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

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.

Keywords: dementia; primary care; shared decision-making.