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

Abstract

Background: Acetylcholinesterase inhibitors (AChEIs) are routinely prescribed for mild-to-moderate Alzheimer's disease (AD). National guidance advises GPs to initiate memantine for patients already taking an AChEI, as it offers small benefits for moderate-to-severe AD, with good tolerability. But this is not routinely done, potentially depriving patients of a beneficial treatment.

Aim: To assess prescribing for AD in general practice, to explore factors influencing prescribing, and to identify additional education needs.

Design & setting: Mixed-methods study involving GPs in England.

Method: An online survey and semi-structured interviews were conducted. Survey responses were analysed in StataNow (version 18.5). Interview transcriptions were coded in NVivo (version 14) by two researchers, who agreed themes. Quantitative and qualitative analyses were integrated and mapped to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW).

Results: Survey responders (n = 104) mostly continued rather than initiated memantine. Less than half were confident in identifying AD stages and developing care plans for moderate-to-severe AD. Overall, 46% of responders were unaware of current national guidance concerning memantine. Interviews (n = 23) mostly concurred with survey findings. Direction from local formularies conflicts with current national guidance. Mapping to TDF and BCW identified barriers to, facilitators, and interventions for changing practice.

Conclusion: Limited time, patchy support, and Quality and Outcomes Framework downgrading contribute to a perception that dementia is not prioritised in general practice. Local systems for diagnosis and treatment reinforce GPs' feelings of inadequacy. GPs assess the impact of AD on patients and families but may not map assessments to a disease stage for memantine initiation. Interventions to change practice should boost knowledge and confidence; local pathways should clearly reflect national guidance.