Psychotropic drug treatment for agitated behavior in dementia

What if physicians fail to manage with guideline prescribing recommendations? A qualitative study

De abstractcommissie heeft op verzoek van de congrescommissie zes abstracts geselecteerd die tijdens het Verenso najaarscongres 'Innovatie' op 25 november 2021 middels een flitspresentatie gepresenteerd worden. Onderstaande abstract is daar een van.

Marlies Dijk, Sarah Tabak, Cees Hertogh, Rob Kok, Rob van Marum, Sytse Zuidema, Eefje Sizoo, Martin Smalbrugge 

Background

Agitation is a common challenging behavior in dementia with a negative influence on patient’s quality of life and a high caregiver burden. Treatment is often difficult. The Dutch Verenso guideline provides recommendations for psychotropic drug (PD) treatment.

Objective

To explore how physicians decide on PD treatment for agitated behavior in dementia when they fail to manage with guideline prescribing recommendations.

Methods

We conducted five online focus groups with a total of 22 elderly care physicians, five clinical geriatricians and four geriatric psychiatrists, in The Netherlands. The focus groups were thematically analyzed.

Results

We identified six main themes. The first overarching theme (1) ‘not one size fits all’ refers to many physicians stating that there is no PD treatment that works in all cases. The next five themes regard the steps physicians indicate to decide on non-guideline PD treatment for agitated behavior in dementia: (2) ‘analysis of problem and cause’, (3) ‘hypothesis of underlying cause and treatment goal’, (4) ‘considerations regarding drug choice’, (5) ‘trial & error’ and (6) ‘last resort’.

Conclusion

The decision on PD treatment for agitated behavior in dementia outside the guideline prescribing recommendations is not a straight forward process. Physicians first go back to the analysis and try to substantiate and justify medication choices as best they can with a hypothesis of underlying cause, using other guidelines, and choosing PD treatment weighed up to the individual. Hypotheses can be weak due to diagnostic uncertainty which can lead to trying different kinds of PDs.

This work was supported by the Verenso grant (Verenso Beurs).

Auteurs

• Marlies T. Dijk MD, Department of Elderly Care Medicine, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
• Sarah Tabak BSc, Department of Elderly Care Medicine, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
• Cees M.P.M. Hertogh MD, PhD, Department of Elderly Care Medicine, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
• Rob M. Kok MD, PhD, Department of Old Age Psychiatry, Parnassia Psychiatric Institute, The Hague, The Netherlands
• Rob J. van Marum MD, PhD, Department of Geriatric Medicine & Clinical Pharmacology Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands, Department of Medicine for Older People, VU University Medical Center, Amsterdam, the Netherlands
• Sytse U. Zuidema MD, PhD, Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
• Eefje M. Sizoo, MD, PhD, Department of Elderly Care Medicine, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
• Martin Smalbrugge, MD, PhD, Department of Elderly Care Medicine, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands