Table 4 Codes Related to Acute/Severe and Mild/Moderate Agitation and/or Aggression Treatment, mapped to the TDF and the COM-B Model. Codes related to acute/severe agitation and/or aggression are written in red, whilst those related to mild/moderate treatment are written in black

Capability

Psychological

Knowledge

Interactions with disease, drugs and foods can be barriers to using medication (biological mechanisms)

Barrier

Severity of agitation can be a barrier to the use of some medications

Barrier

Lack of education among friend and family caregivers on drug approaches for agitation and aggression

Barrier

Lack of non-pharmacological interventions available for agitation or aggression

Barrier

Lack of training specifically for non-pharmacological treatment approaches among LTC staff

Barrier

Needing to use trial and error to choose non-pharmacological approach

Barrier

Gentle Persuasion Approach taught among staff

Facilitator

Specifically assessing basic needs as first line non-pharmacological treatment

Facilitator

Ensuring staff have the competence and training to administer non-pharmacological treatment approaches

Facilitator

Non-pharmacological interventions are only administered by nursing staff, not physicians, thus barriers to use are not known by physicians

Barrier

Best treatment approach is dependent on the person (drug vs. non-drug)

Facilitator

Cognitive and Interpersonal skills

Agitation symptoms are too severe (e.g. safety concerns) limiting non-pharmacological interventions but permitting pharmacological interventions

Barrier/ Facilitator

Lack of non-pharmacological interventions available for agitation or aggression

Barrier

Lack of training specifically for non-pharmacological treatment approaches among LTC staff

Barrier

Needing to use trial and error to choose non-pharmacological approach

choose non-pharmacological approach

Barrier

Gentle Persuasion Approach taught among staff

Facilitator

Specifically assessing basic needs as first line non-pharmacological treatment

Facilitator

Ensuring staff have the competence and training to administer non-pharmacological treatment approaches

Facilitator

Treatment for agitation depends on the confidence and education of staff to administer non-pharmacological interventions

Facilitator

Use of medication because it helps address agitated behaviours related to dementia

Facilitator

Staff are afraid to use non-pharmacological interventions

Barrier

IM administration route eases ability to administer medication

Facilitator

Best treatment approach is dependent on the person (drug vs. non-drug)

Facilitator

Memory, Attention and Decision Making Processes

Comorbid neuropsychiatric diagnosis can conflict with treating agitation symptoms

Barrier

Difficulty coordinating timing for intervention among a group of residents (E.g. reluctance to participate in non-pharmacological activities)

Barrier

Advancement in dementia results in frequent changes in non-pharmacological treatment plan needed

Barrier

Loss of personal traits or skills after administering medication for agitation

Barrier

Behavioural Regulation

Overuse of restraints

Barrier

Having non-pharmacological options available such as verbal de-escalation, wait and re-approach, and redirection can be critical for acute or severe agitation

Facilitator

Agitation symptoms are too severe (e.g. safety concerns) limiting non-pharmacological interventions but permitting pharmacological interventions

Barrier/ Facilitator

Using chemical restraints (i.e. medications) because agitation symptoms do not respond to other interventions

Facilitator

Acute/severe agitation can warrant emergency services

Barrier

Challenges in physically administering medication (e.g.; medication administration can be traumatizing for a person with dementia)

Barrier

Comorbid neuropsychiatric diagnosis can conflict with treating agitation symptoms

Barrier

Poor response or worsening of behaviour when medications were used

Barrier

Reliance on medications

Barrier

Adverse side effects of medications

Barrier

Use of Medication because it is convenient

Barrier

Not all types of agitation are responsive to medications

Barrier

Routine monitoring of non-pharmacological approaches

Facilitator

Routine monitoring of medications

Facilitator

Positive outcomes from non-pharmacological treatments for agitation

Facilitator

Use of medication because it helps address agitated behaviours related to dementia

Facilitator

IM administration route eases ability to administer medication

Facilitator

Using documentation to monitor interventions

Facilitator

Some residents do respond well to medications for agitation and/or aggression

Facilitator

Ensuring plans are in place to reassess residents to potentially deprescribe medication

Facilitator

Physical

Physical Skills

-

-

Opportunity

Social

Social influences

Drug shortages and availability can be a barrier to the use of some medications

Barrier

Challenges in identifying side effects from the drugs

Barrier

Challenges in monitoring medications (i.e. no monitoring of medications)

Barrier

Lack of non-pharmacological interventions available for agitation or aggression

Barrier

Difficulty coordinating timing for intervention among a group of residents (E.g. reluctance to participate in non-pharmacological activities)

Barrier

Advancement in dementia results in frequent changes in non-pharmacological treatment plan needed

Barrier

Easy to access prescriptions for agitation medications

Barrier/Facilitator

Use of Medication Because it is convenient

Barrier

Staff pressures on physicians to move to medication sooner

Barrier

Resources are available that support the use of non-pharmacological interventions (e.g. geriatric mental health)

Facilitator

Physical

Environmental Context and Resources

Drug shortages and availability can be a barrier to the use of some medications

Barrier

Challenges in identifying side effects from the drugs

Barrier

Challenges in monitoring medications (i.e. no monitoring of medications)

Barrier

Challenges in physically administering medication (e.g.; medication administration can be traumatizing for a person with dementia)

Barrier

Lack of non-pharmacological interventions available for agitation or aggression

Barrier

Difficulty coordinating timing for intervention among a group of residents (E.g. reluctance to participate in non-pharmacological activities)

Barrier

Advancement in dementia results in frequent changes in non-pharmacological treatment plan needed

Barrier

Use of Medication because it is convenient

Barrier

Not all types of agitation are responsive to medications

Barrier

Easy to access prescriptions for agitation medications

Barrier/Facilitator

Lack of sensory experience non-pharmacological approaches

Barrier

Intentional use of non-pharmacological

treatment strategies

Facilitator

No regular guidelines to use restraints for agitated patients

Facilitator

Takes time to acquire consent for a mechanical restraint

Barrier

Staff pressures on physicians to move to medication sooner

Barrier

Resources are available that support the use of non-pharmacological interventions (e.g. geriatric mental health)

Facilitator

Motivation

Reflective

Social/Professional Role and Identity

Lack of education among friend and family caregivers on drug approaches for agitation and aggression

Barrier

Having familiar and developing trust with healthcare providers each time to administer non-pharmacological support for residents

Facilitator

Although doctors prescribe, the whole interdisciplinary team reports on the effectiveness of treatments

Facilitator

Takes time to acquire consent for a mechanical restraint

Barrier

Staff are afraid to use non-pharmacological interventions

Barrier

Non-pharmacological interventions are only administered by nursing staff, not physicians, thus barriers to use are not known by physicians

Barrier

Staff pressures on physicians to move to medication sooner

Barrier

Families or caregivers may not want medications used for the resident

Barrier

Beliefs about capabilities

Interactions with disease, drugs and foods can be barriers to using medication (biological mechanisms)

Barrier

Severity of agitation can be a barrier to the use of some medications

Barrier

Challenges in identifying side effects from the drugs

Barrier

Challenges in monitoring medications (i.e. no monitoring of medications)

Barrier

Choosing non-pharmacological approaches as first line

Facilitator

Ensuring staff have the competence and training to administer non-pharmacological treatment approaches

Facilitator

Staff are afraid to use non-pharmacological interventions

Barrier

Optimism

Seeing the patient improve with medication (E.g. making patients more content)

Facilitator

Positive outcomes from non-pharmacological treatments for agitation

Facilitator

Choosing non-pharmacological approaches as first line

Facilitator

Treatment for agitation depends on the confidence and education of staff to administer non-pharmacological interventions

Facilitator

Some residents do respond well to medications for agitation and/or aggression

Facilitator

Beliefs about Consequences

Agitation symptoms are too severe (e.g. safety concerns) limiting non-pharmacological interventions but permitting pharmacological interventions

Barrier/Facilitator

Using chemical restraints (i.e. medications) because agitation symptoms do not respond to other interventions

Facilitator

Acute/severe agitation can warrant emergency services

Barrier

Poor response or worsening of behaviour when medications were used

Barrier

Reliance on medications

Barrier

Risk of using non-pharmacological approach (e.g. behaviour does not improve)

Barrier

Adverse side effects of medications

Barrier

Needing to use trial and error to choose non-pharmacological approach

Barrier

Seeing the patient improve with medication (E.g. making patients more content)

Facilitator

Positive outcomes from non-pharmacological treatments for agitation

Facilitator

Choosing non-pharmacological approaches as first line

Facilitator

Specifically assessing basic needs as first line non-pharmacological treatment

Facilitator

Use of medication because it helps address agitated behaviours related to dementia

Facilitator

Inconsistent monitoring of interventions

Barrier

Ensuring plans are in place to reassess residents to potentially deprescribe medication

Facilitator

Intentions

Agitation symptoms are too severe (e.g. safety concerns) limiting non-pharmacological interventions but permitting pharmacological interventions

Barrier/Facilitator

Using chemical restraints (i.e. medications) because agitation symptoms do not respond to other interventions

Facilitator

Acute/severe agitation can warrant emergency services

Barrier

Needing to use trial and error to choose non-pharmacological approach

Barrier

Lack of sensory experience non-pharmacological approaches

Barrier

Routine monitoring of non-pharmacological approaches

Facilitator

Routine monitoring of medications

Facilitator

Seeing the patient improve with medication (E.g. making patients more content)

Facilitator

Specifically assessing basic needs as first line non-pharmacological treatment

Facilitator

No regular guidelines to use restraints for agitated patients

Facilitator

IM administration route eases ability to administer medication

Facilitator

Some residents do respond well to medications for agitation and/or aggression

Facilitator

Challenges in monitoring medications (i.e. no monitoring of medications)

Barrier

Best treatment approach is dependent on the person (drug vs. non-drug)

Facilitator

Goals

Agitation symptoms are too severe (e.g. safety concerns) limiting non-pharmacological interventions but permitting pharmacological interventions

Barrier/Facilitator

Using chemical restraints (i.e. medications) because agitation symptoms do not respond to other interventions

Facilitator

Needing to use trial and error to choose non-pharmacological approach

Barrier

Lack of sensory experience non-pharmacological approaches

Barrier

Routine monitoring of non-pharmacological approaches

Facilitator

Routine monitoring of medications

Facilitator

Seeing the patient improve with medication (E.g. making patients more content)

Facilitator

Specifically assessing basic needs as first line non-pharmacological treatment

Facilitator

No regular guidelines to use restraints for agitated patients

Facilitator

IM administration route eases ability to administer medication

Facilitator

Best treatment approach is dependent on the person (drug vs. non-drug)

Facilitator

Automatic

Reinforcement

Overuse of restraints

Barrier

Having non-pharmacological options available such as verbal de-escalation, wait and re-approach, and redirection can be critical for acute or severe agitation

Facilitator

Routine monitoring of

non-pharmacological approaches

Facilitator

Routine monitoring of medications

Facilitator

Having familiar and developing trust with healthcare providers each time to administer non-pharmacological support for residents

Facilitator

Inconsistent monitoring of interventions

Barrier

Using documentation to monitor interventions

Facilitator

Challenges in monitoring medications (i.e. no monitoring of medications)

Barrier

Ensuring plans are in place to reassess residents to potentially deprescribe medication

Facilitator

Emotion

Challenges in physically administering medication (e.g.,; medication administration can be traumatizing for a person with dementia)

Barrier

Comorbid neuropsychiatric diagnosis can conflict with treating agitation symptoms

Barrier

Loss of personal traits or skills after administering medication for agitation

Barrier

Not all types of agitation are responsive to medications

Barrier