A new study has shown that primary care physicians (PCPs) continue to prescribe medications for behavioural and psychological symptoms of dementia (BPSD) because they view them as safer and more effective than controlled studies report. PCPs use drugs for symptoms with a direct threat of harm but also to meet patient-oriented goals, including easing patient suffering.

Guidelines, policies, and warnings have been applied to reduce the use of medications for behavioural and psychological symptoms of dementia (BPSD). Because of rare dangerous side effects, antipsychotics have been singled out in these efforts. However, antipsychotics are still prescribed off-label to hundreds of thousands of seniors residing in nursing homes and communities.

The objective of the study was to evaluate how and why primary-care physicians (PCPs) employ nonpharmacologic strategies and drugs for BPSD. Semi-structured interviews analyzed via template, immersion and crystallization, and thematic development of 26 PCPs in full-time primary-care practice for at least 3 years in Northwestern Virginia.

PCPs described 4 major themes regarding BPSD management: (1) nonpharmacologic methods have substantial barriers; (2) medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate; (3) pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications; and (4) PCPs need practical evidence-based guidelines for all aspects of BPSD management.

PCPs continue to prescribe medications as they meet patient-oriented goals and because PCPs perceive drugs, including antipsychotics and their alternatives, to be more effective and less dangerous than the evidence suggests. PCPs endorse that increasing nonmedication methods for treating BPSD would decrease the need for drugs, but they also describe many barriers to the use of these methods.

To optimally treat BPSD, PCPs need supportive verified prescribing guidelines and access to nonpharmacologic modalities that are as affordable, available, and efficacious as drugs; these require and deserve significant additional research and payer support. Opportunities may exist to optimize the use of resources already present in communities.

Increasing education about medication risks and increasing speciality support were not identified as factors likely to reduce medication use. Those who design guidelines and policies should consider recruiting community PCPs to participate in the development of clinically meaningful recommendations.