What are the challenges of delivering tailored care for sleep disturbance among community-dwelling people living with dementia or mild cognitive impairment?

Conference:

SAPC ASM 2023 - Brighton

Talk Code:

2D.6

Presenter:

Aidin Aryankhesal

Co-authors:

Aidin Aryankhesal, Jessica Blake, Molly Megson, Simon Briscoe, Geoff Wong, on be half of TIMES Programme Team

Author institutions:

University of East Anglia, University of Hall, University of Exeter Medical School, Oxford University

Problem

Sleep disturbance (SD) is prevalent among people living with dementia (PLwD) or mild cognitive impairment (MCI) and is especially difficult to address in primary care, due to the challenges of diagnosis and management of SD within this population.

Approach

A realist review of the literature was conducted to identify the causes behind the challenges and barriers to the diagnosis and management of SD among PLwD or MCI. We systematically searched MEDLINE, PsycINFO, CINAHL, ASSIA, and Health Management Information Consortium (HMIC) to identify challenges and barriers to the diagnosis and management of SD among PLwD or MCI in primary care across the Organisation for Economic Co-operation and Development (OECD) member nations. A total of 60 documents were selected from 1869 hits, based on our eligibility criteria and citation tracking. The selected documents were analysed and challenges coded and iteratively refined into realist causal explanations (i.e. into context-mechanism-outcome-configurations) using data from included documents. A programme theory was developed to summarise causal relationships.

Findings

The findings highlight concerns about the use of long-term or inappropriate medication. Chronic use of medication often resulted from health care professionals’ (HCP) time and resource constraints, limited awareness of other SD management options, the need for immediate results, and the absence of appropriate assessment tools. This resulted in late, inaccurate or no diagnosis of SD. When SD was diagnosed, medication was often inappropriately prescribed long-term. Further challenges to an accurate diagnosis and management of SD occurred when PLwD or MCI were unable to recognise SD or they lived alone. Primary care doctors regarded pharmaceutical interventions as the primary intervention for SD and usually did not re-assess their patients for de-prescribing. Comorbidities, which are prevalent among most PLwD or MCI, also hindered de-prescribing. Informal and paid carers were also reported to expect an ongoing prescription of sleep medication due to a fear of relapse or deterioration of the PLwD or MCI’s sleep quality. Understaffed care homes, especially during night shifts, and rigid care routines also reinforced the use of chronic medication, which was often used to reduce the burden on staff workload. Where relevant, lack of insurance coverage for some non-pharmaceutical interventions was also reported to drive pharmacological interventions.

Consequences

Medicines are primarily, and often inappropriately, relied on to manage SD in PLwD or MCI. Improvements that aid the early diagnosis and subsequent management of SD, especially through non-pharmacological alternatives, are needed. This could be done by upskilling clinicians and HCP, improving assessment tools, and providing more support for informal and formal carers.

Submitted by:

Aidin Aryankhesal

Funding acknowledgement:

This study is part of a project funded by the NIHR Programme Grants for Applied Research (NIHR202345). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.