Collaborating with pharmacists to improve medication use in dementia care: views from healthcare professionals in Sweden

Collaborating with pharmacists to improve medication use in dementia care: views from healthcare professionals in Sweden | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Collaborating with pharmacists to improve medication use in dementia care: views from healthcare professionals in Sweden Catharina Carlqvist, Mirjam Ekstedt, Elin Christina Lehnbom This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3975153/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Dementia is a major global public health challenge, and with the growing elderly population, its prevalence is expected to increase in the coming years. In Sweden, municipalities are responsible for providing special housing for the elderly (SÄBO), which offers services and care for older individuals needing specific support. SÄBO is both the person´s home and a care environment and workplace. Polypharmacy in patients with dementia is common and increases the risk of medication interactions. Involving clinical pharmacists in medication reviews has been shown to result in safer medication use and more appropriate prescribing. However, less attention has been given to how other healthcare professionals view the implementation of such pharmacist services. Thus, this study aims to explore their views towards pharmacist-supported medication reviews for people with dementia. Methods This descriptive qualitative study used semi-structured interviews and qualitative content analysis to explore healthcare professionals’ views on pharmacist-supported medication reviews for people with dementia. The study was conducted in a southern Swedish special housing and included nurses, assistant nurses, general practitioners (GPs), and a pharmacist. Due to the COVID-19 pandemic, interviews were conducted over the phone. The Swedish Ethical Review Authority approved the study. Results The analysis revealed three main categories, and eleven subcategories.: 1) Approaches to safe medication use, 2) Approaches to work processes and 3) The role of the pharmacist. Nurses focused on non-pharmacological treatments, while GPs emphasized the importance of medication reviews in assessing the benefits and side-effects of prescribed medication. Pharmacists were valued for their reliable medication expertise, appreciated by GPs for saving time and providing recommendations prior to consultations with individuals with dementia and their next-of-kin. Although medication reviews were considered beneficial, there was skepticism about their ability to solve all medication-related problems associated with dementia care. Conclusions The healthcare professionals generally had a positive attitude towards collaborating with pharmacists. The study highlighted the importance of involving healthcare professionals in the implementation of new work processes to ensure employee commitment and successful adoption. Clinical pharmacy Collaboration Dementia Drug-related problems Health care professionals Independent Living Implementation Medication review Polypharmacy Qualitative study Special housing Background Dementia is a term used to describe several chronic and progressive diseases that cause significant damage to the brain. Depending on which parts of the brain are affected, dementia can manifest itself in different ways, but common symptoms include impaired memory, language deficits, problems with time perception and loss of orientation skills ( 1 ). Dementia can also cause changes in behavior, such as increased anxiety and aggression, which can be challenging for family and caregivers to handle ( 2 ). As a result, special housing for the elderly (SÄBO) has been established in Sweden to provide apartment-based care that aims to create a supportive environment for individuals with dementia. SÄBO is both the person´s home and a care environment and workplace ( 3 ). According to the World Health Organization (WHO), over 55 million people worldwide are currently living with dementia ( 4 ), with 130,000–150,000 cases in Sweden alone. As the elderly population continues to grow, the prevalence of dementia is expected to increase in the coming years ( 5 ). In Sweden, local municipalities are responsible for providing care to residents in special housing, as outlined in the national Social Services Act. Healthcare professionals who provide direct patient care in special housing typically include enrolled nurses, nursing assistants with upper secondary level schooling, and registered nurses. Registered nurses often delegate the administration of medications to enrolled nurses and nursing assistants who have training in medication administration ( 6 ). There are several medications available to treat the symptoms of dementia. However, since many people with dementia also have other chronic conditions ( 7 ), they are at a high risk of polypharmacy. Polypharmacy refers to the concurrent use of multiple medications, which can increase the likelihood of potentially dangerous drug interactions or undesirable side effects. While there is no exact definition of the number of medications that constitutes polypharmacy, it typically refers to the use of five or more medications ( 8 ). It is crucial to take steps to optimize medical treatment for individuals with dementia ( 9 ). This can be achieved by carefully selecting pharmacological and non-pharmacological treatments, stopping medications that are no longer needed, and adjusting dosages to minimize or prevent drug-related problems. Medication reviews, which involve a structured evaluation of a patient's medications, have been recommended as a method to identify and resolve drug-related harm ( 10 , 11 ). According to regulations from the Swedish National Board of Health and Welfare ( 12 ), patients aged 75 years or older who are prescribed five or more medications have the right to receive a yearly medication review with a physician. This helps ensure that their medications are being used safely and effectively. Previous studies have demonstrated that involving clinical pharmacists in medication reviews can result in safer medication use in various populations ( 13 ), including individuals with dementia ( 14 ). However, healthcare professionals’ perspectives on the implementation of medication reviews and other pharmacist services have received less attention. This is crucial because successful implementation depends on their acceptance, given factors such as time constraint and information ( 15 ). In a previous qualitative study, GPs in Sweden expressed a positive attitude towards collaborating with clinical pharmacists in hospitals ( 16 ). However, they also emphasized their autonomy as decision-makers and the need for more information about the service, such as how to get in touch with the pharmacist when needed. The management of a Swedish county recently proposed introducing clinical pharmacists to conduct medication reviews for people with dementia living in special housing. However, a top-down approach may result in less employee commitment to new ways of working compared to a bottom-up approach, where employees are involved and have input in the process ( 17 ). Therefore, it is critical to understand the perspectives and experiences of healthcare professionals when evaluating the success of the new work process. In this study, representatives of all healthcare professionals closely involved in a patient’s care were interviewed to gain a comprehensive understanding of their experiences. The aim was to explore healthcare professionals’ views on the implementation of pharmacist-supported medication reviews in special housing for people with dementia. Methods Study design The study used a descriptive qualitative design, involving semi-structured interviews that were analyzed using qualitative content analysis guided by Graneheim and Lundman ( 18 ). Setting The study was conducted in special housing in a municipality in southern Sweden. Since 1996 the non-profit organization Silviahemmet Foundation has offered registered nurses and assistant nurses to complete a one-year course in advanced dementia care at Sophiahemmet University, after which they receive the exclusive title Silvia Nurse or Silvia Sister from HM Queen Silvia ( 19 ). The Silvia Nurses and Silvia Sisters worked in special housing, while general practitioners (GPs) worked at different nearby healthcare centers in the southeast region of Sweden. All interviewed GPs had one or more patients in the special housing where the Silvia nurses and sisters worked. The pharmacist, employed by the county council, provided medication review services to patients in special housing. Sampling and recruitment of participants A purposive sampling strategy was used to identify and recruit healthcare professionals who provide care in special housing for individuals with dementia. The eligible healthcare professionals included registered nurses, assistant nurses, GPs, and pharmacists. All registered nurses and assistant nurses had qualifications in caring for individuals with cognitive decline and all held a Queen Silvia (Assistant) Nurse Diploma. Healthcare professionals who had participated in or collaborated with the pharmacist on a medication review were eligible for inclusion. The leadership informed healthcare professionals about the study, and contact details were forwarded to the researchers. ECL provided further information about the study to potential informants, and all but one GP agreed to participate in the study. Data collection A semi-structured interview guide was developed by ECL and ME to explore how healthcare professionals involved in multi-disciplinary medication reviews viewed the process and potential outcomes. Due to the COVID-19 pandemic and the researcher (ECL) being in a different city than the informants, the interviews were conducted over the phone. All interviews were audio-recorded and transcribed verbatim by a professional. Data collection continued until saturation was reached, indicating no further new information was emerging ( 20 ). A total of four GPs, two nurses, two assistant nurses and one pharmacist were interviewed. The interviews’ duration ranged from 18 to 46 minutes, with an average length of 32 minutes. Participants were not reimbursed for their time as interviews took place during office hours. Data analysis The interview data were analyzed using qualitative content analysis guided by Graneheim and Lundman ( 18 ), led by CC. First, the verbatim transcripts were read thoroughly several times to gain an overall understanding of the data. Meaningful units containing sentences or phrases related to the aim were identified and labeled with descriptive codes close to the text. Next, the codes were compared and contrasted with other codes, and similar codes were merged. Related codes were classified into subcategories, mainly reflecting the manifest content of the text. Finally, broader main categories were formed by grouping related subcategories together. The analysis was iterative, with codes, subcategories, and categories continuously modified during the analysis process. To increase trustworthiness of the results, there was an ongoing dialogue among all the authors throughout the analysis process. Refinements were made until agreement was reached about the content of the analysis. Ethics Ethical approval was granted by the Swedish Ethical Review Authority (2019–06322), and the Consolidated Criteria for Reporting Qualitative Studies (COREQ) ( 21 ) was used to report the findings of this study. Results The results describe healthcare professionals’ (GPs, pharmacist, nurses and nurse assistants) experiences of medication reviews conducted by a clinical pharmacist for individuals with dementia. The results are organized into three categories and 11 subcategories identified in the analysis, as shown in Table 1 . Table 1 Categories and subcategories extracted from content analysis. Categories Subcategories Integrating multidisciplinary approaches for holistic dementia care Balancing medication and care in dementia treatment Addressing discrepancies in medication management Challenges and benefits of continuity in dementia patient care Family dynamic and communication in dementia care Optimizing medication safety through pharmacy involvement and staff education Strengthening dementia care through effective communication, medication management, and teamwork The role and challenges of medication reviews in dementia care Communication barriers in collaborative dementia care Valuing interprofessional collaboration and education in dementia care Advancing dementia care through pharmacist integration and role expansion The impact of pharmacist involvement in medication management Integrating pharmacists for comprehensive care in multidisciplinary teams Expanding pharmacist roles to enhance patient care and support GPs Integrating care, collaboration, and education to improve dementia treatment Balancing medication and care in dementia treatment Regarding medication selection and dosing, nurses expressed a greater focus on non-pharmacological treatments compared to GPs. They emphasized that pharmacological treatment was not always the best treatment option for individuals with dementia. Pain was as an example where nurses instead favored a greater focus on the caring aspects as a more suitable and safer approach to relieve symptoms. “ We strive for individuals with dementia to have as few medications as possible ” IP6, nurse Nurses also expressed concern about the overuse of antipsychotic medications, which they felt were sometimes prescribed for the wrong indication. They also raised concerns that not all individuals with dementia were receiving anti-dementia medications, which they believed more individuals should be prescribed. Nurses attributed some GPs’ lack of specialist training in dementia care as a major barrier to making appropriate medication decisions. However, they also acknowledged that some GPs commitment and knowledge were enablers for achieving safe and appropriate medication use. “ I actually think, unfortunately, that the knowledge among our general practitioners here at the healthcare centers is not really there either, with dementia medications and such, and then they resort to these sedative medications instead. ” IP6, nurse Nurse assistants perceived that they had detailed knowledge about the individuals, which was vital for GPs to make informed decisions about medication regimens. However, they felt frustrated that their input was not fully utilized. They rarely met with GPs and instead provided their input to the nurse, who may or may not have brought it up with the GP. Nurse assistants were concerned that misinterpretation of an individual’s symptoms could lead to inappropriate medication interventions, but this concern was not reflected in the GPs’ responses. GPs, on the other hand, seemed more focused on continuous monitoring after starting a new medication or making a dose change. They emphasized the importance of evaluating a patient’s medication regimen to prevent or avoid possible harms of medications. “ But I think it’s important in the long run with follow-up, that every time I start a new blood pressure medication, there is a follow-up after 30 days, whether you like it or not, whether it’s over the phone or in person. ” IP8, GP Addressing discrepancies in medication management Several healthcare professionals in the study expressed concerns about incomplete and inaccurate medication and prescription lists. Nurses described how they used medication administration lists to administer medications to residents, which could be different from the list of current prescriptions. GPs acknowledged their responsibility to cancel current prescriptions when a medication has been ceased or there is a dose change. This was seen as a way to improve the accuracy of medication lists and prevent medication errors. Having access to the same information was also considered to be of great importance. Some healthcare professionals mentioned that they shared the same medication lists, which provided a common ground. The pharmacist recognized that the dose-dispensing system provided a low risk for discrepancies. Challenges and benefits of continuity in dementia patient care Most of the healthcare professionals in the study emphasized the importance of continuity of care. They raised concerns about patients seeing multiple GPs’, which could interfere with the treatment plan and compromise patient safety. Seeing the same patients over time was described as making the work more efficient for GPs and contributing to patient safety. However, one nurse pointed out that patients’ right to choose a GP constitutes an obstacle to having one GP, preferably someone with specialist training and interest in dementia care, attend to all individuals with dementia in special housing. Instead, nurses had to liaise with many different GPs, some of whom had a strong interest in geriatric patients and patients with dementia while other GPs were more interested in other patient populations. In this collaborative project where a clinical pharmacist performed medication reviews, the GPs’ visited the residents in special housing, promoting continuity of care and improving medication safety. This continuity of care also extended beyond GPs, as all medication reviews in this project were conducted by the same clinical pharmacist. Nurse assistants and registered nurses appreciated this, as they got to know the pharmacist and knew what to expect from them and what they could contribute. Family dynamic and communication in dementia care The relationships that staff were able to form with the residents and their next-of-kin were identified as other factors that influenced patient care. Caring for individuals with dementia can be complicated because they are often unable to communicate what is troubling them. One GP reported that it was sometimes difficult to discontinue medications due to reluctance from either the individual with dementia or their next-of-kin. On the other hand, one nurse reported that most relatives felt comfortable handing over the responsibility of medication management to healthcare professionals. This was because the relatives were often exhausted from caring for someone with dementia over a long period of time. Optimizing medication safety through pharmacy involvement and staff education Nurses and nurse assistants perceived their role in providing safe care for their patients regarding medications. The dose-dispensing system, where a patient’s regular medications are individually packaged in dose units in a pharmacy and delivered to individuals in special housing or collected by staff every fortnight, was perceived as an improvement in medication safety. However, nurse assistants found it difficult to identify tablets by appearance due to generic substitutions, highlighting the importance of having sufficient medication knowledge. One nurse assistant emphasized the important role of pharmacists in educating and informing nurse assistants about changes in medication. The pharmacist had received requests to help with continuing education, confirming the need for more education and the potential to use pharmacists as a valuable resource of medication knowledge. Strengthening dementia care through effective communication, medication management, and teamwork The role and challenges of medication reviews in dementia care Healthcare professionals viewed medication reviews as a meaningful method for improving patient treatment. The pharmacist highlighted medication reviews could provide an opportunity to optimize a patient’s overall treatment plan. One nurse stressed the importance of reviewing all medication when a new individual moves into special housing. While medication reviews were considered useful, one GP expressed skepticism that they could solve all dementia-related problems. GPs viewed performing medication reviews as a natural component of patient visits for assessing the benefits and side-effects of prescribed medication, particularly for older adults who are prescribed multiple medications. However, GPs differed in their approach to when and how to conduct medication reviews. In most cases, performing a simple medication review was regarded as sufficient, and a comprehensive medication review was almost never considered necessary. However, sometimes an initial simple medication review would evolve into a comprehensive review when needed. During a medication review, GPs recognized the importance of considering clinical data, side effects, and the risk of interactions. GPs described the procedure as a thorough evaluation of all medications, in discussion with the patient when possible. This was also an opportunity to identify and correct potential medication discrepancies. “ So, I go through each medication, what effects and side effects they may have had on patients. Are there any risks of side effects, such as dizziness and falls, and are there any other side effects that cause suffering for the patient? What is the benefit of this medication? And what is the harm? We weigh the benefits against the harm. Does the patient even need it? How is their kidney function, liver function, and risk of interactions ?” IP2, GP GPs and the pharmacist highlighted the importance of having sufficient time to conduct a meaningful medication review, particularly for complex patients requiring a comprehensive medication review. However, due to time restraints, one GP only considered new medications and not medications the patient had used long-term during medication reviews. A lack of time was perceived as a significant barrier and threat to patient safety. A GP described time constraints like this: ” The biggest threat, which is actually the most important, is that the doctor does not have time to devote to medication review during the meeting with the patient and cannot go through the patient’s treatment .” IP2, GP However, one GP viewed involving pharmacists in conducting medication reviews as resource-intensive and resulting in double work, as both the GP and the pharmacist had to document their findings. Additionally, if the pharmacist had identified suboptimal treatment and recommended a change, the GP still had to devote time to understand the problem and consider the recommended solution against other alternatives. Communication barriers in collaborative dementia care During the interviews, participants highlighted how communication as a transfer of information affected collaboration and the ability to see the overall picture. Both the pharmacist and a nurse raised concerns about communication difficulties with GP. A barrier discussed was the lack of direct communication between the pharmacist and GPs, which obstructed effective collaboration. After conducting a medication review, the pharmacist entered medical notes into the electronic medical record and sent a digital message to the GP. However, a shortcoming described was the lack of possibility to nuance recommendations. Nevertheless, the pharmacist expressed a willingness to be more involved and easily accessible for GPs for further communication. Deficient communication between GPs and nurses was also described, as changes in medication could be made without notice, posing a risk to patient safety, according to the nurse. The willingness of GPs to initiate contacts with colleagues was also questioned internally. Additionally, GPs reported not always receiving feedback after specialist care at referral hospitals, making it difficult to have control over current medication regimen. It was also challenging for GPs to obtain enough information from hospitals about patients' medication and treatment, despite established digital communication methods. Valuing interprofessional collaboration and education in dementia care The work of the pharmacist was mostly appreciated by other healthcare professionals, and the pharmacist experienced that GPs were grateful for the work done. It was believed that pharmacists have an important role in meeting primary care needs, and the introduction of municipality pharmacists was suggested to achieve better drug use. One nurse described that the project had been educational for them and led to greater vigilance regarding medication treatment. The discussion climate was mostly described by participants as open and respectful, and building personal relationships through physical visits was identified as an important facilitator. " It has been very positive, partly for my own part, that you have learned a lot and started to reflect a lot on the medication that the person uses, that you should always think about whether they are current, and so on ." IP9, nurse However, as GPs have overall responsibility for the patient's care, one GP did not feel comfortable implementing the pharmacist's recommendation without further consideration. Not all GPs shared this view, and some appreciated the input from the pharmacist and the ability to discuss pharmacotherapy with another healthcare professional. When asked for possible solutions or other ways of collaborating, the pharmacist suggested more resources in terms of personnel so that different healthcare professionals could meet, discuss, and agree on a solution, rather than communicating through messages. This would facilitate more effective collaboration and reduce the need for double work. However, one nurse felt that they were less listened to by physicians, indicating a need for further improvement in communication and collaboration between healthcare professionals. Advancing dementia care through pharmacist integration and role expansion The impact of pharmacist involvement in medication management Most GPs viewed pharmacists as reliable healthcare professionals who served as an important source of medication expertise. These GPs appreciated that involving a pharmacist saved time, as they were provided with recommendations and viewpoints in advance of their meetings with patients. Treatment proposals by pharmacists were often seen as relevant and contributing to patient safety. “ I think that these people [pharmacists]do a great job and make a big contribution to the patient’s medication safety .” IP4, GP The pharmacist experienced that the GPs' need for support varied depending on their level of professional confidence. They also pointed out that GPs had not been given the opportunity to discuss with the pharmacist the types of medication related problems they wanted help with. As a result, the collaboration between GPs and the pharmacist was described as suboptimal. One nurse believed that it would be valuable for GPs to have the pharmacist as a discussion partner in cases of disagreements, and it was also suggested that GPs would benefit from initiating more contact with the pharmacist. Pharmacists were also found to provide valuable support to nurses and assistant nurses. For one nurse, receiving confirmation from a pharmacist was empowering and made it easier to stand up to GPs in cases of suspected suboptimal treatment. The pharmacist reported that nurses asked for help with medication administration problems, such as tablet crushing or splitting. Additionally, one assistant nurse stated that it was preferable to ask a pharmacist rather than a GP for medication-related questions. However, the possibility to initiate contact with pharmacists was limited to GPs, and one nurse desired the opportunity to ask the pharmacist directly in case of questionable medication decisions. Integrating pharmacists for comprehensive care in multidisciplinary teams The pharmacist highlighted how the different professions completed each other by applying pharmaceutical consideration, caring, and medical treatment. One GP pointed out that pharmacists can offer help in discovering medication interactions in patients who have recently been hospitalized. However, as pointed out by one nurse, the pharmacist needs to take into account the whole story behind the medication choices made and not only have pharmaceutical considerations in mind. Therefore, collaboration with assistant nurses working close with the individual with dementia was described as necessary to aid the pharmacist in making optimal treatment suggestions. One nurse said that the pharmacist's questions stimulated reflection on the individual’s medication, and the knowledge learned from the pharmacist was applied to other individuals. Involving a pharmacist at the time of diagnosis was suggested by a nurse to prolong the time at home for patients with dementia and improve their well-being. Furthermore, one GP stated that the use of pharmacist services was most valuable for optimizing treatment in elderly patients (75–85 years of age) with many medications. Consequently, the management of patients with multimorbidity and dementia was said to especially benefit from the support of a pharmacist. One shortcoming that was brought up by both the pharmacist and a nurse was the absence of follow-up on the pharmacist’s recommendations: “ Currently, there is no direct follow-up on those recommendations, uh... regarding whether they benefit the patient in the long run. It would have been very interesting to follow up on how... both the municipal staff and then... relatives and doctors, to see if there has been any difference in the recommendations like that.” IP3, pharmacist Expanding pharmacist roles to enhance patient care and support GPs One GP mentioned potential areas for future pharmacist work tasks, such as routine prescription renewals and blood pressure measurements, which could reduce workload for the GP. It was also suggested that pharmacists could make home visits to check how patients handle their medications. Furthermore, one nurse believed that it would be valuable for individuals in special housing to have medication reviews conducted by pharmacists, as these patients may receive medical care from many different providers. Discussion The aim of this study was to explore the views of healthcare professionals towards the implementation of pharmacist-supported medication reviews in special housing homes for people with dementia. The main results indicate that healthcare professionals value the expertise of pharmacists, particularly in ensuring medication safety and efficiency in patient care. Communication challenges between pharmacists and other healthcare staff were identified, affecting the optimal integration of pharmacists’ recommendations. There is consensus on the potential benefits of expanding pharmacists’ roles, including routine prescription management and home visits, to better support GPs and enhance patient care. However, a lack of follow-up on the implementation of pharmacists’ suggestions was noted, highlighting a gap in assessing the long-term benefits of involvement in dementia care. Despite the generally positive views of healthcare professionals towards the contributions of pharmacists and the value of their input in medication management, there was some skepticism regarding the suitability of pharmacist-supported medication reviews for individuals with dementia who live in special housing facilities where they receive care and oversight. This level of monitoring may not require the same level of intervention as needed for other patient groups. Instead, it was suggested that individuals living independently at home, especially those with multiple comorbidities and polypharmacy, might be a more suitable target group for pharmacist involvement. Furthermore, the shortage of GPs, which poses a potential risk to patient safety ( 22 ), needs to be addressed. Leveraging pharmacists’ expertise through targeted task shifting could potentially alleviate the pressure on overburdened GPs ( 23 ). While this approach is promising, concerns regarding patient safety have been raised in a Norwegian study examining horizontal task-shifting between specialists with varying levels of expertise ( 24 ). This highlights the importance of careful planning and preparation before implementing task-shifting across professions. To optimize the potential benefits of pharmacist involvement for GPs, it is recommended that GPs proactively identify and refer patients who could benefit most from pharmacists’ expertise, including patients experiencing polypharmacy, side effects, or medication efficacy issues. This targeted approach could ensure pharmacist interventions are directed where they are most needed, enhancing patient safety and care outcomes. Effective communication within multidisciplinary teams is vital in ensuring high-quality patient care, particularly for vulnerable populations. While the interviewed healthcare professionals recognize the value of pharmacists in medication management, there are communication challenges that hinder the optimal integration of pharmacists’ recommendations. These challenges are not unique to this study; previous research has consistently highlighted the critical role of clear and structured communication channels in multidisciplinary healthcare settings ( 25 , 26 ). Opportunities for improvement include establishing regular interdisciplinary meetings and utilizing shared electronic health records to facilitate real-time information exchange. Interprofessional learning, whether at the workplace or as part of students’ education, could be a valuable facilitator for overcoming these barriers ( 27 ). Furthermore, actively engaging patients in communication, where feasible, can personalize care, ensuring medication regimens align with both guidelines and individual needs and preferences, particularly when treatment goals shift from prolonging life to enhancing quality of life ( 28 ). Addressing these communication barriers is essential to fully realize the potential benefits of pharmacist involvement in dementia care, as it would foster a more cohesive approach to medication management and ultimately enhance patient outcomes. The potential for expanding the role of pharmacists is a topic of growing interest in Sweden, particularly as a strategy to alleviate the increasing workload on GPs and to provide more comprehensive care. This study suggests that pharmacists could assume additional responsibilities, such as managing routine prescription renewals and performing home visits, especially for patients with complex care needs. This proposed expansion mirrors the successful integration of nurse prescribing rights in certain clinical areas ( 29 ) and the role of clinical pharmacists in other countries ( 30 , 31 ). Empowering pharmacists in a similar capacity would not only enhance the quality of care for patients by ensuring more timely and precise medication management but also contribute to a more efficient use of healthcare resources. By redistribution of certain tasks traditionally performed by GPs to pharmacists, the healthcare system can leverage the specialized knowledge of pharmacists to improve patient outcomes and address the challenges of an overburdened primary care infrastructure. Strengths and limitations A diverse range of healthcare professionals were interviewed, offering rich insights into the complexity of medication management among people with dementia. We endeavored to interview all relevant professionals who had participated in medication reviews and found conflicting views, especially among GPs. It had been interesting to interview more GPs to elicit their perspective, but as this was a new initiative no more GPs than were interviewed had been involved in multidisciplinary medication reviews. Conclusion This study contributes valuable insights into optimizing medication management practices, a key aspect of enabling individuals with dementia to live safely and comfortably at home. While the expertise of pharmacists is highly valued in ensuring medication safety and enhancing the efficiency of patient care, communication barriers within the multidisciplinary team pose significant challenges to fully integrating pharmacists’ recommendations. The potential for role expansion of pharmacists is recognized as a promising avenue to alleviate the workload of GPs. A thorough evaluation of potential patient safety risks is essential to fully realize the benefits of pharmacist contributions to dementia care while ensuring medication safety and maintain the patient care efficiency. Declarations Ethics approval and consent to participate Ethical approval was granted by the Swedish Ethical Review Authority (2019-06322), and all participant provided informed consent prior to the interview. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to the participants not providing consent for their data to be shared publicly, but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by a grant from Forte – The Swedish Research Council for health, Working Life and Welfare, project number 2016-00148. Author’s contributions CC has been involved in the analysis of data, the interpretation of data, and the drafting of the manuscript. ME and ECL have made significant contributions to the conception and design of the study, the interpretation of data, and have substantively revised the manuscript. ECL collected the data. All authors have approved the submitted version. Acknowledgements The authors would like to express their gratitude to Anna Lindahl for her valuable contribution to the initial data analysis. Additionally, we extend our sincere thanks to all the participants who took the time to engage in the interviews. References Arvanitakis Z, Shah RC, Bennett DA. Diagnosis and Management of Dementia: Review. Jama. 2019;322(16):1589-99. Afram B, Stephan A, Verbeek H, Bleijlevens MH, Suhonen R, Sutcliffe C, et al. Reasons for institutionalization of people with dementia: informal caregiver reports from 8 European countries. J Am Med Dir Assoc. 2014;15(2):108-16. Sveriges Kommuner och Regioner. Särskilt boende för äldre (SÄBO) [Internet]. Stockholm: Sveriges Kommuner och Regioner; 3 October 2023 [Available from: https://skr.se/skr/integrationsocialomsorg/socialomsorg/aldre/sarskiltboendealdre.28193.html. World Health Organization. Dementia [Internet]. World Health Organization; March 15, 2023 [Available from: https://www.who.int/news-room/fact-sheets/detail/dementia. Socialstyrelsen. En nationell strategi för demenssjukdom. 2022. Lindblad M, Flink M, Ekstedt M. Safe medication management in specialized home healthcare - an observational study. BMC health services research. 2017;17(1):598. Bunn F, Burn AM, Goodman C, Rait G, Norton S, Robinson L, et al. Comorbidity and dementia: a scoping review of the literature. BMC medicine. 2014;12:192. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC geriatrics. 2017;17(1):230. Cross AJ, Etherton-Beer CD, Clifford RM, Potter K, Page AT. Exploring stakeholder roles in medication management for people living with dementia. Research in social & administrative pharmacy : RSAP. 2021;17(4):707-14. Molist-Brunet N, Sevilla-Sánchez D, Puigoriol-Juvanteny E, Barneto-Soto M, González-Bueno J, Espaulella-Panicot J. Improving individualized prescription in patients with multimorbidity through medication review. BMC geriatrics. 2022;22(1):417. Griese-Mammen N, Hersberger KE, Messerli M, Leikola S, Horvat N, van Mil JWF, et al. PCNE definition of medication review: reaching agreement. International journal of clinical pharmacy. 2018;40(5):1199-208. Socialstyrelsen. Socialstyrelsens föreskrifter och allmänna råd (HSLF-FS 2017:37) om ordination och hantering av läkemedel i hälso- och sjukvården [Internet]. Socialstyrelsen; 6 February 2020 [updated September 15, 2022. Available from: https://patientsakerhet.socialstyrelsen.se/lagar-och-foreskrifter/foreskrifter-och-handbocker/hslf-fs-201737/. Jokanovic N, Tan EC, Sudhakaran S, Kirkpatrick CM, Dooley MJ, Ryan-Atwood TE, et al. Pharmacist-led medication review in community settings: An overview of systematic reviews. Research in social & administrative pharmacy : RSAP. 2017;13(4):661-85. McDerby N, Kosari S, Bail K, Shield A, Peterson G, Naunton M. Pharmacist-led medication reviews in aged care residents with dementia: A systematic review. Australas J Ageing. 2020;39(4):e478-e89. Bø KE, Halvorsen KH, Risør T, Lehnbom EC. 'Illuminating determinants of implementation of non-dispensing pharmacist services in home care: a qualitative interview study'. Scandinavian journal of primary health care. 2023;41(1):43-51. Vinterflod C, Gustafsson M, Mattsson S, Gallego G. Physicians' perspectives on clinical pharmacy services in Northern Sweden: a qualitative study. BMC health services research. 2018;18(1):35. Gadolin C, Andersson T. Healthcare quality improvement work: a professional employee perspective. Int J Health Care Qual Assur. 2017;30(5):410-23. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-12. Stiftelsen Silviahemmet. Utbildning i demensvård [Internet]. Drottningholm: Stiftelsen Silviahemmet; [Available from: https://www.silviahemmet.se/utbildning/. Kvale S, Brinkmann S. Det kvalitative forskningsintervju [InterView: Learning the craft of qualitative research interviewing]. 3. ed. Oslo: Gylendal; 2021. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2007;19(6):349-57. Hicks R. Current staff shortages a significant threat to patient saefty, say doctors. Medscape UK. 19 May 2023. Groenewegen P, Boerma WGW, Spreeuwenberg P, Seifert B, Schäfer W, Batenburg R, et al. Task shifting from general practitioners to practice assistants and nurses in primary care: a cross-sectional survey in 34 countries. Prim Health Care Res Dev. 2022;23:e60. Malterud K, Aamland A, Fosse A. How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway. Scandinavian journal of primary health care. 2020;38(1):24-32. Radcliffe E, Servin R, Cox N, Lim S, Tan QY, Howard C, et al. What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis. BMC geriatrics. 2023;23(1):591. Brooks L, Elliott J, Stolee P, Boscart VM, Gimbel S, Holisek B, et al. Development, successes, and potential pitfalls of multidisciplinary chronic disease management clinics in a family health team: a qualitative study. BMC Prim Care. 2023;24(1):126. Verbeek FHO, van Lierop MEA, Meijers JMM, van Rossum E, Zwakhalen SMG, Laurant MGH, et al. Facilitators for developing an interprofessional learning culture in nursing homes: a scoping review. BMC health services research. 2023;23(1):178. Reeve E, Bell JS, Hilmer SN. Barriers to Optimising Prescribing and Deprescribing in Older Adults with Dementia: A Narrative Review. Curr Clin Pharmacol. 2015;10(3):168-77. Koskiniemi S, Sund R, Liukka M, Härkänen M. Readmissions after appointments with nurse prescribers: A register-based study. J Clin Nurs. 2023;32(21-22):7783-90. Birt L, Dalgarno L, Poland F, Wright D, Bond C. What happens when pharmacist independent prescribers lead on medicine management in older people's care homes: a qualitative study. BMJ open. 2023;13(10):e068678. Walpola RL, Issakhany D, Gisev N, Hopkins RE. The accessibility of pharmacist prescribing and impacts on medicines access: A systematic review. Research in social & administrative pharmacy : RSAP. 2024. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 10 Apr, 2024 Reviews received at journal 09 Apr, 2024 Reviews received at journal 02 Apr, 2024 Reviewers agreed at journal 01 Apr, 2024 Reviewers agreed at journal 30 Mar, 2024 Reviewers invited by journal 28 Mar, 2024 Editor assigned by journal 28 Mar, 2024 Editor invited by journal 04 Mar, 2024 Submission checks completed at journal 04 Mar, 2024 First submitted to journal 21 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3975153","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276165381,"identity":"9034aaae-8158-4558-bf5a-c56f06c97e83","order_by":0,"name":"Catharina Carlqvist","email":"","orcid":"","institution":"Linnaeus University","correspondingAuthor":false,"prefix":"","firstName":"Catharina","middleName":"","lastName":"Carlqvist","suffix":""},{"id":276165382,"identity":"99904d00-e6df-441d-bac7-5c3cbe33e5b4","order_by":1,"name":"Mirjam Ekstedt","email":"","orcid":"","institution":"Linnaeus University","correspondingAuthor":false,"prefix":"","firstName":"Mirjam","middleName":"","lastName":"Ekstedt","suffix":""},{"id":276165383,"identity":"6878c172-0a4a-4c3d-91cc-803de3715ee2","order_by":2,"name":"Elin Christina Lehnbom","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACdsYGECXDIMHABqRtwCR+wAzRwgPVksbARlAPM4SCaTnMQNAafmbmtgcMNQw8/NK9xx58zDmf2CffwPbgAx4tks2M7QYMxxh4JOecSzecue12YhsbA7vhDDxaDA4ztkkAvcNjcCPHTJoXooVNmgePFnuYFnuIlnOEtRgww2yRAGs5QFiLBMiWhGMSPBI3csyBfkk2bmNLbJPE5xf+9vZnEh9qbOT4Z+SYPfi4zU52fvPhYxL4QgwMEoCRggQgkTsKRsEoGAWjgAIAAH7iPMaD+6UcAAAAAElFTkSuQmCC","orcid":"","institution":"UiT The Arctic University of Norway","correspondingAuthor":true,"prefix":"","firstName":"Elin","middleName":"Christina","lastName":"Lehnbom","suffix":""}],"badges":[],"createdAt":"2024-02-21 10:01:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3975153/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3975153/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52077015,"identity":"81698b9b-c4b8-447e-bcb5-5c9c6e5b9d30","added_by":"auto","created_at":"2024-03-06 10:00:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":479662,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3975153/v1/7ab096d0-0edf-48bb-859b-34e2bee33863.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Collaborating with pharmacists to improve medication use in dementia care: views from healthcare professionals in Sweden","fulltext":[{"header":"Background","content":"\u003cp\u003eDementia is a term used to describe several chronic and progressive diseases that cause significant damage to the brain. Depending on which parts of the brain are affected, dementia can manifest itself in different ways, but common symptoms include impaired memory, language deficits, problems with time perception and loss of orientation skills (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Dementia can also cause changes in behavior, such as increased anxiety and aggression, which can be challenging for family and caregivers to handle (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). As a result, special housing for the elderly (S\u0026Auml;BO) has been established in Sweden to provide apartment-based care that aims to create a supportive environment for individuals with dementia. S\u0026Auml;BO is both the person\u0026acute;s home and a care environment and workplace (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to the World Health Organization (WHO), over 55\u0026nbsp;million people worldwide are currently living with dementia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), with 130,000\u0026ndash;150,000 cases in Sweden alone. As the elderly population continues to grow, the prevalence of dementia is expected to increase in the coming years (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Sweden, local municipalities are responsible for providing care to residents in special housing, as outlined in the national Social Services Act. Healthcare professionals who provide direct patient care in special housing typically include enrolled nurses, nursing assistants with upper secondary level schooling, and registered nurses. Registered nurses often delegate the administration of medications to enrolled nurses and nursing assistants who have training in medication administration (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are several medications available to treat the symptoms of dementia. However, since many people with \u003cb\u003edementia\u003c/b\u003e also have other chronic conditions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), they are at a high risk of polypharmacy. Polypharmacy refers to the concurrent use of multiple medications, which can increase the likelihood of potentially dangerous drug interactions or undesirable side effects. While there is no exact definition of the number of medications that constitutes polypharmacy, it typically refers to the use of five or more medications (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is crucial to take steps to optimize medical treatment for individuals with dementia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This can be achieved by carefully selecting pharmacological and non-pharmacological treatments, stopping medications that are no longer needed, and adjusting dosages to minimize or prevent drug-related problems. Medication reviews, which involve a structured evaluation of a patient's medications, have been recommended as a method to identify and resolve drug-related harm (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). According to regulations from the Swedish National Board of Health and Welfare (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), patients aged 75 years or older who are prescribed five or more medications have the right to receive a yearly medication review with a physician. This helps ensure that their medications are being used safely and effectively.\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated that involving clinical pharmacists in medication reviews can result in safer medication use in various populations (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), including individuals with dementia (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, healthcare professionals\u0026rsquo; perspectives on the implementation of medication reviews and other pharmacist services have received less attention. This is crucial because successful implementation depends on their acceptance, given factors such as time constraint and information (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In a previous qualitative study, GPs in Sweden expressed a positive attitude towards collaborating with clinical pharmacists in hospitals (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, they also emphasized their autonomy as decision-makers and the need for more information about the service, such as how to get in touch with the pharmacist when needed.\u003c/p\u003e \u003cp\u003eThe management of a Swedish county recently proposed introducing clinical pharmacists to conduct medication reviews for people with dementia living in special housing. However, a top-down approach may result in less employee commitment to new ways of working compared to a bottom-up approach, where employees are involved and have input in the process (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Therefore, it is critical to understand the perspectives and experiences of healthcare professionals when evaluating the success of the new work process.\u003c/p\u003e \u003cp\u003eIn this study, representatives of all healthcare professionals closely involved in a patient\u0026rsquo;s care were interviewed to gain a comprehensive understanding of their experiences. The aim was to explore healthcare professionals\u0026rsquo; views on the implementation of pharmacist-supported medication reviews in special housing for people with dementia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study used a descriptive qualitative design, involving semi-structured interviews that were analyzed using qualitative content analysis guided by Graneheim and Lundman (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in special housing in a municipality in southern Sweden. Since 1996 the non-profit organization Silviahemmet Foundation has offered registered nurses and assistant nurses to complete a one-year course in advanced dementia care at Sophiahemmet University, after which they receive the exclusive title Silvia Nurse or Silvia Sister from HM Queen Silvia (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). The Silvia Nurses and Silvia Sisters worked in special housing, while general practitioners (GPs) worked at different nearby healthcare centers in the southeast region of Sweden. All interviewed GPs had one or more patients in the special housing where the Silvia nurses and sisters worked. The pharmacist, employed by the county council, provided medication review services to patients in special housing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and recruitment of participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA purposive sampling strategy was used to identify and recruit healthcare professionals who provide care in special housing for individuals with dementia. The eligible healthcare professionals included registered nurses, assistant nurses, GPs, and pharmacists. All registered nurses and assistant nurses had qualifications in caring for individuals with cognitive decline and all held a Queen Silvia (Assistant) Nurse Diploma.\u003c/p\u003e\n\u003cp\u003eHealthcare professionals who had participated in or collaborated with the pharmacist on a medication review were eligible for inclusion. The leadership informed healthcare professionals about the study, and contact details were forwarded to the researchers. ECL provided further information about the study to potential informants, and all but one GP agreed to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA semi-structured interview guide was developed by ECL and ME to explore how healthcare professionals involved in multi-disciplinary medication reviews viewed the process and potential outcomes. Due to the COVID-19 pandemic and the researcher (ECL) being in a different city than the informants, the interviews were conducted over the phone. All interviews were audio-recorded and transcribed verbatim by a professional. Data collection continued until saturation was reached, indicating no further new information was emerging (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). A total of four GPs, two nurses, two assistant nurses and one pharmacist were interviewed. The interviews\u0026rsquo; duration ranged from 18 to 46 minutes, with an average length of 32 minutes. Participants were not reimbursed for their time as interviews took place during office hours.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eData analysis\u003c/h2\u003e\n \u003cp\u003eThe interview data were analyzed using qualitative content analysis guided by Graneheim and Lundman (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e), led by CC. First, the verbatim transcripts were read thoroughly several times to gain an overall understanding of the data. Meaningful units containing sentences or phrases related to the aim were identified and labeled with descriptive codes close to the text.\u003c/p\u003e\n \u003cp\u003eNext, the codes were compared and contrasted with other codes, and similar codes were merged. Related codes were classified into subcategories, mainly reflecting the manifest content of the text. Finally, broader main categories were formed by grouping related subcategories together. The analysis was iterative, with codes, subcategories, and categories continuously modified during the analysis process.\u003c/p\u003e\n \u003cp\u003eTo increase trustworthiness of the results, there was an ongoing dialogue among all the authors throughout the analysis process. Refinements were made until agreement was reached about the content of the analysis.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEthical approval was granted by the Swedish Ethical Review Authority (2019\u0026ndash;06322), and the Consolidated Criteria for Reporting Qualitative Studies (COREQ) (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e) was used to report the findings of this study.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe results describe healthcare professionals\u0026rsquo; (GPs, pharmacist, nurses and nurse assistants) experiences of medication reviews conducted by a clinical pharmacist for individuals with dementia. The results are organized into three categories and 11 subcategories identified in the analysis, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategories and subcategories extracted from content analysis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubcategories\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntegrating multidisciplinary approaches for holistic dementia care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBalancing medication and care in dementia treatment\u003c/p\u003e \u003cp\u003eAddressing discrepancies in medication management\u003c/p\u003e \u003cp\u003eChallenges and benefits of continuity in dementia patient care\u003c/p\u003e \u003cp\u003eFamily dynamic and communication in dementia care\u003c/p\u003e \u003cp\u003eOptimizing medication safety through pharmacy involvement and staff education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrengthening dementia care through effective communication, medication management, and teamwork\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe role and challenges of medication reviews in dementia care\u003c/p\u003e \u003cp\u003eCommunication barriers in collaborative dementia care\u003c/p\u003e \u003cp\u003eValuing interprofessional collaboration and education in dementia care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvancing dementia care through pharmacist integration and role expansion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe impact of pharmacist involvement in medication management\u003c/p\u003e \u003cp\u003eIntegrating pharmacists for comprehensive care in multidisciplinary teams\u003c/p\u003e \u003cp\u003eExpanding pharmacist roles to enhance patient care and support GPs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eIntegrating care, collaboration, and education to improve dementia treatment\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eBalancing medication and care in dementia treatment\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRegarding medication selection and dosing, nurses expressed a greater focus on non-pharmacological treatments compared to GPs. They emphasized that pharmacological treatment was not always the best treatment option for individuals with dementia. Pain was as an example where nurses instead favored a greater focus on the caring aspects as a more suitable and safer approach to relieve symptoms.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe strive for individuals with dementia to have as few medications as possible\u003c/em\u003e\u0026rdquo; IP6, nurse\u003c/p\u003e \u003cp\u003eNurses also expressed concern about the overuse of antipsychotic medications, which they felt were sometimes prescribed for the wrong indication. They also raised concerns that not all individuals with dementia were receiving anti-dementia medications, which they believed more individuals should be prescribed.\u003c/p\u003e \u003cp\u003eNurses attributed some GPs\u0026rsquo; lack of specialist training in dementia care as a major barrier to making appropriate medication decisions. However, they also acknowledged that some GPs commitment and knowledge were enablers for achieving safe and appropriate medication use.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI actually think, unfortunately, that the knowledge among our general practitioners here at the healthcare centers is not really there either, with dementia medications and such, and then they resort to these sedative medications instead.\u003c/em\u003e\u0026rdquo; IP6, nurse\u003c/p\u003e \u003cp\u003eNurse assistants perceived that they had detailed knowledge about the individuals, which was vital for GPs to make informed decisions about medication regimens. However, they felt frustrated that their input was not fully utilized. They rarely met with GPs and instead provided their input to the nurse, who may or may not have brought it up with the GP. Nurse assistants were concerned that misinterpretation of an individual\u0026rsquo;s symptoms could lead to inappropriate medication interventions, but this concern was not reflected in the GPs\u0026rsquo; responses.\u003c/p\u003e \u003cp\u003eGPs, on the other hand, seemed more focused on continuous monitoring after starting a new medication or making a dose change. They emphasized the importance of evaluating a patient\u0026rsquo;s medication regimen to prevent or avoid possible harms of medications.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eBut I think it\u0026rsquo;s important in the long run with follow-up, that every time I start a new blood pressure medication, there is a follow-up after 30 days, whether you like it or not, whether it\u0026rsquo;s over the phone or in person.\u003c/em\u003e\u0026rdquo; IP8, GP\u003c/p\u003e \u003cp\u003e \u003cb\u003eAddressing discrepancies in medication management\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeveral healthcare professionals in the study expressed concerns about incomplete and inaccurate medication and prescription lists. Nurses described how they used medication administration lists to administer medications to residents, which could be different from the list of current prescriptions.\u003c/p\u003e \u003cp\u003eGPs acknowledged their responsibility to cancel current prescriptions when a medication has been ceased or there is a dose change. This was seen as a way to improve the accuracy of medication lists and prevent medication errors.\u003c/p\u003e \u003cp\u003eHaving access to the same information was also considered to be of great importance. Some healthcare professionals mentioned that they shared the same medication lists, which provided a common ground. The pharmacist recognized that the dose-dispensing system provided a low risk for discrepancies.\u003c/p\u003e \u003cp\u003e \u003cb\u003eChallenges and benefits of continuity in dementia patient care\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMost of the healthcare professionals in the study emphasized the importance of continuity of care. They raised concerns about patients seeing multiple GPs\u0026rsquo;, which could interfere with the treatment plan and compromise patient safety. Seeing the same patients over time was described as making the work more efficient for GPs and contributing to patient safety.\u003c/p\u003e \u003cp\u003eHowever, one nurse pointed out that patients\u0026rsquo; right to choose a GP constitutes an obstacle to having one GP, preferably someone with specialist training and interest in dementia care, attend to all individuals with dementia in special housing. Instead, nurses had to liaise with many different GPs, some of whom had a strong interest in geriatric patients and patients with dementia while other GPs were more interested in other patient populations.\u003c/p\u003e \u003cp\u003eIn this collaborative project where a clinical pharmacist performed medication reviews, the GPs\u0026rsquo; visited the residents in special housing, promoting continuity of care and improving medication safety. This continuity of care also extended beyond GPs, as all medication reviews in this project were conducted by the same clinical pharmacist. Nurse assistants and registered nurses appreciated this, as they got to know the pharmacist and knew what to expect from them and what they could contribute.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFamily dynamic and communication in dementia care\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe relationships that staff were able to form with the residents and their next-of-kin were identified as other factors that influenced patient care. Caring for individuals with dementia can be complicated because they are often unable to communicate what is troubling them.\u003c/p\u003e \u003cp\u003eOne GP reported that it was sometimes difficult to discontinue medications due to reluctance from either the individual with dementia or their next-of-kin. On the other hand, one nurse reported that most relatives felt comfortable handing over the responsibility of medication management to healthcare professionals. This was because the relatives were often exhausted from caring for someone with dementia over a long period of time.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOptimizing medication safety through pharmacy involvement and staff education\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNurses and nurse assistants perceived their role in providing safe care for their patients regarding medications. The dose-dispensing system, where a patient\u0026rsquo;s regular medications are individually packaged in dose units in a pharmacy and delivered to individuals in special housing or collected by staff every fortnight, was perceived as an improvement in medication safety.\u003c/p\u003e \u003cp\u003eHowever, nurse assistants found it difficult to identify tablets by appearance due to generic substitutions, highlighting the importance of having sufficient medication knowledge. One nurse assistant emphasized the important role of pharmacists in educating and informing nurse assistants about changes in medication.\u003c/p\u003e \u003cp\u003eThe pharmacist had received requests to help with continuing education, confirming the need for more education and the potential to use pharmacists as a valuable resource of medication knowledge.\u003c/p\u003e\n\u003ch3\u003eStrengthening dementia care through effective communication, medication management, and teamwork\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eThe role and challenges of medication reviews in dementia care\u003c/b\u003e \u003c/p\u003e \u003cp\u003eHealthcare professionals viewed medication reviews as a meaningful method for improving patient treatment. The pharmacist highlighted medication reviews could provide an opportunity to optimize a patient\u0026rsquo;s overall treatment plan. One nurse stressed the importance of reviewing all medication when a new individual moves into special housing. While medication reviews were considered useful, one GP expressed skepticism that they could solve all dementia-related problems.\u003c/p\u003e \u003cp\u003eGPs viewed performing medication reviews as a natural component of patient visits for assessing the benefits and side-effects of prescribed medication, particularly for older adults who are prescribed multiple medications. However, GPs differed in their approach to when and how to conduct medication reviews.\u003c/p\u003e \u003cp\u003eIn most cases, performing a simple medication review was regarded as sufficient, and a comprehensive medication review was almost never considered necessary. However, sometimes an initial simple medication review would evolve into a comprehensive review when needed. During a medication review, GPs recognized the importance of considering clinical data, side effects, and the risk of interactions. GPs described the procedure as a thorough evaluation of all medications, in discussion with the patient when possible. This was also an opportunity to identify and correct potential medication discrepancies.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eSo, I go through each medication, what effects and side effects they may have had on patients. Are there any risks of side effects, such as dizziness and falls, and are there any other side effects that cause suffering for the patient? What is the benefit of this medication? And what is the harm? We weigh the benefits against the harm. Does the patient even need it? How is their kidney function, liver function, and risk of interactions\u003c/em\u003e?\u0026rdquo; IP2, GP\u003c/p\u003e \u003cp\u003eGPs and the pharmacist highlighted the importance of having sufficient time to conduct a meaningful medication review, particularly for complex patients requiring a comprehensive medication review. However, due to time restraints, one GP only considered new medications and not medications the patient had used long-term during medication reviews. A lack of time was perceived as a significant barrier and threat to patient safety. A GP described time constraints like this:\u003c/p\u003e \u003cp\u003e\u0026rdquo;\u003cem\u003eThe biggest threat, which is actually the most important, is that the doctor does not have time to devote to medication review during the meeting with the patient and cannot go through the patient\u0026rsquo;s treatment\u003c/em\u003e.\u0026rdquo; IP2, GP\u003c/p\u003e \u003cp\u003eHowever, one GP viewed involving pharmacists in conducting medication reviews as resource-intensive and resulting in double work, as both the GP and the pharmacist had to document their findings. Additionally, if the pharmacist had identified suboptimal treatment and recommended a change, the GP still had to devote time to understand the problem and consider the recommended solution against other alternatives.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCommunication barriers in collaborative dementia care\u003c/b\u003e \u003c/p\u003e \u003cp\u003e During the interviews, participants highlighted how communication as a transfer of information affected collaboration and the ability to see the overall picture. Both the pharmacist and a nurse raised concerns about communication difficulties with GP. A barrier discussed was the lack of direct communication between the pharmacist and GPs, which obstructed effective collaboration.\u003c/p\u003e \u003cp\u003e After conducting a medication review, the pharmacist entered medical notes into the electronic medical record and sent a digital message to the GP. However, a shortcoming described was the lack of possibility to nuance recommendations. Nevertheless, the pharmacist expressed a willingness to be more involved and easily accessible for GPs for further communication.\u003c/p\u003e \u003cp\u003eDeficient communication between GPs and nurses was also described, as changes in medication could be made without notice, posing a risk to patient safety, according to the nurse. The willingness of GPs to initiate contacts with colleagues was also questioned internally. Additionally, GPs reported not always receiving feedback after specialist care at referral hospitals, making it difficult to have control over current medication regimen. It was also challenging for GPs to obtain enough information from hospitals about patients' medication and treatment, despite established digital communication methods.\u003c/p\u003e \u003cp\u003e \u003cb\u003eValuing interprofessional collaboration and education in dementia care\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe work of the pharmacist was mostly appreciated by other healthcare professionals, and the pharmacist experienced that GPs were grateful for the work done. It was believed that pharmacists have an important role in meeting primary care needs, and the introduction of municipality pharmacists was suggested to achieve better drug use.\u003c/p\u003e \u003cp\u003eOne nurse described that the project had been educational for them and led to greater vigilance regarding medication treatment. The discussion climate was mostly described by participants as open and respectful, and building personal relationships through physical visits was identified as an important facilitator.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eIt has been very positive, partly for my own part, that you have learned a lot and started to reflect a lot on the medication that the person uses, that you should always think about whether they are current, and so on\u003c/em\u003e.\" IP9, nurse\u003c/p\u003e \u003cp\u003eHowever, as GPs have overall responsibility for the patient's care, one GP did not feel comfortable implementing the pharmacist's recommendation without further consideration. Not all GPs shared this view, and some appreciated the input from the pharmacist and the ability to discuss pharmacotherapy with another healthcare professional.\u003c/p\u003e \u003cp\u003e When asked for possible solutions or other ways of collaborating, the pharmacist suggested more resources in terms of personnel so that different healthcare professionals could meet, discuss, and agree on a solution, rather than communicating through messages. This would facilitate more effective collaboration and reduce the need for double work. However, one nurse felt that they were less listened to by physicians, indicating a need for further improvement in communication and collaboration between healthcare professionals.\u003c/p\u003e\n\u003ch3\u003eAdvancing dementia care through pharmacist integration and role expansion\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eThe impact of pharmacist involvement in medication management\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMost GPs viewed pharmacists as reliable healthcare professionals who served as an important source of medication expertise. These GPs appreciated that involving a pharmacist saved time, as they were provided with recommendations and viewpoints in advance of their meetings with patients.\u003c/p\u003e \u003cp\u003eTreatment proposals by pharmacists were often seen as relevant and contributing to patient safety.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI think that these people [pharmacists]do a great job and make a big contribution to the patient\u0026rsquo;s medication safety\u003c/em\u003e.\u0026rdquo; IP4, GP\u003c/p\u003e \u003cp\u003eThe pharmacist experienced that the GPs' need for support varied depending on their level of professional confidence. They also pointed out that GPs had not been given the opportunity to discuss with the pharmacist the types of medication related problems they wanted help with. As a result, the collaboration between GPs and the pharmacist was described as suboptimal.\u003c/p\u003e \u003cp\u003eOne nurse believed that it would be valuable for GPs to have the pharmacist as a discussion partner in cases of disagreements, and it was also suggested that GPs would benefit from initiating more contact with the pharmacist. Pharmacists were also found to provide valuable support to nurses and assistant nurses. For one nurse, receiving confirmation from a pharmacist was empowering and made it easier to stand up to GPs in cases of suspected suboptimal treatment.\u003c/p\u003e \u003cp\u003eThe pharmacist reported that nurses asked for help with medication administration problems, such as tablet crushing or splitting. Additionally, one assistant nurse stated that it was preferable to ask a pharmacist rather than a GP for medication-related questions. However, the possibility to initiate contact with pharmacists was limited to GPs, and one nurse desired the opportunity to ask the pharmacist directly in case of questionable medication decisions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIntegrating pharmacists for comprehensive care in multidisciplinary teams\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe pharmacist highlighted how the different professions completed each other by applying pharmaceutical consideration, caring, and medical treatment. One GP pointed out that pharmacists can offer help in discovering medication interactions in patients who have recently been hospitalized.\u003c/p\u003e \u003cp\u003eHowever, as pointed out by one nurse, the pharmacist needs to take into account the whole story behind the medication choices made and not only have pharmaceutical considerations in mind. Therefore, collaboration with assistant nurses working close with the individual with dementia was described as necessary to aid the pharmacist in making optimal treatment suggestions.\u003c/p\u003e \u003cp\u003eOne nurse said that the pharmacist's questions stimulated reflection on the individual\u0026rsquo;s medication, and the knowledge learned from the pharmacist was applied to other individuals. Involving a pharmacist at the time of diagnosis was suggested by a nurse to prolong the time at home for patients with dementia and improve their well-being. Furthermore, one GP stated that the use of pharmacist services was most valuable for optimizing treatment in elderly patients (75\u0026ndash;85 years of age) with many medications. Consequently, the management of patients with multimorbidity and dementia was said to especially benefit from the support of a pharmacist. One shortcoming that was brought up by both the pharmacist and a nurse was the absence of follow-up on the pharmacist\u0026rsquo;s recommendations:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eCurrently, there is no direct follow-up on those recommendations, uh... regarding whether they benefit the patient in the long run. It would have been very interesting to follow up on how... both the municipal staff and then... relatives and doctors, to see if there has been any difference in the recommendations like that.\u0026rdquo;\u003c/em\u003e IP3, pharmacist\u003c/p\u003e \u003cp\u003e \u003cb\u003eExpanding pharmacist roles to enhance patient care and support GPs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOne GP mentioned potential areas for future pharmacist work tasks, such as routine prescription renewals and blood pressure measurements, which could reduce workload for the GP. It was also suggested that pharmacists could make home visits to check how patients handle their medications.\u003c/p\u003e \u003cp\u003eFurthermore, one nurse believed that it would be valuable for individuals in special housing to have medication reviews conducted by pharmacists, as these patients may receive medical care from many different providers.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The aim of this study was to explore the views of healthcare professionals towards the implementation of pharmacist-supported medication reviews in special housing homes for people with dementia. The main results indicate that healthcare professionals value the expertise of pharmacists, particularly in ensuring medication safety and efficiency in patient care. Communication challenges between pharmacists and other healthcare staff were identified, affecting the optimal integration of pharmacists\u0026rsquo; recommendations. There is consensus on the potential benefits of expanding pharmacists\u0026rsquo; roles, including routine prescription management and home visits, to better support GPs and enhance patient care. However, a lack of follow-up on the implementation of pharmacists\u0026rsquo; suggestions was noted, highlighting a gap in assessing the long-term benefits of involvement in dementia care.\u003c/p\u003e \u003cp\u003eDespite the generally positive views of healthcare professionals towards the contributions of pharmacists and the value of their input in medication management, there was some skepticism regarding the suitability of pharmacist-supported medication reviews for individuals with dementia who live in special housing facilities where they receive care and oversight. This level of monitoring may not require the same level of intervention as needed for other patient groups. Instead, it was suggested that individuals living independently at home, especially those with multiple comorbidities and polypharmacy, might be a more suitable target group for pharmacist involvement. Furthermore, the shortage of GPs, which poses a potential risk to patient safety (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), needs to be addressed. Leveraging pharmacists\u0026rsquo; expertise through targeted task shifting could potentially alleviate the pressure on overburdened GPs (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). While this approach is promising, concerns regarding patient safety have been raised in a Norwegian study examining horizontal task-shifting between specialists with varying levels of expertise (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This highlights the importance of careful planning and preparation before implementing task-shifting across professions. To optimize the potential benefits of pharmacist involvement for GPs, it is recommended that GPs proactively identify and refer patients who could benefit most from pharmacists\u0026rsquo; expertise, including patients experiencing polypharmacy, side effects, or medication efficacy issues. This targeted approach could ensure pharmacist interventions are directed where they are most needed, enhancing patient safety and care outcomes.\u003c/p\u003e \u003cp\u003eEffective communication within multidisciplinary teams is vital in ensuring high-quality patient care, particularly for vulnerable populations. While the interviewed healthcare professionals recognize the value of pharmacists in medication management, there are communication challenges that hinder the optimal integration of pharmacists\u0026rsquo; recommendations. These challenges are not unique to this study; previous research has consistently highlighted the critical role of clear and structured communication channels in multidisciplinary healthcare settings (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Opportunities for improvement include establishing regular interdisciplinary meetings and utilizing shared electronic health records to facilitate real-time information exchange. Interprofessional learning, whether at the workplace or as part of students\u0026rsquo; education, could be a valuable facilitator for overcoming these barriers (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Furthermore, actively engaging patients in communication, where feasible, can personalize care, ensuring medication regimens align with both guidelines and individual needs and preferences, particularly when treatment goals shift from prolonging life to enhancing quality of life (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Addressing these communication barriers is essential to fully realize the potential benefits of pharmacist involvement in dementia care, as it would foster a more cohesive approach to medication management and ultimately enhance patient outcomes.\u003c/p\u003e \u003cp\u003eThe potential for expanding the role of pharmacists is a topic of growing interest in Sweden, particularly as a strategy to alleviate the increasing workload on GPs and to provide more comprehensive care. This study suggests that pharmacists could assume additional responsibilities, such as managing routine prescription renewals and performing home visits, especially for patients with complex care needs. This proposed expansion mirrors the successful integration of nurse prescribing rights in certain clinical areas (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and the role of clinical pharmacists in other countries (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Empowering pharmacists in a similar capacity would not only enhance the quality of care for patients by ensuring more timely and precise medication management but also contribute to a more efficient use of healthcare resources. By redistribution of certain tasks traditionally performed by GPs to pharmacists, the healthcare system can leverage the specialized knowledge of pharmacists to improve patient outcomes and address the challenges of an overburdened primary care infrastructure.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA diverse range of healthcare professionals were interviewed, offering rich insights into the complexity of medication management among people with dementia. We endeavored to interview all relevant professionals who had participated in medication reviews and found conflicting views, especially among GPs. It had been interesting to interview more GPs to elicit their perspective, but as this was a new initiative no more GPs than were interviewed had been involved in multidisciplinary medication reviews.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study contributes valuable insights into optimizing medication management practices, a key aspect of enabling individuals with dementia to live safely and comfortably at home. While the expertise of pharmacists is highly valued in ensuring medication safety and enhancing the efficiency of patient care, communication barriers within the multidisciplinary team pose significant challenges to fully integrating pharmacists\u0026rsquo; recommendations. The potential for role expansion of pharmacists is recognized as a promising avenue to alleviate the workload of GPs. A thorough evaluation of potential patient safety risks is essential to fully realize the benefits of pharmacist contributions to dementia care while ensuring medication safety and maintain the patient care efficiency.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Swedish Ethical Review Authority (2019-06322), and all participant provided informed consent prior to the interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to the participants not providing consent for their data to be shared publicly, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a grant from Forte \u0026ndash; The Swedish Research Council for health, Working Life and Welfare, project number 2016-00148.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCC has been involved in the analysis of data, the interpretation of data, and the drafting of the manuscript. ME and ECL have made significant contributions to the conception and design of the study, the interpretation of data, and have substantively revised the manuscript.\u003c/p\u003e\n\u003cp\u003eECL collected the data. All authors have approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their gratitude to Anna Lindahl for her valuable contribution to the initial data analysis. Additionally, we extend our sincere thanks to all the participants who took the time to engage in the interviews.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArvanitakis Z, Shah RC, Bennett DA. Diagnosis and Management of Dementia: Review. Jama. 2019;322(16):1589-99.\u003c/li\u003e\n\u003cli\u003eAfram B, Stephan A, Verbeek H, Bleijlevens MH, Suhonen R, Sutcliffe C, et al. Reasons for institutionalization of people with dementia: informal caregiver reports from 8 European countries. J Am Med Dir Assoc. 2014;15(2):108-16.\u003c/li\u003e\n\u003cli\u003eSveriges Kommuner och Regioner. S\u0026auml;rskilt boende f\u0026ouml;r \u0026auml;ldre (S\u0026Auml;BO) [Internet]. Stockholm: Sveriges Kommuner och Regioner; 3 October 2023 [Available from: https://skr.se/skr/integrationsocialomsorg/socialomsorg/aldre/sarskiltboendealdre.28193.html.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Dementia [Internet]. World Health Organization; March 15, 2023 [Available from: https://www.who.int/news-room/fact-sheets/detail/dementia.\u003c/li\u003e\n\u003cli\u003eSocialstyrelsen. En nationell strategi f\u0026ouml;r demenssjukdom. 2022.\u003c/li\u003e\n\u003cli\u003eLindblad M, Flink M, Ekstedt M. Safe medication management in specialized home healthcare - an observational study. BMC health services research. 2017;17(1):598.\u003c/li\u003e\n\u003cli\u003eBunn F, Burn AM, Goodman C, Rait G, Norton S, Robinson L, et al. Comorbidity and dementia: a scoping review of the literature. BMC medicine. 2014;12:192.\u003c/li\u003e\n\u003cli\u003eMasnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC geriatrics. 2017;17(1):230.\u003c/li\u003e\n\u003cli\u003eCross AJ, Etherton-Beer CD, Clifford RM, Potter K, Page AT. Exploring stakeholder roles in medication management for people living with dementia. Research in social \u0026amp; administrative pharmacy : RSAP. 2021;17(4):707-14.\u003c/li\u003e\n\u003cli\u003eMolist-Brunet N, Sevilla-S\u0026aacute;nchez D, Puigoriol-Juvanteny E, Barneto-Soto M, Gonz\u0026aacute;lez-Bueno J, Espaulella-Panicot J. Improving individualized prescription in patients with multimorbidity through medication review. BMC geriatrics. 2022;22(1):417.\u003c/li\u003e\n\u003cli\u003eGriese-Mammen N, Hersberger KE, Messerli M, Leikola S, Horvat N, van Mil JWF, et al. PCNE definition of medication review: reaching agreement. International journal of clinical pharmacy. 2018;40(5):1199-208.\u003c/li\u003e\n\u003cli\u003eSocialstyrelsen. Socialstyrelsens f\u0026ouml;reskrifter och allm\u0026auml;nna r\u0026aring;d (HSLF-FS 2017:37) om ordination och hantering av l\u0026auml;kemedel i h\u0026auml;lso- och sjukv\u0026aring;rden [Internet]. Socialstyrelsen; 6 February 2020 [updated September 15, 2022. Available from: https://patientsakerhet.socialstyrelsen.se/lagar-och-foreskrifter/foreskrifter-och-handbocker/hslf-fs-201737/.\u003c/li\u003e\n\u003cli\u003eJokanovic N, Tan EC, Sudhakaran S, Kirkpatrick CM, Dooley MJ, Ryan-Atwood TE, et al. Pharmacist-led medication review in community settings: An overview of systematic reviews. Research in social \u0026amp; administrative pharmacy : RSAP. 2017;13(4):661-85.\u003c/li\u003e\n\u003cli\u003eMcDerby N, Kosari S, Bail K, Shield A, Peterson G, Naunton M. Pharmacist-led medication reviews in aged care residents with dementia: A systematic review. Australas J Ageing. 2020;39(4):e478-e89.\u003c/li\u003e\n\u003cli\u003eB\u0026oslash; KE, Halvorsen KH, Ris\u0026oslash;r T, Lehnbom EC. \u0026apos;Illuminating determinants of implementation of non-dispensing pharmacist services in home care: a qualitative interview study\u0026apos;. Scandinavian journal of primary health care. 2023;41(1):43-51.\u003c/li\u003e\n\u003cli\u003eVinterflod C, Gustafsson M, Mattsson S, Gallego G. Physicians\u0026apos; perspectives on clinical pharmacy services in Northern Sweden: a qualitative study. BMC health services research. 2018;18(1):35.\u003c/li\u003e\n\u003cli\u003eGadolin C, Andersson T. Healthcare quality improvement work: a professional employee perspective. Int J Health Care Qual Assur. 2017;30(5):410-23.\u003c/li\u003e\n\u003cli\u003eGraneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-12.\u003c/li\u003e\n\u003cli\u003eStiftelsen Silviahemmet. Utbildning i demensv\u0026aring;rd [Internet]. Drottningholm: Stiftelsen Silviahemmet; [Available from: https://www.silviahemmet.se/utbildning/.\u003c/li\u003e\n\u003cli\u003eKvale S, Brinkmann S. Det kvalitative forskningsintervju [InterView: Learning the craft of qualitative research interviewing]. 3. ed. Oslo: Gylendal; 2021.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2007;19(6):349-57.\u003c/li\u003e\n\u003cli\u003eHicks R. Current staff shortages a significant threat to patient saefty, say doctors. Medscape UK. 19 May 2023.\u003c/li\u003e\n\u003cli\u003eGroenewegen P, Boerma WGW, Spreeuwenberg P, Seifert B, Sch\u0026auml;fer W, Batenburg R, et al. Task shifting from general practitioners to practice assistants and nurses in primary care: a cross-sectional survey in 34 countries. Prim Health Care Res Dev. 2022;23:e60.\u003c/li\u003e\n\u003cli\u003eMalterud K, Aamland A, Fosse A. How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway. Scandinavian journal of primary health care. 2020;38(1):24-32.\u003c/li\u003e\n\u003cli\u003eRadcliffe E, Servin R, Cox N, Lim S, Tan QY, Howard C, et al. What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis. BMC geriatrics. 2023;23(1):591.\u003c/li\u003e\n\u003cli\u003eBrooks L, Elliott J, Stolee P, Boscart VM, Gimbel S, Holisek B, et al. Development, successes, and potential pitfalls of multidisciplinary chronic disease management clinics in a family health team: a qualitative study. BMC Prim Care. 2023;24(1):126.\u003c/li\u003e\n\u003cli\u003eVerbeek FHO, van Lierop MEA, Meijers JMM, van Rossum E, Zwakhalen SMG, Laurant MGH, et al. Facilitators for developing an interprofessional learning culture in nursing homes: a scoping review. BMC health services research. 2023;23(1):178.\u003c/li\u003e\n\u003cli\u003eReeve E, Bell JS, Hilmer SN. Barriers to Optimising Prescribing and Deprescribing in Older Adults with Dementia: A Narrative Review. Curr Clin Pharmacol. 2015;10(3):168-77.\u003c/li\u003e\n\u003cli\u003eKoskiniemi S, Sund R, Liukka M, H\u0026auml;rk\u0026auml;nen M. Readmissions after appointments with nurse prescribers: A register-based study. J Clin Nurs. 2023;32(21-22):7783-90.\u003c/li\u003e\n\u003cli\u003eBirt L, Dalgarno L, Poland F, Wright D, Bond C. What happens when pharmacist independent prescribers lead on medicine management in older people\u0026apos;s care homes: a qualitative study. BMJ open. 2023;13(10):e068678.\u003c/li\u003e\n\u003cli\u003eWalpola RL, Issakhany D, Gisev N, Hopkins RE. The accessibility of pharmacist prescribing and impacts on medicines access: A systematic review. Research in social \u0026amp; administrative pharmacy : RSAP. 2024.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical pharmacy, Collaboration, Dementia, Drug-related problems, Health care professionals, Independent Living, Implementation, Medication review, Polypharmacy, Qualitative study, Special housing","lastPublishedDoi":"10.21203/rs.3.rs-3975153/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3975153/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDementia is a major global public health challenge, and with the growing elderly population, its prevalence is expected to increase in the coming years. In Sweden, municipalities are responsible for providing special housing for the elderly (S\u0026Auml;BO), which offers services and care for older individuals needing specific support. S\u0026Auml;BO is both the person\u0026acute;s home and a care environment and workplace. Polypharmacy in patients with dementia is common and increases the risk of medication interactions. Involving clinical pharmacists in medication reviews has been shown to result in safer medication use and more appropriate prescribing. However, less attention has been given to how other healthcare professionals view the implementation of such pharmacist services. Thus, this study aims to explore their views towards pharmacist-supported medication reviews for people with dementia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis descriptive qualitative study used semi-structured interviews and qualitative content analysis to explore healthcare professionals\u0026rsquo; views on pharmacist-supported medication reviews for people with dementia. The study was conducted in a southern Swedish special housing and included nurses, assistant nurses, general practitioners (GPs), and a pharmacist. Due to the COVID-19 pandemic, interviews were conducted over the phone. The Swedish Ethical Review Authority approved the study.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis revealed three main categories, and eleven subcategories.: 1) Approaches to safe medication use, 2) Approaches to work processes and 3) The role of the pharmacist. Nurses focused on non-pharmacological treatments, while GPs emphasized the importance of medication reviews in assessing the benefits and side-effects of prescribed medication. Pharmacists were valued for their reliable medication expertise, appreciated by GPs for saving time and providing recommendations prior to consultations with individuals with dementia and their next-of-kin. Although medication reviews were considered beneficial, there was skepticism about their ability to solve all medication-related problems associated with dementia care.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe healthcare professionals generally had a positive attitude towards collaborating with pharmacists. The study highlighted the importance of involving healthcare professionals in the implementation of new work processes to ensure employee commitment and successful adoption.\u003c/p\u003e","manuscriptTitle":"Collaborating with pharmacists to improve medication use in dementia care: views from healthcare professionals in Sweden","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-06 09:52:25","doi":"10.21203/rs.3.rs-3975153/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-10T11:04:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-09T21:29:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-02T11:31:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3470109f-7ee8-4bea-b4cb-0bcb811b228f","date":"2024-04-01T16:12:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2602a297-8e1a-414f-920a-6ad125253894","date":"2024-03-30T11:14:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-28T11:00:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-28T10:39:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-03-04T08:24:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-04T08:24:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-02-21T09:56:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"63b6005f-57c0-4fc1-a02c-6f7bd6c2164a","owner":[],"postedDate":"March 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-31T13:21:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-06 09:52:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3975153","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3975153","identity":"rs-3975153","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}