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How Clinicians Discuss Medications During Primary Care Encounters Among Older Adults with Cognitive Impairment

  • Ariel R. GreenEmail author
  • Jennifer L. Wolff
  • Diane M. Echavarria
  • Malcolm Chapman
  • Annie Phung
  • Devon Smith
  • Cynthia M. Boyd
Original Research
  • 44 Downloads

Abstract

Background

People with cognitive impairment experience high rates of polypharmacy and potentially inappropriate medication use. How clinicians communicate about medications may affect to what extent patients and family companions understand and participate in decisions about medication use.

Objective

To characterize how primary care clinicians discuss medications during encounters with older adults with cognitive impairment and their companions.

Design

Qualitative content analysis of audio-recorded clinical encounters from SAME Page, a randomized controlled trial to examine the effects of a patient-family agenda setting checklist on primary care visit communication among patients with cognitive impairment. Visits occurred between August 2016 and August 2017.

Participants

Patients were 65 or older, had > 1 incorrect answer on a cognitive screener, and attended visits with a relative or unpaid companion. Clinicians were physicians, nurse practitioners, or physician assistants at participating practices.

Approach

The encounters were transcribed verbatim. We used qualitative content analysis to identify major themes.

Key Results

Patients were on average 79.9 years of age. The average MMSE score was 21.6. About half of clinicians reported practicing for 15 or more years (n = 8). We identified three major themes. First, we found numerous instances in which primary care clinicians introduced patients and companions to key principles of optimal prescribing and deprescribing. Second, clinicians used a variety of approaches to foster shared decision-making about medication use. Third, several challenges prevented clinicians from working together with patients and companions to optimize prescribing and deprescribing.

Conclusions

This study offers insight into key language clinicians can use to initiate discussions about optimizing prescribing, as well as barriers they face in doing so. Examples identified in these transcripts should be tested with patients and caregivers to examine how such communications are received and interpreted. Future research should develop and test interventions that seek to overcome obstacles to optimizing prescribing for older adults with cognitive impairment.

KEY WORDS

shared decision-making primary care dementia 

Notes

Funding Information

Research reported in this publication was conducted with grant support from the National Institute on Aging under award numbers K23AG054742 (Green), 5R21AG049967-02 (Wolff), K24AG056578 (Boyd), and 5T35AG026758-14 (Chapman, Phung, Smith).

Compliance with Ethical Standards

The study was approved by the institutional review board of the Johns Hopkins Bloomberg School of Public Health. The funding agency did not have a role in the design, conduct, or reporting of the study results.

Conflict of Interest

Dr. Boyd writes a chapter on multimorbidity for UpToDate, for which she receives a royalty. All remaining authors declare that they do not have a conflict of interest.

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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Ariel R. Green
    • 1
    Email author
  • Jennifer L. Wolff
    • 2
  • Diane M. Echavarria
    • 2
  • Malcolm Chapman
    • 3
  • Annie Phung
    • 4
  • Devon Smith
    • 5
  • Cynthia M. Boyd
    • 1
  1. 1.Division of Geriatric Medicine and Gerontology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  3. 3.University of North Carolina School of MedicineChapel HillUSA
  4. 4.Philadelphia College of Osteopathic Medicine – GeorgiaSuwaneeUSA
  5. 5.Northeast Ohio Medical UniversityRootstownUSA

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