, Thang TL, Nam NH, Ng SJ, Abbas KS, et al. A Consensus-Based Checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med. 2021 Apr 22;36(10):3179–87.