Abstract
Background
Few guidelines address fracture prevention medication use in nursing home (NH) residents with dementia.
Objective
We sought to identify factors that influence prescriber decision-making for deprescribing of bisphosphonates for older NH residents with dementia.
Methods
We conducted 12 semi-structured interviews with prescribers who care for older adults with dementia in NHs.
Main Measures
Interview prompts addressed experiences treating fractures, benefits, and harms of bisphosphonates, and experiences with deprescribing. Coding was guided by the social-ecological framework including patient-level (intrapersonal) and external (interpersonal, system, community, and policy) influences.
Results
Most prescribers were physicians (83%); 75% were female and 75% were White. Most (75%) spent less than half of their clinical effort in NHs and half were in the first decade of practice. Among patient-level influences, prescribers uniformly agreed that a prior bisphosphonate treatment course of several years, emergence of adverse effects, and changing goals of care or limited life expectancy were compelling reasons to deprescribe. External influences were frequently discussed as barriers to deprescribing. At the interpersonal level, prescribers noted that family/informal caregivers are diverse in their involvement in decision-making, and frequently concerned about the adverse effects of bisphosphonates, but perceive deprescribing as “withdrawing care.” At the health system level, prescribers felt that frequent transitions make it difficult to determine duration of prior treatment and to implement deprescribing. At the policy level, prescribers highlighted the lack of guidelines addressing residents with limited mobility and dementia or criteria for deprescribing, including uncertainty in the setting of prior fractures and lack of bone densitometry in NHs.
Conclusion
Systems-level barriers to evaluating bone densitometry and treatment history in NHs may impede person-centered decision-making for fracture prevention. Further research is needed to evaluate the residual benefits of bisphosphonates in medically complex residents with limited mobility and dementia to inform recommendations for deprescribing versus continued use.
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Data Availability
De-identified data is available upon reasonable request to the corresponding author.
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Funding
Dr. Niznik is supported by a K08 award from the NIA (K08 AG071794).
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Dr. Colon-Emeric reports grants fro UCB Pharma, outside the submitted work. Dr. Lund reports other financial activities from GlaxoSmithKline, outside the submitted work. All other authors have no relevant conflicts to report.
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Niznik, J., Colón-Emeric, C., Thorpe, C.T. et al. Prescriber Perspectives and Experiences with Deprescribing Versus Continuing Bisphosphonates in Older Nursing Home Residents with Dementia. J GEN INTERN MED 38, 3372–3380 (2023). https://doi.org/10.1007/s11606-023-08275-4
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DOI: https://doi.org/10.1007/s11606-023-08275-4