General practitioners’ knowledge, attitudes and experiences of managing behavioural and psychological symptoms of dementia: a mixed methods systematic review

Problem

Behavioural and psychological symptoms of dementia (BPSD) is a universal feature of dementia and has been identified by GPs as a particularly challenging aspect of dementia care. Psychotropic medication remain the mainstay of treatment despite known risks and limited effectiveness. Non-pharmacological interventions are recommended first line in most cases but uptake of these strategies is low. The aim of this study was to synthesise the existing published literature on GPs’ knowledge, attitudes and experiences of managing BPSD with a view to informing future interventions to support GPs in their management of BPSD.

Approach

We conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs’ experiences of managing BPSD. 7 electronic databases were searched from inception to October 2017. Each stage of the review process involved at least two authors working independently. To synthesise the qualitative and quantitative results an integrated design was adopted. This involved transforming quantitative data obtained from GPs’ responses to standardised questionnaires into qualitative form so that it could be combined with data from qualitative studies and subjected to qualitative analysis. Once the data was all in qualitative form, the meta-ethnographic approach was employed to synthesise the findings while preserving the context of the primary data. The JBI Checklist for Qualitative Research was used to assess the quality of the qualitative studies. A new original tool was developed by two of the reviewers to assess the quality of descriptive cross-sectional studies. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to assess the confidence in our individual review findings.

Findings

The search returned 1,638 citations after duplicates were removed. 1,558 citations were removed following abstract screening leaving 75 full-texts to be assessed for eligibility. 11 studies were included in the review; 4 qualitative, 6 quantitative and 1 mixed-methods. Representing the views of 526 GPs from five different countries. Three main concepts specific to GPs’ experiences of managing BPSD emerged; unmet primary care resource needs, justification of antipsychotic prescribing and the pivotal role of families. A ‘line of argument’ was drawn which described how, in the context of resource limitations, a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached. This is first review to systematically review and synthesise the literature on GPs’ knowledge, attitudes and experiences of managing BPSD and identifies areas that, if targeted, could improve the management of BPSD.

Consequences

This systematic review offers new insights into GPs’ perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.