With rising prevalence, general practitioners are at the frontline of caring for people living with dementia. Some of the most challenging symptoms are the behavioural and psychological symptoms of dementia (BPSD) and it is believed that nearly all people with dementia will develop these symptoms at some stage during the course of the disease (Savva et al, 2009).
BPSDs can include aggression, sexual disinhibition, agitation as well as psychological symptoms of anxiety and depression. BPSDs have significant effect on the individual with dementia leading to increased rates of admission to nursing homes and extended stays in hospital. They also have a significant impact on the caregivers; both emotionally and physically.
One of the key problems in this area is that the evidence for the management of BPSDs is limited. Although non-pharmacological interventions such as personalised music therapy are recommended as first line treatment, these interventions are not taken up (Marston et al, 2014). On the other hand, commonly used treatments such as antipsychotics have limited evidence and significant side effects.
So do GPs need more support in managing BPSDs? This mixed-methods systematic review by Jennings and colleagues aimed to develop a better understanding of general practitioners’ knowledge, attitudes and experiences of managing BPSDs with the hope to informing future interventions to help GPs.
The researchers searched seven electronic bibliographic databases: MEDLINE (Ovid), Embase (Elsevier), CINAHL, PsychINFO, Academic search complete, SocIndex and Social Science full text. Other search methods used were hand-searching key journals and reference proceedings, citation searching of highly cited key papers and scanning reference lists of key papers.
They used the following criteria:
- Studies that explore knowledge, attitude or experience of GPs in the management of BPSDs in nursing homes and/or the community
- Qualitative or quantitative study design
- Studies must include GPs.
- Studies that do not describe in detail the knowledge and attitudes of GPs in relation to BPSD
- Non-English language studies
- Studies reporting the perspective of non-GP health care professionals where the view of GPS are not represented or analysed separately
- Studies reporting on GPs’ perspective of managing another aspect of dementia, without any reference to the management of BPSD
- Opinion pieces and non-peer reviewed articles.
Abstracts were screened by two reviewers from the team for eligibility. They listed all papers that were excluded after reading full text with the reason for exclusion.
Data was extracted by two reviewers. The lead author open-coded all included studies focusing on first order interpretations (views of participants) extracted from the results section and second order interpretations (views of authors) extracted from the discussion and conclusion. Third order interpretations were developed producing a line of argument to summarise the perspectives of GPs.
All included papers were independently assessed by two authors for methodological validity. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess the quality of included qualitative studies. A new original tool developed by the two reviewers was used to assess quality of descriptive cross-sectional studies.
Results were reported in line with ENTREQ and the authors presented their strategy using the PRISMA flow diagram. Two reviewers applied the CERQual tool to the review findings.
For quantitative results, GPs response to standardised questionnaires were transformed into qualitative data to combine with the qualitative studies. The Noblit and Hare (1988) meta-ethnographic approach was used to synthesise the data which was analysed using Nvivo.
Of 1,638 identified articles, 75 full text papers were reviewed and 11 were included. Of the 11 included studies: 4 were qualitative, 6 were quantitative and 1 was mixed methods. The studies included the views of 526 GPs from 5 different countries.
The four qualitative studies were rated to be high quality with the most common weakness being poor reflexivity.
The seven quantitative and mixed method studies ranged from low, moderate to high quality.
The analysis showed produced three key concept and 8 sub-themes reflecting GPs experiences of managing BPSDs.
Unmet primary care needs
- GPs knowledge and self-efficacy: GPs lacked confidence in their own knowledge and ability to manage BPSDs
- Lack of defined pathways of care: GPs find it hard to access relevant advice and support from other health professionals
- Time-intensive: managing BPSDs is overwhelming for GPs who are under tight time constraints.
Justification of antipsychotic prescribing
- Antipsychotics to facilitate coping: GPs see the use of antipsychotic medication as a way to improve quality of life, which outweigh the risk factors
- Barriers to implementation of non-pharmacological strategies: Pressure from nursing home staff to prescribe medication, understaffed nursing homes, lack of shared perspective from the caring team and such strategies seen as impractical due to limits on resources
- Traditional prescribing role: Some GPs feel more comfortable with the traditional role of the “prescriber”.
Pivotal role of families
- Influence of family: GPs are also tasked with managing expectations and supporting the family caregivers especially in the community
- Community based supports for family caregivers: GPs expressed lack of knowledge and difficulty accessing support for family caregivers in the community.
- GPs can feel isolated in managing BPSDs in patients with dementia leading to reported low self-efficacy. There is no defined integrated pathway in managing BPSDs and time pressures can leave GPs feeling overwhelmed and using more reactive strategies then proactive strategies.
- The use of psychotropic medications over non-pharmacological treatments was highlighted by this review. Prescribing non-pharmacological interventions can be out of the comfort zone of some GPs. Pressure from frontline nursing staff leads GPs to rely on pharmacological treatments.
- GPs also play a role in supporting caregivers, while there is limited knowledge on the available support for caregivers in the community. In some cases, GP are reliant on family caregivers to manage BPSD.
Strengths and limitations
The researchers applied a very thorough approach with two reviewers working independently. They also made available the excluded articles and reasons for exclusion.
The included studies covered a period of 22 years which is a significant period during which the understanding, attitudes and management of dementia would vary as practices change. This raises the question of how representative the results are of contemporary GPs’ experiences.
Additionally, some of the studies focused specifically on management strategies of BPSDs such as use of psychotropic medication, which resulted in a strong focus on this throughout the review.
The authors noted that the use of meta-ethnography can limit the richness or integrity of the original published studies, leading to the data being overly deconstructed.
Implications for practice
This review has highlighted a number of areas of focus for improvement of interventions in management of BPSDs.
- There is a need to address reliance on psychotropic medication for the management of BPSDs in primary care
- Consideration should be given to the allocation of resources in nursing homes to facilitate non-pharmacological interventions for BPSDs. This includes education and support for the delivery of such interventions
- There is a need for more integrated care pathways, with clearly defined roles within the care team
- Open discussion (with the patient and their family) about BPSDs, early in the course of illness, could help to manage expectations in future.
Conflicts of interest
Jennings AA, Foley T, Walsh KA, Coffey A, Browne JP, Bradley CP. (2018) General Practitioners’ knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review. International Journal of Geriatric Psychiatry.2018:1-14
Savva GM, Zaccai J, Matthews FE, Davidson JE, McKeith I, Brayne C. (2009) Prevalence, correlates and course of behavioural and psychological symptoms of dementia in the population. British Journal of Psychiatry. 2009;194(3):212-219. [PubMed abstract]
Marston L, Nazareth I, Petersen I, Walters K, Osborn DP. (2014) Prescribing of antipsychotics in UK primary care: a cohort study. BMJ Open. 2014; 4(12):e006135
Noblit GW, Hare RD. (1988) Meta-ethnography: synthesizing qualitative studies. Newbury Park, California:SAGE;1988. [Amazon]