Illustrative quotations for barrier themes and subthemes
| Analytical and descriptive themes | Subtheme and references | Characteristics of studies from which subthemes were derived Type of PIMs; age focus*; setting (number of references) | Illustrative quotations “Italicised text”=primary quote (ie, quote from a study participant from an included paper) ‘Non-italicised text’=secondary quote (ie, quote from study authors’ findings from an included paper) |
|---|---|---|---|
| Awareness | |||
| Poor insight46 47 49 | Misc PIMs (3); Older (2) and all ages (1); Primary (2) and secondary care (1) | “When I saw the list of patients [to be discussed with the researcher], I was quite happy about the prescriptions…but obviously when you look at them in more detail there are anomalies there that ought to be either checked on, reviewed or even altered”46 | |
| Discrepant beliefs and practice31 34 38 41 44 | Benzos (2) and minor opiates (1), Polypharm (1), PPIs (1); Older (1) and all ages (4); Primary care (5) | ‘In contrast to stated beliefs about best practice, physicians estimated that 5–10% of their older adult patients were using benzodiazepines on a daily basis for at least the past 3 months’38 | |
| Inertia | |||
| Prescriber beliefs/attitude | Fear of unknown/negative consequences of change (for the prescriber, patient and staff)29–31 34–36 38 40 42–47 49 | Antidepressants (2), Benzos (2) and minor opiates (1), hypnotics (1), Misc PIMs (4), Polypharm (2), PPIs (2), psychotropics (1); Older (9) and all ages (6); Primary (12), residential aged (2) and secondary (1) care | “He gets very worried and excitable if you attempt to change anything… even just something minor would cause him virtually a breakdown”46 “We can't predict the effect [of deprescribing] for the individual patient”31 “It's scary to stop a medication that's been going for a long time, because you kind of think am I opening a can of worms here, because I don't know what the reasons were for them starting that medication. To explore all that will take, you know, I can't do all that now, I will have to do that another time”40 “I suggest to them that ideally we should try to get them off of that, but if they're saying, been there, done that, that didn't work for me when I came off of this, I don't think it's worth getting into a big knock-down drag-out [fight] with them or having them leave my practice over this issue”38 |
| Drugs work, few side effects34 35 38 39 41 43–45 47 | Benzos (3) and minor opiates (1), hypnotics (1), Misc PIMs (1), PPIs (2), psychotropics (1); Older (4) and all ages (5); Primary (8) and residential aged (1) care | ‘In their [the physicians’] view psychotropic medication helps the elderly patient remain functional and is the least problematic solution… The physicians stated that they often do not see side effects and that patients often do not report them…’35 | |
| Prescribing is kind, meets needs (of patient, staff, carer)34 37–41 43 44 | Antidepressants (1), Benzos (4) and minor opiates (1), hypnotics (1), PPIs (1); Older (3) and all ages (5); Primary (7) and residential aged (1) care | “There is a paradox concerning older patients. You do not want to make them grow dull, but on the other hand you know their chronic problems, and you know that at their age the drugs are not so addictive. You want them to keep their minds clear, but on the other hand I do have a tendency to be permissive to older patients”34 “…It treats our own pain as well as our patients’ pain, 'cos we want to help people and make people feel better. So if we give people something and make them feel better, then everybody seems to be happier”39 | |
| Stopping is difficult, futile has/will fail 31 34 36–38 42 43 46 47 | Antidepressants (1), Benzos (3) and minor opiates (1), hypnotics (1), Polypharm (1), Misc PIMs (2); Older (6) and all ages (3); Primary (7) and residential aged (2) care | “Let's pretend it’s an octogenarian…if it's gonna make the patient feel better, I don't care if the patient's on it for the rest of their life”38 ‘Most frequent concern identified was the difficulty anticipated in persuading older patients to withdraw after years of using benzodiazepines’36 “In my experience, patients get hooked on PPIs, it is almost addictive like heroin and people appear to experience severe indigestion symptoms on attempting to stop them”44 | |
| Stopping is a lower priority issue38 40 44 45 49 | Antidepressants (1), Benzos (1), Misc PIMs (1), PPIs (2); Older (3) and all ages (2); Primary (4) and secondary (1) care | “We are always faced with multiple problems and PPIs are just one issue…”44 | |
| Prescriber behaviour | Devolve responsibility 29 34 35 40–43 49 | Antidepressants (2), Benzos (1) and minor opiates (1), hypnotics (1), Misc PIMs (2), psychotropics (1); Older (5) and all ages (3); Primary (5), secondary (1) and residential aged (2) care | ‘They [the physicians] recognized that the inappropriate use of psychotropic medication for elderly patients was a public health problem, but they felt that it was beyond the scope of the individual physician’35 “(…) I ask them if it should be a sleeping pill or another of the available options and mostly they have a need for sleeping pills”43 “I have been running this practice for twelve years. I took it over from an older colleague. I took over all his patients. They were mostly old people. Prescribing policy has been rather liberal, and I have continued this policy”34 |
| Self-efficacy | |||
| Skills/knowledge | Skills/knowledge gaps30–35 40 45 49 | Antidepressants (1), Benzos and minor opiates (1), Misc PIMs (1), Polypharm (4), PPIs (1), psychotropics (1); Older (7) and all ages (2); Primary (8) and secondary (1) care | “I don't have enough time for education about the newest information on psychiatric disorders, and better communication with specialists would be very helpful”41 ‘Side effects are not always recognised as such’ 32 “When house officers come on our ward, they haven't necessarily been trained in geriatrics. So they arrive here, and then they start with 10 mg of morphine every four hours. That's too much” (Hospital based geriatrician)49 “You look at the medication list and want to reduce it but then you can't find things you can eliminate”31 |
| Information/influencers | Lack of evidence30 31 33 | Polypharm (3); Older age (3); Primary care (3) | “To me, the guidelines are kind of a hindrance. At the moment they do not cater for older patients”31 |
| Incomplete clinical picture 30–33 40 41 46 47 49 | Antidepressants (1), Benzos (1), Misc PIMs (3), Polypharm (4); Older (7) and all ages (2); Primary (8) and secondary (1) care | “The problem is that the medication lists of the doctors involved are not exchanged and are consequently inconsistent”31 “One has discovered that they might have completely different expectations than what the doctor had from the beginning. Do they want to survive for five more years or? And so on. What are their expectations?”30 ‘Medicines, (mainly for chronic conditions) were sometimes not appropriately reviewed because there was no written information on indication and follow-up or because this was not readily available’49 “Sometimes the older people decide for themselves to reduce some of their medication or to adjust the doses without telling their GP. Therefore as their GP you can have the wrong impression about their medication intake…”32 | |
| Guidelines/specialists30–33 38 44 46 49 | Benzos (1), Misc PIMs (2), Polypharm (4), PPIs (1); Older (6) and all ages (2); Primary (7) and secondary (1) care | ‘When existing guidelines are debated, GPs felt deceived and insecure… The importance of individualising treatment was also expressed and many guidelines were perceived as too rigid leading to a standardized ‘kit’ of medicines per indication…’30 “I have difficulty not following the guidelines if I don't have good reasons to do so”31 “When the hospital consultant recommends a treatment it's difficult… for us not to prescribe unless there is a very good reason. To some extent we feel obliged to carry on when they have initiated it”46 | |
| Other health professionals (aged care) 42 43 | Antidepressants (1) and hypnotics (1); Older patients (2); Aged care (2) | “(…) in such a situation it amounts to the sleeping pill, because everybody else's need is the sleeping pill, and I would have to fight tooth and nail if really I wanted to avoid this”43 “They (RACF nurses) called me on the carpet to tell me that withdrawing antidepressants was not a clever thing to do because the patient became angrier and resisted care. They therefore demanded that I reinstate medication”42 | |
| Feasibility | |||
| Patient | Ambivalence/resistance to change 29–32 35 37 38 40 43 44 46 48 49 | Antidepressants (1), Benzos (2), hypnotics (1), Misc PIMs (4), Polypharm (3), PPIs (1), psychotropics (1); Older (9) and all ages (4); Primary (11), secondary (1) and residential aged (1) care | “When I said initially we wanted her to come off it, she said, oh no, I’ve been on that for ages, and I don't want to come off it”48 “The discontent rarely lies with the patient themselves”31 |
| Poor acceptance of alternatives37 38 42–44 | Antidepressants (1), Benzos (2), hypnotics (1), PPIs (1); Older (3) and all ages (2); Primary (3) and residential aged (2) care | “…these types of people and they tend not to want to help themselves, you know they won't take the hypnotherapy and they won't go to yoga classes and they won't do anything else. They just want a quick fix”37 | |
| Difficult and intractable adverse circumstance 34 35 37 39 40 | Antidepressants (1), Benzos (2) and minor opiates (1), psychotropics (1); Older (2) and all ages (3); Primary care (5) | “I think they have horrible lives, a lot of them… I think it's a combination of all things, their health, their social circumstances… I think a lot of people are on antidepressants because of everything put together. And you can't… change most of the factors that cause it”40 | |
| Discrepant goals to prescriber 30 33 | Polypharm (2); Older age (2); Primary care (2) | “I kind of get aggravated that half of the medicines that I think are totally rubbish are the ones that the patient really wants to take”33 | |
| Resources | Time and effort30 33 34 37 38 40–42 46 48 49 | Antidepressants (2), Benzos (3) and minor opiates (1), Misc PIMs (3), Polypharm (2); Older (7) and all ages (4); Primary (9), secondary (1) and residential aged (1) care | “We have a big problem with long-term hypnotic use. It would take an awful lot of work and it's purely a time and work problem”46 |
| Insufficient reimbursement37 38 | Benzos (2); Older (1) and all ages (1); Primary (2) care | ‘A lack time or resources to provide counselling, especially due to the absence of remuneration for doing so’37 | |
| Limited availability of effective alternatives37 38 41–43 | Antidepressants (1), Benzos (3), hypnotics (1); Older (3) and all ages (2); Primary (3) and residential aged (2) care | ‘…There is hardly any alternative to medicamentous therapy’43 | |
| Work practices | Prescribe without review34 35 42 43 45–47 | Antidepressants (1), Benzos and minor opiates (1), hypnotics (1), Misc PIMs (2), PPIs (1), psychotropics (1); Older (4) and all ages (3); Primary (5) and residential aged (2) care | “(…) then he gets something and he continues this pill, and then the issue is over for him, then it's quiet, and then he has his pill and then he sleeps through, and from time to time you may enquire, it if occurs to you while looking at his medication”43 “When we work in a large health centre, then we sign prescriptions for each other…when a colleague is absent, we issue prescriptions for him that day. Any prescription I issue is my responsibility, but if you are asked to prescribe a particular drug [for a colleague] then you sign it in the reception. I don't check which other drugs that person uses”47 |
| Medical culture | Respect prescriber's right to autonomy and hierarchy 29 30 34 37 45 46 49 | Benzos (1) and minor opiates (1), Misc PIMs (3), Polypharm (1), PPIs (1); Older (2) and all ages (5); Primary (6) and secondary (1) care | ‘The GPs rarely contact colleagues, for example, hospital specialists, as there is a perceived lack of routines for this as well as an informal understanding not to pursue colleagues’ motivations for prescriptions’30 |
| Health beliefs and culture | Culture to prescribe more32 42 47 | Antidepressants (1), Misc PIMs (1), Polypharm (1); Older patients (3), Primary (2) and residential aged (1) care | “The number of medications grows slowly. There is a complaint, we give new medication, it continues without really stopping it after a while… and it is our responsibility to try and withdraw it from the patient”32 |
| Prescribing validates illness34 40 43 | Antidepressants (1), Benzos and minor opiates (1), hypnotics (1); Older (2) and all ages (1); Primary (2) and residential aged (1) care | “They feel that unless they are on a tablet for it then they are not having any treatment. There are a lot of those kinds of people”40 | |
| Regulatory | Quality measure driven care33 | Polypharm (1); Older (1); Primary care (1) | “Another factor that we experience at the VA is these electronic reminders that tell you to do things…What I do really depends on who is in front of me…So the reminder comes up and it makes no sense. This guy's LDL is 101.8… Should I go from 40 to 80 of simvastatin? And what's the risk and benefit there?”33 |
*Age focus refers to the indicative age group of patients who were the focus of participant discussions, as suggested by the terms used in each article, which did not specify the exact age ranges.
Benzos, benzodiazepines; Misc, miscellaneous; PIMs, potentially inappropriate medications; Polypharm, polypharmacy, PPIs, proton pump inhibitors.