Prescribing memantine in general practice in England: a mixed-methods study

Existing division of responsibilities

Overall, 46% (46.2%, n = 48) of survey responders and a similar proportion of interviewees were unaware of the 2018 NICE guidance regarding memantine.¹³ Most interviewees gave precedence to local formulary recommendations, while 46.2% (n = 48) of survey responders reported that they ‘regularly’ referred patients with moderate-to-severe AD to specialists. Most interview responders reported that, according to their local formulary classifications, memantine is assigned ‘amber’ status. This classification indicates that only specialists (geriatricians and psychiatrists) should initiate memantine. GPs are recommended to continue this treatment under a shared care agreement.

Reflecting the established division of responsibilities between general practice and specialist care providers, only 14.4% (n = 15) of survey responders regularly initiated memantine, while 63.5% (n = 66) regularly continued a memantine prescription.

Many GPs did not separate their views about adopting additional responsibilities for treatment (for example, for initiating memantine for their patients with moderate-to-severe AD) from existing processes for diagnosing dementia in their locality. Some GPs accepted the logic of the existing division of responsibilities:

'I don't see most GPs where I work wanting to initiate this, if there’s already a service available … not wanting to initiate it before they’d been formally assessed, because you need to get that diagnosis first and memantine may hinder that process. I'm not quite sure how it would fit into our current work in practice.' (Male [M], 5–9 years since registering as a GP, Yorkshire and Humberside [YH], Index of Multiple Deprivation [IMD] decile 2)

However, other GPs questioned existing practices and believed that adjustments to responsibilities in general practice could benefit their patients:

'If we're not confident with a drug … if we haven't done it often, we're a bit fearful of it … it also goes hand in hand with this sort of mystique around the diagnosis itself. So those who would benefit from memantine … are … medium to severe. And often with the right sort of story … it would be completely reasonable to make the diagnosis without having to put them through stuff [such as being referred back to specialist care].' (Female [F], 15–20 years, South East England [SE], IMD decile 5)

Some, usually more experienced, GPs had acted against local practice and initiated memantine themselves:

'I really don't know what our formulary says, but I've been using memantine for quite a long time really.' (M, 15–20 years, South West England [SW], IMD decile 8)

Many GPs used screening tools only as part of local procedures for accessing specialist services and believed that time pressure, even with a double appointment, precluded in-depth assessments needed to determine dementia severity. Several were not complimentary about the standard assessment tools available to GPs (for example, the 6-Item Cognitive Impairment Test,²² General Practitioner’s Assessment of Cognition,²³ and the Mini-Mental State Examination²⁴) and mentioned the challenge of using standard screening tools to assess patients with differing pre-morbid intellectual capacities. Some GPs were unable to use certain tools because licences had not been renewed in their area.

The interval between referral of a patient from general practice and an appointment at a memory clinic mostly ranged from 3–6 months. Referral criteria varied and some GPs were critical about delays:

'Nightmare situation that we have … a service that takes months to get an appointment … then eventually after about six months after the referral we get a diagnosis. I don't see why GPs can't do it.' (F, 15–20 years, North West England [NW], IMD decile 5)

Availability of support

GPs acknowledged that they were dependent on a range of community-based services to support and supplement their care for people with dementia. The local frailty team, community dementia nurses, and voluntary organisations (for example, Admiral Nurses) were often mentioned. There were gaps in some locations, whereas in others these services had taken the lead. Navigating complicated systems that were subject to changes in staff and remit could be difficult:

'In our area we've got community dementia nurses who will, when we've made a diagnosis … go out and see the patient and family and talk about the diagnosis and driving and living wills and support groups. So that’s very useful. I think if we haven't got that, then that would make our life very much more difficult.' (M, 15–20 years, SW, IMD decile 8)

Most survey responders had access to a specialist for advice about patients with AD (69.2%, n = 72). Interviewees reported a range of experiences in this respect: from responsiveness and collaborative working, to frustration with the unavailability of specialists or those in a sufficiently senior role. Several GPs identified NHS advice and guidance,²⁵ integrated into clinical systems (for example, EMIS and SystmOne), as a useful source of specialist support. However, availability varied by location.

Two GPs with an extended role (GPwERs) in dementia provided insights from their dual role in general practice and in specialist memory clinics. One mentioned changes to her scope of practice following postgraduate training:

'I probably do most of the prescribing in my own GP surgery for [dementia and frailty] ... I would previously have referred back to the old age psychiatry team or linked back in with the specialist services before changing the medication. I wouldn't have felt confident, even though it’s in the NICE guidelines, I just didn't have the experience of doing it.' (F, 5–9 years, SE, IMD decile 6)

The other recognised the reasons for poor-quality dementia assessments provided by GPs to the memory clinic:

'That’s largely two things, one, GPs don't have enough time to do a proper assessment. But secondly, they very often don't think to ask the sort of functional questions that add weight to the memory issue.' (F, 15–20 years, SE, IMD decile 5)

GPs noted increased use of new Additional Roles Reimbursement Scheme²⁶ staff, often shared across primary care networks, who supported people with AD and their families while maintaining up-to-date knowledge of local resources:

'In our practice we're really fortunate we've got a really good system of social prescribing. We've got a wellbeing coordinator with an interest in elderly and mental health issues. So I would be keen to … get them [patients with AD] hooked into one of those services, get that up and running and monitoring … ' (M, 15–20 years, YH, IMD decile 3)

Access and continuity of care

Almost all interviewees expressed a strong belief in the importance of continuity of care for this patient group, although many felt unable to offer it in their general practice. They asserted that prior knowledge of individuals and their families was essential to accurately assessing the impact of cognitive decline:

'When new stuff crops up, physical health, mental health, social stuff, it’s absolutely critical … to know the background, to know where you started from, to make an assessment of what’s going on.' (M, 10–14 years, North East England [NE], IMD decile 1)

GPs from smaller practices were more often able to provide continuity of care for their patients. Several GPs acknowledged that continuity of care had been compromised by the prevalence of part-time working in general practice. In some cases, continuity was provided by a consistent group of people, rather than an individual GP:

'I don't think that continuity needs to just come from one person … as part of a team around the patient. So for example, a frailty nurse that really knows that patient or care home nurse, in addition to the GP. I think that’s really important.' (F, 5–9 years, SW, IMD decile 9)

Some GPs spoke about asking patients to attend for two consultations, so that a thorough assessment could be made, before referring to a memory clinic. However, owing to widespread pressure on access to general practice, GPs reported that it was often difficult to book a further appointment with the same GP.

Some practices in areas of greater deprivation had prioritised continuity:

'I think we're all very keen that our patients trust us and given the area, with sort of high levels of deprivation and high distrust of professionals and service, it’s important that [dementia] review comes from someone that they know and trust … I think that’s quite reassuring for the patient … but also the carer.' (M, 10–14 years, NW, IMD decile 1)

Competing priorities

Some GPs spoke about the pressure to respond to a range of competing priorities in their general practice, and the tendency to engage with conditions and issues that were incentivised by associated funding via the Quality and Outcomes Framework (QOF). Several GPs noted the recent downgrading of the QOF dementia indicator and associated payments from 39 to 19 possible points,²⁷ and suggested that new initiatives or changes in dementia care would require additional funding. Many believed that dementia was not afforded the high profile it deserves:

'It feels as if dementia is not getting as much of the attention as it needs … it is getting more prevalent … So it then means that we need to give more care, be more aware and, because the treatment and the management of dementia is mostly proactive, anticipatory, then you have to have been thinking about those things earlier on.' (F, 0–4 years, NE, IMD decile 1)

Most GPs had some responsibilities for patients with AD living in care homes and emphasised the importance of good relationships with care home staff. This was sometimes facilitated by a partnership between an experienced member of care home staff and an identified ‘link GP’. One GP expressed frustration with the local specialist multidisciplinary care team, which made decisions about moderate-to-severe dementia care without first-hand knowledge of the patients:

‘We have to fill in a form and then another nurse … does a 2-hour assessment. And then they take it to this big meeting, where they have a big old chat and none of them actually met the patient … sometimes the expertise of people who are on the ground seeing them all the time and knowing the family and knowing the nuances is lost.’ (M, 10–14 years, NE, IMD decile 1)

Confidence, knowledge, and skills gaps

Many GPs believed that they had become somewhat deskilled by the process of referring patients to secondary care for memory assessment, but opportunities for training were not consistently available. Most GPs were open to the idea of training in dementia care, and they identified a wide range of topics as the focus of any potential training, including local referral conventions, legal and capacity issues, and improving diagnosis skills. A minority of survey responders reported being ‘very confident’ or ‘confident’ about assessing the stage of AD for a patient (39.4%, n = 41) or about developing a care plan for a patient with moderate-to-severe AD (42.3%, n = 44). Less than half ‘regularly’ (41.3%, n = 43) or ‘occasionally’ (36.5%, n = 38) conducted annual reviews with patients with moderate-to-severe AD.

Although most GPs recognised gaps in their knowledge in respect of dementia, they often mentioned a lack of time in which to receive training. They had differing preferences about the format of training and upskilling. Some favoured a ‘top-down’ approach, whereby all GPs in a location could receive the same training:

'We have patient educational time-out sessions ... one a month … local CCG [clinical commissioning group] group-led ones … that would be the perfect opportunity for them to educate us. Educate every single GP in the local area.' (F, 15–20 years, NW, IMD decile 5)

Others suggested an online forum to which they could bring queries about dementia care to discuss with colleagues in their locality:

'We have something called Clinicians Connect … a Microsoft Teams chat channel. All day long that’s been having things posted on it about … "I don't know what to do about this. Does anyone else have any thoughts?" And it’s not just the GPs. We've got our pharmacists … ANPs [advanced nurse practitioners] … nursing staff … physios. Everyone’s on it … I mean the amount of learning that comes out of it!' (F, 15–20 years, SE, IMD decile 4)

Some GPs mentioned online sources of information they had independently accessed, such as Red Whale and eLearning for Healthcare, and through their membership of the Royal College of General Practitioners.

The two GPwER interviewees strongly valued the particular perspective their role afforded. Several other interviewees believed that they would benefit from gaining first-hand experience of a specialist dementia setting:

'It might be quite nice to sit into one of the … memory clinic assessments and just seeing our colleagues at work and you know how they assess it and what sort of things they go through, that might be interesting.' (M, 15–20 years, East of England, IMD decile 5)

Patient-centred care

Many GPs were dissatisfied with the primacy afforded to specialist diagnosis of dementia, which they believed undervalued their holistic understanding of patients and ability to address a wide range of aspects impacted by AD:

'I don't think this is about diagnosis per se … therefore it’s not about a single condition, whether it’s dementia or hypertension or arthritis or whatever. It’s about how we make sense with the person of their daily life.' (F, 15–20 years, NW, IMD decile 1)

GPs contrasted these skills with services offered by specialist teams, who had less familiarity with individual patients and their families:

'I think the main [thing] is the centrality of holism, generally and sometimes the difficulties I have with specialists are that people are in their silos, so the psychiatrist is focused on just psychiatry and the geriatricians … and actually it sometimes feels like me and my nurse colleague are the only ones that are taking the whole patient into account, and I think that’s a really valuable perspective.' (M, 10–14 years, NE, IMD decile 1)

Prescribing versus non-pharmacological care

Several GPs were concerned about interactions between dementia medications (including memantine) and other medications taken by their patients. Others felt concerns about interactions were overemphasised, leading patients to stop effective, ‘first-line’ medications (for example, amitriptyline) for dementia drugs with limited benefits:

'But you know the sort of risk is phenomenally low, and I wonder sometimes if we're not giving people the best treatment because of it.' (M, 10–14 years, West Midlands [WM], IMD decile 8)

GPs had often gained experience of memantine in a care home setting and expressed a range of views about its tolerability and effectiveness:

'I use it [memantine] in care homes … when I feel that people are moving from … mild to moderate to severe … in certain cases, it can be helpful.' (F, 5–9 years, SE, IMD decile 6)

'I know there’s evidence for them of some kind of modest benefit. But I've seen … quite a few patients in the care home who have had symptoms which have stopped when we've taken them off them … the nurses in the care home really don't like memantine at all.' (M, 10–14 years, NE, IMD decile 1)

Several GPs observed that patients in care homes are often prescribed too many medications and identified deprescribing as one of their key responsibilities.

Several responders were critical about what they perceived as an emphasis on pharmacological responses to the problems presented by AD:

'It frustrates me sometimes that so much resource goes into medication when actually I think the things that would change and improve people’s lives and ultimately their deaths, because often a lot of people [with] dementia are or would be … on our gold standard framework … towards the end of their life, are not medicines and those are the things that really do help people.' (M, 5–9 years, WM, IMD decile 9)

Table 3 presents themes on AD care and prescribing in general practice, including facilitators for and barriers to memantine use, mapped to TDF domains, BCW components, and potential functions to guide interventions for modifying GP practice.