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Dementia is a global health issue, and no cure currently exists. The majority of people diagnosed with the disease experience behavioral and psychological symptoms of dementia (BPSD). These symptoms can be a burden for both the patient and their relatives and are a reason for relocation to a nursing home as well as being prescribed psychotropic medication. The first line of treatment for BPSD is non-pharmacological, but antidepressants are often used in older nursing home residents with dementia, sometimes in an attempt to lower BPSD although the treatment is off-label. Deprescribing in this population is often complicated and requires collaboration between general practitioners (GP), nursing home staff, patients, and relatives. We hypothesized that improving GP and nursing home staff's knowledge about BPSD, antidepressants, and deprescribing in combination with using a more structured approach to strengthen communication would increase their collaboration and willingness to attempt deprescribing, thus improving the treatment of BPSD by reducing unnecessary antidepressants. The aim of this thesis was to develop a new model situated in general practice for the management of BPSD in nursing home residents with dementia. Moreover we sought to investigate if the model could effectively and safely reduce the use of psychotropic medication. As an overall framework, we used the Medical Research Council’s updated guidelines from 2021 to develop and evaluate the intervention. We conducted a qualitative systematic review and further developed an intervention through an iterative process. The effectiveness of the intervention was evaluated in a cluster randomized controlled trial. Based on the findings from a qualitative systematic review and interviews with stakeholders during the tailoring process, we changed the focus from antipsychotic medication to antidepressants and made it optional to include relatives during the intervention. The final complex in

Introduction Polypharmacy is a common concern, especially in the older population. In some countries more that 50% of all individuals over 60 receive five or more drugs, most often due to multimorbidity and increased longevity. However, polypharmacy is associated with multiple adverse events, and more medication may not always be the answer. The terms “appropriate” and “inappropriate” are often used to distinguish between “much” and “too much” medications in relation to polypharmacy in research and practice, but no explicit definition exists to describe what these terms encompass. The aim of this review is to unfold the different understandings of and perspectives on (in)appropriate polypharmacy and suggest a framework for further research and practice. Method A scoping review was conducted using the framework of Arksey and O’Malley and Levac et al. Pubmed, Embase, PsycINFO, CINAHL, Cochrane database, Scopus and Web of Science were searched for references in English, Danish, Norwegian and Swedish using the search string “Polypharmacy” AND “Appropriate” OR “Inappropriate”. Data was extracted on author information, aims and objectives, methodology, study population and setting, country of origin, main findings and implications, and all text including the words “appropriate,” “inappropriate,” and “polypharmacy.” Qualitative meaning condensation analysis was used and data charted using descriptive and thematic analysis. Results Of 3982 references, a total of 92 references were included in the review. Most references were from 2016-2021, from fields related to medicine or pharmacy, and occurred within primary and secondary healthcare settings. Based on the qualitative analysis, a framework were assembled consisting of Context, three domains (Standardization, Practices and Values & Concerns) and Patient Perspective. Conclusion Inappropriate polypharmacy is a concept loaded by its heterogeneity and the usefulness of a single d

Medicingennemgange bliver udført på mange forskellige måder og med forskellig effekt. Det er kommet øget fokus på, at medicingennemgangsmodellerne også skal omfatte kommunikation om medicinændringer imellem sektorerne. Medicingennemgange på tværs af sektorer er tidskrævende og udfordrende i et presset sundhedsvæsen., Medication review is a pillar in the new recommendations from the Danish Health Authorities regarding patients with multimorbidity and polypharmacy. This review finds that general practitioners should be primary in coordinating medication. Medication reviews can be conducted differently with various co-interventions to try to improve cross-sectoral collaboration. It seems imperative that the interventions involve improved communication for optimal sharing and implementation of changes to the medication with primary care in a key role.

Background: There is a high use of antidepressants among institutionalized older persons with dementia. According to the latest guidelines it is suggested to deprescribe antidepressants. General practitioners (GPs) typically encounter multiple barriers when attempting to deprescribe antidepressants. Questions: The aim is to reduce the use of antidepressants in institutionalized older persons with dementia without increasing morbidity or mortality. Secondary outcomes include a difference in the use of other psychotropic medication, mortality, morbidity, and severity of BPSD. Method: The study is a cluster-randomized controlled trial based in general practices in Denmark. Randomization was 1:1 to intervention and control group. In total 20 practices that recruited up to 15 patients with dementia living in nursing homes is included. The intervention includes two tailored components; 1) a cased-based training course including teaching material to be used by the GP to educate nursing home staff on BPSD, 2) a dialog tool including a symptom assessment scale to be used in a structured consultation at the nursing home to encourage deprescribing of antidepressants. The control group recieves enhanced care as usual. Outcomes: We anticipate that the intervention will reduce the use of antidepressants through strengthening communication between GPs, nursing home staff and patients/relatives. Discussion: Research on this population is scarce and it is difficult to do. Many barriers exists and we will look further into this in a process evaluation which will also assess the implementability. Take home message for practice: This study will aid in the difficult task in deprescribing for a vulnerable population

BACKGROUND: The effectiveness of psychotropic medication on behavioral and psychological symptoms of dementia (BPSD) is limited, while associated with a higher risk of adverse events. Non-pharmacological treatment of BPSD is advocated as treatment of first choice. However, many general practitioners (GPs) find it difficult to initiate deprescribing, and when attempting to discontinue psychotropic medication in nursing home residents, they face many barriers. Therefore, we hypothesize that an intervention aimed at improving communication with and involvement of nursing home staff, relatives, and patients by GPs can optimize the pharmacological treatment of BPSD. The aim is to reduce the use of antidepressants in nursing home residents with dementia without increasing morbidity or mortality.OBJECTIVE: The primary outcome is reduction of antidepressant. Secondary outcomes include difference in use of other psychotropic medication, mortality, morbidity, and severity of BPSD.METHOD: The study is a cluster-randomized controlled trial based in general practices in Denmark. We aim to include 22 practices, each of which will recruit up to 15 patients with dementia living in nursing homes. The intervention period is 3 months, and the total study period is 1 year. Randomization is 1:1 to intervention and control group by computer algorithm. Both groups receive education on BPSD and its evidence-based treatment. The intervention includes three tailored components; (1) teaching material and training to be used by the GP to educate nursing home staff on BPSD, (2) a pre-visit reflection tool to encourage nursing home staff to evaluate symptoms and reflect on relatives involvement in the discontinuation process; and (3) a dialog tool to facilitate shared decision making on optimization of BPSD treatment during the visits at the nursing home. The control group includes enhanced care as usual. The primary and secondary outcomes will be assessed at the end of the stud

Objective: To study 1) whether the accuracy of point-of-care (POC) urine tests (dipstick, phase-contrast microscopy and culture) differs when performed on first-void urine (FVU) compared to mid-stream urine (MSU), and 2) if a delay of analysis up to four hours affects the accuracy of POC tests when performed on urine from symptomatic of urinary tract infection (UTI), non-pregnant women in general practice. Design: Prospective diagnostic study using paired samples. Setting/Intervention: Three general practices in Copenhagen. Each woman delivered FVU and MSU samples from the same void. As a reference standard, 8 ml of MSU was sent for culture at the Microbiology Department. Patients: 117 women with one or more symptoms of UTI. Main outcome measures: Sensitivity, specificity and agreement with the reference standard of FVU and MSU with different time delays (zero vs. one vs. four hours) as compared to reference standard (MSU at time zero in boric acid tubes). Results: All three POC tests performed on MSU were significantly more in agreement with the reference than when performed on FVU when analysis was done immediately. The error rate was 16% for MSU vs. 23% for FVU with POC culture, 27% vs. 40% with microscopy and 25% vs. 33% with dipstick testing. Delay of analysis up to four hours did not decrease agreement with the reference. Conclusion/Implication: MSU samples should be used in general practice for optimal accuracy of POC tests. Analysis can be delayed up to four hours.Key points Point-of-care tests (dipstick testing, microscopy and culture) for diagnosing urinary tract infection performed on mid-stream urine samples are significantly more accurate than when performed on first-void urine samples. Delay of analysis up to four hours did not decrease the accuracy of any of the point-of-care tests. Point-of-care culture was more accurate than dipstick and microscopy both when performed on mid-stream urine and first-void urine The main contaminant in first-void uri