Clinicians' Perspectives on Barriers and Enablers of Optimal Prescribing in Patients with Dementia and Coexisting Conditions

Ariel R. Green; Patricia Lee; Emily Reeve; Jennifer L. Wolff; Chi Chiung Grace Chen; Rachel Kruzan; Cynthia M. Boyd

doi:10.3122/jabfm.2019.03.180335

Article Figures & Data

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Table 1.

Participant Characteristics

Characteristic	Value
Age, mean (SD) (years)	46.6 (9)
Race/ethnicity, n (%)
White	10 (48)
African American	0 (0)
Asian	9 (43)
Hispanic	0 (0)
Other	2 (10)
Academic degree, n (%)
MD	18 (86)
DO	1 (5)
CRNP	2 (10)
Specialty, n (%)^*
Family medicine	6 (29)
Internal medicine	6 (29)
Geriatric medicine	3 (14)
Urogynecology	3 (14)
Endocrinology	3 (14)
Cardiology	3 (14)
Clinic site, n (%)
Urban	8 (38)
Suburban	9 (43)
Rural/suburban^†	4 (19)
Years since completing clinical training, mean (SD)	13.8 (10)
No. of clinic sessions per week, mean (SD)^‡	7.3 (3)
Proportion of patients with dementia in panel, n (%)^§
<10%	13 (62)
10% to 25%	8 (38)
26% to 75%	0 (0)
>75%	0 (0)

SD, standard deviation.
↵* Participants could select more than one response.
↵† The clinic served a mix of rural and suburban populations.
↵‡ One 4-hour session per week.
↵§ As estimated by participant.

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Table 2.

Clinician-Perceived Barriers to Optimizing Prescribing in Dementia

Subtheme	Representative Quotation
Lack of data	Not only do I have to look at the evidence, but I also have to look at the whole patient…I can't just focus on the guidelines…So many of these decisions are subjective rather than objective. (primary care provider)
Difficulty of assessing medication effects in an individual patient	I would always do a little of the typical delirium check like, “Does a stone float?” I often ask them, “Do you see anything you think isn't there or do you hear anything you think isn't happening?” (primary care provider)
Need to consider caregiver availability, knowledge, and skills in prescribing decisions	I have limited time with patients so I…really need to be selective about who I end up talking to about [behavioral strategies to treat incontinence]. If it's someone who's lucky to have someone even looking in on them once a day, then what's the point of talking to them about that? (urogynecologist)
Perceptions of patient and caregiver beliefs and expectations	Caregivers worry about this decision means I gave up on mom or that I'm her executioner because I stopped that med. (primary care provider)
Cognitive biases	I told the daughter, “I really don't see having this cholesterol lowering medicine.” It seemed like within maybe just 2 months, she went into the ER and she had a stroke. (primary care provider)
System barriers	Maybe it is my place, but I'm not very good at calling another specialist and saying, “I'm concerned about this…” I'm the generalist. I'm not the specialist. They know more than I do; this is their area. (primary care provider)

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Table 3.

Language Used by Clinicians to Discuss Medications and Deprescribing with Patients and Caregivers

Subtheme	Representative Quotation
Explicit mention of life expectancy	I probably put it something like this: “Do you know that even if a person does not have any medical issues, dementia by itself can shorten your life expectancy? In your father or mother, the goal is to keep them comfortable. With medications there is risk and what are we trying to achieve?” (primary care provider)
Focus on quality of life	I broach it as a positive thing for the patient: “We're not harming them in any way [by stopping medicines], but we're trying to give them a better quality of life.” (cardiologist)
Focus on long-term benefits of medication versus short-term harms	Someone like yourself with a lot of other medical problems, with maybe heart problems, lung problems, memory problems, there probably is not a ton of benefit to us being very aggressive in controlling your diabetes…I can certainly get your blood sugars normal, but the problem is by doing that, I expose you to a lot of risks. (endocrinologist)
Conditional or subjective language	I tell them the side effects of this medicine [bladder antimuscarinic] sometimes are a dry mouth. It might cause a little memory problem. (primary care clinician)
Negative framing	There are all these medications that you could try [for incontinence] but they come with a significant risk of causing confusion. (primary care provider)