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The Gerontologist
cite as: Gerontologist, 2017, Vol. 00, No. 00, 110
doi:10.1093/geront/gnx178
Advance Access publication November 19, 2017

Research Article

The Lesser of Two Evils Versus Medicines not


Smarties: Constructing Antipsychotics in Dementia
Dilbagh Gill, MPharm, Saleh Almutairi, PhD, MSc, BSc, and
ParastouDonyai, PhD, BPharm, BSc*
Department of Pharmacy, University of Reading, UK.
*Address correspondence to: Parastou Donyai, PhD, BPharm, BSc, Department of Pharmacy, University of Reading, Harry Nursten Building,
Whiteknights, PO Box 226, Reading RG6 6AP, UK. E-mail: p.donyai@reading.ac.uk

Received: June 28, 2017; Editorial Decision Date: October 15, 2017

Decision Editor: Barbara J.Bowers, PhD

Abstract
Background and Objectives: Because antipsychotics are associated with an increased risk of morbidity and mortality, they
should only be prescribed in dementia in limited circumstances. But antipsychotics are prescribed to a large proportion of
residents in formal care settings despite guidance and warnings to the contrary, justifying a study into how professionals
define and in turn create realities about antipsychotic usage in dementia.
Research Design and Methods: Twenty-eight professionals with a role in the care and management of patients with demen-
tia in care homes were recruited and interviewed in this qualitative study. Agap in the literature about the social construc-
tion of antipsychotics in dementia prompted the use of critical discourse analysis methodology.
Results: Antipsychotics were portrayed in 2 distinct ways; as the lesser of two evils they were conceptualized as the less
harmful or unpleasant of 2 bad choices and as medicines not Smarties (a brand of sweets/candy) they were conceptual-
ized as prescribed too frequently and indiscriminately. The first resource could be used to defend the prescribing of antip-
sychotics and uphold the prescribers privilege to do so whereas the second enabled the speaker to reject their own wilful
involvement in overprescribing.
Discussion and Implications: When prescribers draw on the lesser of two evils paradigm to sanction the overprescribing
of antipsychotics, implicit assumptions about these medications as being the best of bad choices should be recognized and
challenged. Future studies should target specific normative beliefs about antipsychotic prescribing consequences, to change
the lexicon of common knowledge which perpetuates bad practice.
Keywords: Dementia, Psychiatry, Qualitative research, Prescribing, Critical discourse analysis

There was an estimated 46.8 million people living with Lagarto, & Mukaetova-Ladinska, 2012). It can be chal-
dementia worldwide in 2015 (Alzheimers Disease lenging for carers and others when a person with dementia
International, 2015). The prevalence of dementia in people experiences agitation, aggression, irritability and outward
aged 60 and over is 6.9% in Western Europe and 6.4% in expressions of hostility (Leggett, Zarit, Taylor, & Galvin,
North America (Alzheimers Disease International, 2015). 2011; Ory, Hoffman, Yee, Tennstedt, & Schulz, 1999;
Dementia is characterized by loss of memory, mental agil- Tremont, 2011; Zimmerman etal., 2005). In specific and
ity, understanding, speech and judgment. However, demen- limited circumstances, antipsychotic medications are per-
tia can also lead eventually to noncognitive symptoms mitted to be prescribed to treat patients whose noncognitive
impacting on temperament and social behaviors (Cerejeira, symptoms are severe and become unmanageable. Although

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effective in controlling some of the challenging behaviors antipsychotic medications in dementia is also evidenced
of dementia, antipsychotic medications can result in a num- in the United States (Samuel, 2015) where in 2012 the
ber of common side-effects including sleep disturbance, Centers for Medicare and Medicaid Services, part of the
blood pressure changes, anticholinergic effects (e.g., dry U.S. Department of Health and Human Services, also
mouth, urinary incontinence, constipation, blurred vision), launched a partnership programme to improve compre-
Parkinsonism, and weight gain. Generally speaking, atyp- hensive dementia care and reduce antipsychotic prescribing
ical antipsychotics such as risperidone, olanzapine, and (Centers for Medicare & Medicaid Services, 2017).
quetiapine are preferred to older (first generation) antip- The prescribing and use of antipsychotics is particularly
sychotics but in the United Kingdom, risperidone is the high in formal institutions providing care for older people.
only antipsychotic licensed for short-term use in dementia. In the United States formal care institutions include com-
The use of atypical antipsychotics in dementia is contro- munity and Veterans Administration (VA) nursing homes
versial because of an association with an increased risk of and in the United Kingdom, nursing homes, residential
morbidity as well as mortality (Ballard, Creese, Corbett, homes (providing personal care only) or a combination
& Aarsland, 2011; Huybrechts et al., 2012; Schneider, of both. Although in the United States antipsychotics are
Dagerman, & Insel, 2005). For this reason, in the United thought to be prescribed to approximately 20%35% of
States, no antipsychotic is approved for the treatment of residents in formal care settings (Chen etal., 2010; Gellad
dementia-related psychosis and since 2008 a Black Box etal., 2012; Kamble, Sherer, Chen, & Aparasu, 2010), this
Warning must appear on package inserts of both atyp- figure is around 20%25% for residents in U.K.care homes
ical and first-generation antipsychotics to warn about the (Department of Health, 2009; Maguire, Hughes, Cardwell,
increased risk of mortality in elderly patients with demen- & OReilly, 2013) A qualitative study with old age psy-
tia-related psychosis (Food and Drug Administration, chiatrists in England uncovered a range of views about
2008). psychotropic prescribing in dementia (Wood-Mitchell,
There have been longstanding warnings about the use James, Waterworth, Swann, & Ballard, 2008). Psychiatrists
of antipsychotic medications in dementia by medicines thought there were pressures on them to prescribe, felt soci-
regulators in the United Kingdom, Europe, and the United etal and systemic influences maintained high prescribing
States (European Medicines Agency, 2008; Food and Drug rates, guidelines were not implementable, and care homes
Administration, 2008; Medicines & Healthcare Products not designed and trained to deal with problematic behav-
Regulatory Agency, 2005). In the United Kingdom, guide- iors (Wood-Mitchell etal., 2008).
lines advocate a range of non-pharmacological inter- When the views of nursing staff were explored, the
ventions for managing the noncognitive and behavioral results were dichotomized as benefits of, versus barriers to,
symptoms of dementia, supporting first-line medication use reducing antipsychotic use (Simmons et al., 2017). What
only where patients are severely distressed or there is an is particularly noteworthy is that the benefits of reducing
immediate risk of harm, and only on meeting some spe- antipsychotic usage (e.g., improvement in patients qual-
cific requirements (National Institute for Health and Care ity of life, families sense of satisfaction and reduction in
Excellence, 2006). In the United States too, the American falls) were couched mainly in relation to the detrimental
Alzheimers Association and the American Geriatric Society effects of antipsychotics whereas the barriers (e.g., resist-
recommend the use of antipsychotics only where non- ance by families, symptom worsening or returning, lack
pharmacological options have failed and there is a threat of alternatives) were couched in relation to the useful-
to life (Alzheimers Association, 2011; Samuel, 2015). The ness of antipsychotics. There has been little work to date
American Psychiatric Association recommends the non- to examine health professionals construction of antipsy-
emergency use of antipsychotics only where symptoms chotics in tackling the behavioral symptoms of dementia
are severe, dangerous and/or cause significant patient dis- from a discourse analytic perspective. This is despite litera-
tress and again on meeting a number of other prerequisites ture on the social construction of dementia itself (Bartlett,
(Reus etal., 2016). Windemuth-Wolfson, Oliver, & Dening, 2017; McInerney,
Although the use of antipsychotic medications might 2017; McParland, Kelly, & Innes, 2017; Peel, 2013; Zeilig,
be warranted in limited circumstances, in the United 2014). This paper uses the definition of discourse analysis
Kingdom it is estimated that only 20% of 180,000 patients developed by Potter & Wetherell (1987) which focuses on
with dementia prescribed an antipsychotic each year may talk as social practice, and on the resources that are drawn
actually benefit from them (Banerjee, 2009). A landmark upon to enable those practices. Under this definition, dis-
report investigating the use of antipsychotics for people course analysis focuses on how language is used to create
with dementia in the National Health Service in England reality, within a social constructionist epistemology which
found that inappropriate use could be resulting in an add- views knowledge as socially contingent and fluidfurther
itional 1,620 cerebrovascular events and another 1,800 explained in the Research Design and Methods section.
deaths each year (Banerjee, 2009)this led to the launch Understanding how people conceptualize antipsychotics
of the national dementia strategy in England (Department is significant because it allows for negative or misleading
of Health, 2009). The inappropriate prescribing of

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The Gerontologist, 2017, Vol. 00, No. 00 3

constructions to be uncovered and questioned rather than (n=7), psychiatrists (n=5), geriatricians (n=2), pharma-
blindly accepted. cists (n=2), a memory-clinic nurse, and a social worker.
Prosser (2010), taking a discourse analytic approach,
analyzed media coverage of prescribed medicines finding
two competing discourses as marvellous medicines and Data Analysis Using Discourse Analysis
dangerous drugs. The good news stories presented The interviews were transcribed verbatim into password-
the beneficial properties of medicines with use of power- protected documents, removing sensitive information to
ful adjectives (super-effective, wonder drug, brainwave keep data anonymized/de-identifiable. The doctoral student
pill, miracle cure ). The adverse news stories instead ensured data integrity in consultation with the author by
presented medicines as maligned, warning about hazards checking the transcripts against the audio files. A critical
and negative consequences. The coverage was judged discourse analysis was undertaken jointly by a Masters-
to be ambiguous, uncertain and contradictory. Prosser level student of pharmacy (first author) and the senior
(2010) argued the way in which medicines are socially author. The focus was to identify concepts key to critical
constructed leads to implicit assumptions about modern discourse analysis, namely; interpretative repertoires and
medicines that could shape opinions. The premise of the subject positions (discourse resources); how these resources
current paper is that health professionals construction of were used to build descriptions, accounts and arguments
antipsychotics in dementia could have a role in construct- (discourse processes); and how different subject positions
ing realities about these medicines which if misleading, were embedded in different interpretative repertoires,
can contribute to their inappropriate prescribing and use. including identifying ideological dilemmas (Wetherell et al.,
The aim of this paper is to explore professionals delibera- 2001). Interpretative repertoires, the common-sense way in
tions about antipsychotic prescribing in dementia using which people talk about the world, are composed of the
critical discourse analysis (Potter & Wetherell, 1987; lexicon of common knowledge, the cultural ideas, expla-
Wetherell, Taylor, & Yates, 2001) within a social construc- nations and terms and metaphors people draw on to
tionist approach. Social constructionists view language as build explanations, descriptions, accounts and arguments
constitutive of the truth and therefore give language a key (Potter & Wetherell, 1987). Because of the fluid nature of
role in negotiating and defining realities (Burr, 2015). The talk, people can take up subject positions to define them-
research question is How do health professionals and selves and their identity through their discourse (Wetherell
care home managers use language to describe and con- et al., 2001). And since these everyday discourses are full
struct antipsychotic medications when discussing their use of inconsistencies they can result in ideological dilemmas,
in dementia? complex and contradictory use of interpretative repertoires
(Billig et al., 1988).
A detailed, line-by-line scrutiny was conducted by read-
Research Design and Methods ing each interview numerous times and considering the
Design whole data before examining small chunks of text (e.g.,
Professionals with a role in the care and management parts of sentences) in relation to the research question,
of patients with dementia in care homes were recruited interpretative repertoires, subject positions and ideological
using purposive sampling. Recruitment was completed dilemmas. There was a particular focus on rhetorical
by posting letters to publicly-available addresses (e.g., choices made by the participants to depict antipsychot-
GP practices) or through known contacts and already- ics. The analysis was tabulated and rhetorical choices and
recruited interviewees. A doctoral student (second subject positions grouped according to concepts they con-
author) carried out in-depth semi-structured face-to-face veyed. Then, the next interview was read and re-read and
interviews using interview schedules (piloted first with considered for additional or supporting material to add to
three volunteers) that focused first on general descriptions concepts already generated, and so on. Although each tran-
of dementia and disease progression, before considering script was treated as a separate case, these were brought
beliefs about and professional experiences with anti- together to identify patterns within a single interview and
psychotic prescribing and use in dementia. Participants across the data set. The focus of analysis was the external
were recruited until no new concepts emerged to inform world of discourse and its meaning and effects, and of how
the study (i.e., sampling saturation). The interviews were specific words, descriptions and explanations were brought
audio-recorded. together and used through the language employed to
account for actions and events. The repertoires were identi-
fied with relevant quotes selected to portray these. Data
Sample validation was demonstrated in data triangulation (collect-
The sample of 28 participants (17 female) consisted of ing data from eight participant sub-groups), description of
care-home managers (CHM) (n = 5), general practition- study procedures, and audit trails.
ers (GPs) (n = 5), community psychiatric nurses (CPNs)

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4 The Gerontologist, 2017, Vol. 00, No. 00

Compliance With Ethical Standards arguably less obviously-harmful situations. For example,
The Universitys Research Ethics Committee (UREC 1217), the medication helps improve quality of life for the
and the local NHS Research & Development office (let- patient who experiences 24hr a day agitated and fearful
ter of access granted June 22, 2012) and Primary Care due to the progressive nature of their illness (Supplementary
Research Partnership (reference TV85) reviewed and Material, extract 2). Here the harm associated with the vul-
approved the research. Written consent from each partici- nerable patients diminished quality of life or being con-
pant was obtained before the interviews. stantly agitated and fearful is presented as more harmful
than harm which might arise from using antipsychotics.
In contrast to being vulnerable, patients were also por-
Results trayed as individuals who pose a threat to those around
them, something which needs managing because again the
Two distinct interpretative repertoires were identified. In
status quo is a less desirable choice to antipsychotic usage.
one, antipsychotic medications were typically portrayed as
Here antipsychotic medications were characterized as a tool
the lesser of two evils whereas in the other as power-
for managing uncontrollable and disruptive patients who
ful medicines not Smarties. Each of these representations
are hitting other patients or the staff, trying to break
is part of a different kind of resource drawn upon to talk
down the window or have ripped a radiator of the wall
about antipsychotics. In the first, antipsychotics were con-
(Supplementary Material, extract 3). In this regard, antip-
ceptualized as an aid to patients and their carers; as devices
sychotics are portrayed as helpful to the carer at home or
that enable the delivery of care. In the second, antipsy-
within a care-home when faced with an even more harmful
chotics were portrayed as substances that are used far too
option of not being able to deal with an aggressive patient.
casually and frequently with little regard for their adverse
Consequently, those caring for the patient with dementia,
effects or reference to usage guidelines. Both repertoires are
as well as health professionals helping these carers (through
describedhere.
prescribing antipsychotics), were another group of people
referred to as part of the construction of antipsychotic
Antipsychotics as The Lesser of Two Evils medications as the lesser of two evils.
There is a proverb Of two evils choose the less, attrib- The interviewees paraphrased quotes to illustrate the
uted to Aristotle (Speake, 2015), which is the basis of a families willingness to accept risks associated with anti-
commonly-used English idiom the lesser of two evils psychotic medication usage for the benefit of being able to
(Ayto, 2009). The meaning conveyed is that the less harm- cope with the patient at homethus presenting the deci-
ful or unpleasant of two bad choices or possibilities should sion to use antipsychotic medication as their (the families)
be chosen. choice. For example, in reference to reducing the dose of
One of the ways in which language was used to construct an antipsychotic, one family member is quoted as saying
antipsychotic medication as the lesser of two evils was in please dont touch anything as I wouldnt be able to cope,
reference to the state of patients with dementia, with two shed have to go into a home (Supplementary Material,
contrasting representations of the patient as a vulnerable extract 4) which conveys the dichotomized choice; being
individual and the patient as a threat. These representations unable to cope with the patient versus maintaining the dose
were deployed during the interviews to build up arguments of an antipsychotic medication and any associated adverse
to support the choice to use antipsychotics in order to consequences. These particular representations portray the
treat patients (and to counter alternative choices). With the relatives and carers (not the health professionals) as being
first, the patient was portrayed as vulnerable, for example, in charge of decisions to start or continue antipsychotics,
when their safety was shown to be compromised because with health professionals merely helping carers tocope.
they leave things on the stove (Supplementary Material, For example, where a nurse states the doctor said,
extract 1). The use of these specific words describes an indi- well we have to respect the fact that hes doing a very, very
vidual struggling to cope with everyday life which makes hard job keeping her at home (Supplementary Material,
them a danger to him/herself. The description infers that extract 4), it suggests that the decision to use antipsychotic
antipsychotics prevent accidents and harm that can arise medications comes primarily from, and is allowed to come
as a result of the patients actions. In the context of the from, the carer. In another extract, the nurse participant
lesser of two evils antipsychotics are presented as a more describes a scenario where if a patient wasnt on these
desirable choice than the status quo which is leaving the medications, her husband wouldnt be able to manage
patient vulnerable to unsafe acts. The evil of the patient her at home and thus she would have to go into residen-
coming to harm as a result of their own behavior is pitched tial care (Supplementary Material, extract 5). The patient
against any presumed evil that might arise from using removed from their loved ones is then described as becom-
antipsychotics. ing distressed, disorientated and quite aggressive. This
The interpretative repertoire the lesser of two evils, culminates in the speaker concluding that these drugs are
however, also pitches the use of antipsychotics against sometimes the lesser of two evils by helping the patient
to remain with their families and stopping a downward

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The Gerontologist, 2017, Vol. 00, No. 00 5

spiral of distress and aggression which might otherwise was in reference to their potent clinical and social adverse
ensue. Thus prescribing an antipsychotic is portrayed as effects on patients and also via a negative representa-
helping to deliver care by helping both the patient and their tion of health professionals who prescribe and use these
carer avoid alternative consequences. medications. For example, one CHM expressed that the
From a critical discourse analytic perspective, when par- patient taking antipsychotics becomes extremely sleepy,
ticipants employed the lesser of two evils repertoire, they is at a greater risk of falling and begins to feel really
were not merely expressing their attitude but actively con- sick (Supplementary Material, extract 6). To portray their
structing people and situations and mobilizing these in a opposition to the use of antipsychotics, they employed a
way that legitimizes the prescribing of antipsychotics. They rhetorical question Theres not an awful lot of plusses are
did this by presenting the use of antipsychotics as a choice there? In the context of medicines not Smarties here
between potential harm that might arise from medication antipsychotics are portrayed as medicines with a range of
versus leaving things as they are, for example, not dealing adverse effects which limits theiruse.
with a vulnerable patient whose behavior puts their life at Another CHM stated I do not like antipsychotic drugs
risk or whose diminished quality of life warrants action. for people with dementia as these are not getting the best
Or not dealing with the patient who poses a threat to oth- out of them (Supplementary Material, extract 7). They
ers, and whose behavior justifies the prescribing of an anti- expressed that these drugs deskill them, in all their long
psychotic, which is presented as a choice made primarily by life skills, reflecting a view of the adverse social effects of
carers with the support of the health professionals. The use antipsychotics (Supplementary Material, extract 8). The
of this interpretative repertoire is encapsulatedhere: participant used powerful imagery to construct their dis-
approval exemplified by I dont believe in my old people
I do find enormous pressure from the homes to pre-
sitting in one big circle, looking into each others eyes
scribe antipsychotic. And even individuals, obviously
and doing nothing (Supplementary Material, extract 9).
married couples when one of the partners has dementia
Within the medicines not Smarties repertoire, these rep-
say, for example, theres two elderly people and theres resentations act as arguments for why these medications
a man with dementia and hes still strongly aggressive, should not be prescribed commonly or indiscriminately.
hes being cared for by his wife and its just on a one to The representation of antipsychotics as potentially harmful
one basis its very difficult to get his, to get the wife to is also supported by a GPs choice of words that antipsy-
manage the behaviours so you do have to sometimes chotics dampen their natural reflexes and calms them
have to prescribe antipsychotics to get that happy, to get too much and consequently you lose a little bit of the
that balance right. (CPN, Interview 12) persons personality which can therefore take away
from the patient (Supplementary Material, extract10).
The adverse effects of antipsychotic medication were
also juxtaposed against non-pharmacological activities that
Antipsychotics as Powerful Medicines Not
might enhance the patients state. ACHM chose to speak
Smarties
in the first person, a tool to portray the patients perspec-
The Oxford Dictionary of Word Origins refers to Smarties tive When my wellbeing is adequately taken care of, my
as follows. behaviour will not be a destructive one (Supplementary
The sugar-coated chocolate sweets called Smarties Material, extract 11). Particularly, some GPs and nurses
were launched in 1937. Because of their similar appear- suggested that those using medication as a first resort
may be less pro-active and prefer somebody to start on
ance to pills, doctors are sometimes accused of handing
an antipsychotic rather than exploring other methods of
out drugs like Smarties. (Cresswell, 2009)
managing behavioral symptoms in patients. Thus another
Smarties are a brand of sugar-coated, inexpensive sweet/ way in which language was used to construct antipsychotic
candy popular in many countries. The sweets are small medication as powerful medicines not Smarties was in
meaning a hexagonal tube contains about 48 of them. The reference to health professionals who decide to prescribe
reference to drugs being handed out like Smarties reflects and use these medicationsin effect, the people who do the
the commonly-held belief that Smarties are shared out, no handing out of medicines like Smarties.
doubt owing to their inexpensive nature and pack size, A nurse stated I know the realities, staff are lowly
while also drawing on their similarity to pills. But unlike paid, poorly motivated and are very overworked
sweets, drugs produce pharmacological effects includ- (Supplementary Material, extract 12) suggesting there
ing unwanted adverse effects which restrict their use, or may not be a desire to explore alternative solutions for the
ought to restrict their use. The meaning conveyed when patient. Noticeably, this speaker alleges care home staff
it is stated that drugs are handed out like Smarties is that want to increase medication all the time to make their
drugs are being prescribed commonly or indiscriminately. life easier. Another nurse referred to these are powerful
The way in which language was used to construct anti- drugs which should not be handed out too readily like
psychotic medication as powerful medicines not Smarties Smarties (Supplementary Material, extract 13)signifying

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6 The Gerontologist, 2017, Vol. 00, No. 00

an unwarranted relaxed attitude toward the prescrib- Table1. The interpretative repertoires predominantly
ing and use of antipsychotics by others. Such portrayals operationalized by the interviewees
were consistent amongst GPs, one of whom said reach-
The lesser of two evils Medicines not Smarties
ing for a prescription pad and pen is very easy to do and
not much thought has gone into initiating antipsychotics Care home managers (3) Care home managers (2)
(Supplementary Material, extract 14). GPs expressed pre- Pharmacist (1) Geriatricians (2)
scribing of antipsychotics should always be justified with GPs (3) Memory clinic nurse (1)
one acknowledging their own role: its still used as the CPNs (4) Pharmacist (1)
easy option as its something as doctors, we do, we just Consultants (5)
prescribe a medicine (Supplementary Material, extract CPNs (3)
15), suggesting that bad habit also plays arole. Social worker (1)
The other way in which participants used language GPs (2)
was to portray their own role in the (over)prescribing and
use of antipsychotic medications, which involved the dis-
missal of guidelines. This is exemplified by one GP who, convenience or from ignorance. Table1 shows the partici-
in a colloquial manner, states I tend to throw them out pants propensity to draw on one or the other repertoire
and hope I get the gist of it (Supplementary Material, during the discussions. Thus for example, three CHMs
extract 16), whereas another clearly states Ive not read structured their discussions mainly around the the lesser
any guidelines moving on to say that most of the prescrib- of two evils repertoire whereas two CHMs around
ing is based on what the consultants say (Supplementary medicines not Smarties.
Material, extract 17). Here, if the speaker implicates them-
selves as someone who prescribes antipsychotics like
Smarties, then they do so unwittingly because they have Discussion and Implications
not read the guidelines relating to antipsychotic use or are When antipsychotics were described as the lesser of two
following consultant advice. evils, they were conceptualized as the less harmful or
From a critical discourse analytic perspective, when the unpleasant of two bad choices or possibilities; as a mechan-
participants employed the medicines not Smarties reper- ism for delivering care to helpless, vulnerable patients or to
toire, they were actively constructing people and circum- support carers who struggle to cope effectively with aggres-
stances and mobilizing these constructions in a way that sive patients. The other evil in this sense was pitched
questions the legitimacy of antipsychotic prescribing. This as physical harm that patients would suffer as a result of
repertoire portrays antipsychotics as potent substances their vulnerability, harm from a diminished quality of life,
with a multitude of clinical and social adverse effects, which or from experiencing fear or agitation, as well as harm
indicates that their use ought to be limited. Antipsychotics that carers would suffer as a result of not being able to
were portrayed as being used too frequently either for the cope with the disruption or unmanageability of an aggres-
convenience of those who provide care for patients with sive patient at home or within a formal care setting. When
dementia, where it is easy to prescribe out of bad habit, or antipsychotics were described as medicines not Smarties
because prescribers have not read or understood the guide- they were conceptualized as prescribed too frequently or
lines associated with antipsychotic prescribing in dementia indiscriminately. They were depicted as having potent clin-
or are following consultant advice. ical and social adverse effects on patients, accompanied
The two interpretative repertoires identified here, by a negative representation of health professionals who
antipsychotics as the lesser of two evils and medicines prescribe and use antipsychotic medications. The adverse
not Smarties appear to be inconsistent, yet they were effects were couched in term of potent medications which
drawn upon by the same individuals in different sections result in drowsiness, salivation, deskilling, dulling of inter-
of an interview and used as social resources. Interpretative actions, and even loss of patients personality, whereas
repertoires enable people to justify particular versions of the negative representation of health professionals who
events, to excuse or validate their own behaviour, to fend administer antipsychotics was conveyed in descriptions of
off criticism or otherwise allow them to maintain a cred- unmotivated or overworked staff or those acting out of bad
ible stance in an interaction (Burr, 2015). The first rep- habit, or lacking knowledge.
ertoire is a resource that can be drawn upon to defend One of the aims of critical discourse analysis is to shed
the prescribing of antipsychotics because it depicts the light on representations circulating in everyday discourses.
benefits of medication and its utility in helping people to In this way, the current study is similar to that of Prosser
care for patients with dementia. The second repertoire (2010) whose examination of newspaper stories unearthed a
is a resource that can be used to put distance between dichotomous representation of marvelous medicines ver-
the speaker and the decision to knowingly sanction the sus dangerous drugs. The discourse resources described in
overprescribing of antipsychotics, since it depicts medi- the current study are not expected to be new because their
cation as potent substances used too readily by others for validity relies on their use by other people in other contexts.

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The Gerontologist, 2017, Vol. 00, No. 00 7

For example, a qualitative study published a decade ago dementia can be taken to mean a complex, unknowable
focusing on benzodiazepine prescribing (also contentious) world of doom, ageing, and a fate worse than death.
describes this as doing something that is the lesser evil With this depiction of dementia in mind, consider now
(Anthierens, Habraken, Petrovic, & Christiaens, 2007), that Van Der Geest & Whyte (1989) argued that medicines
whereas another on the same topic highlights the medi- have a metonymic association with medical doctors who
cines not Smarties repertoire (Rogers et al., 2007). That prescribe them, with laboratories that produce them, with
the repertoires described in this study are in line with find- medical science that forms their ultimate ground. In this
ings in other studies about the (over)prescribing of medi- sense, it can be argued that antipsychotics embody the last
cines acts to verify their soundness as common discourse remnant of medical comfort that can be imparted to shield
resources. Another aim of critical discourse analysis, how- the patient from the impending doom of dementia. Thus
ever, is to identify how discourse resources are used to con- if doctors can be persuaded to transfer the power of anti-
struct and reconstruct social realities and the distribution psychotic medicines to carers then the powerless patient
of power. Therefore, another important point is how these can be treated with due care and consideration, with antip-
identified repertoires are used as discourse processes to sychotics portrayed as having a calming effect by allay-
depict decisions in relation to antipsychotic usage, that is, ing agitation, fearfulness, disorientation, and aggression.
the way in which individuals or groups are characterized as Thought of in this way, the lesser of two evils portrays
benefiting from or sanctioning antipsychotic usage. This is antipsychotics as the less harmful or unpleasant of two bad
completed here with reference to the existing critical litera- choices or possibilities because they can empower carers
ture on the meaning of medicines and dementia. to deliver compassionate care. Drawing on this repertoire
In their seminal paper examining medicines as metaphors therefore acts as a resource not only to defend the prescrib-
and metonyms Van Der Geest & Whyte (1989) described ing of antipsychotics but to uphold the prescribers priv-
medicines as being more than simply biochemically effica- ilege to do so. The apparent contrast between guidelines,
ciousit is not simply that medicines are powerful, they which advocate limiting the use of antipsychotic medica-
argue, but that people believe them to be powerful. Thus tion to severe circumstances, versus a belief that symptoms
the key to their charm is their concretenessthat they which result in patient suffering and distress necessitate
have a concrete presence and are portable. This means that pharmacological treatment, is also highlighted in a study of
by virtue of containing the power of healing in them (versus caregiver perspectives about the management of dementia
e.g., psychotherapy where a psychologist needs to admin- (Kerns, Winter, Winter, Kerns, & Etz, 2017). The authors of
ister treatment), medicines become democratic such that that paper highlight that this preference is expressed despite
anyone who gains access to them can apply their power. clear enunciation of side-effects and the potential risk for
Thus doctors have it in their gift to transfer the power of harm from antipsychotics (Kerns etal., 2017), which is also
medicines through prescribing. In addition, Van Der Geest reported elsewhere (Corneg-Blokland, Kleijer, Hertogh, &
& Whyte (1989) argued that medicines can become vehi- Van Marum, 2012).
cles of individualization, especially where a treatment can In the lesser of two evils repertoire the effectiveness
be carried out privately focusing on the individual body, of antipsychotic medication is similarly emphasized in
and particularly when sickness might reflect poorly on preference to the portrayal of their side-effects (in con-
the patient or family. Whether dementia reflects poorly on trast to medicines not Smarties where side-effects are a
the patient or their family is a cultural matter also worth main focus). Etkin (1992) argued that because the inter-
considering. pretation of signs or symptoms of illness and medication
The literature points to discourses that construct effects is embedded in cultural meanings, there can be dis-
dementia as the tragedy discourse and the living well agreement about what is primary and what is secondary
discourse, with the criticism that such a consideration to effective treatment such that a medicines side effect
divides people with dementia into those living well or suc- might be embraced by another paradigm as a requisite
cessfully with the condition and those no longer able to part of a process in which therapy is under way. Take for
maintain societys notion of living well, thus living in the example the portrayal of antipsychotics as the lesser of
shadows (McParland etal., 2017). Zeilig (2014) examining two evils, where the effect of medication is to improve
dementia as a cultural metaphor argued that the framing of quality of life by dealing with someone who is 24 hr a
dementia operates on two levels; it is generalized as a vast, day agitated and fearful. Here a calming effect of antip-
natural or monstrous force that we must fight, and also sychotics is taken to indicate their effectiveness. Yet this
located as a very specific condition that affects individuals same effect is instead portrayed as a side-effect through the
in extreme ways. In both cases, the effect, Zeilig argued, is medicines not Smarties repertoire, where for example it
to make us feel both terrified and powerless. Zeilig even is stated I dont believe in my old people sitting in one
argued that dementia can be considered a metonym, a big circle, looking into each others eyes and doing noth-
figure of speech in which a word for a part of a subject ing. Although the calming effect of antipsychotics is rep-
is taken for the whole. In this case, she argued, the word resented as the very sign of the medication working as the
lesser of two evils, this effect of antipsychotics is rejected

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8 The Gerontologist, 2017, Vol. 00, No. 00

through the interpretative repertoire medicines not too frequently or indiscriminately. These repertoires reflect
Smarties in preference for a more negative representation a shared understanding that antipsychotic prescribing is a
of their effects, of a sedentary and motionless existence. choice that is taken. The first repertoire is a resource that
On the one hand, antipsychotics can act as the antidote people might draw upon to defend the overprescribing of
to the impending demise of those with dementia and on antipsychotics because it emphasizes the benefits of medi-
the other these potent substances can intoxicate them. cation and its utility in helping people to care for patients
Drawing on the second repertoire acts to distance the with dementia. The second can be used to distance the
speaker from others who overuse these medications and to speaker from wilful involvement in the overprescribing of
enable the speaker to reject their own wilful involvement antipsychotics. Uncovering these repertoires and their uses
in overprescribing. allows them to be questioned rather than blindly accepted.
How people think and speak communicates and cor- The findings could help practitioners, researchers and
roborates their understanding of social phenomena; it policy makers to understand and challenge the effects of
also has a role in constructing and verifying their version these discourses on the inappropriate prescribing of antip-
of reality, which in turn has the potential to impact on sychotics in dementia through formal training and future
their own, and others actions and behaviors (Burr, 2015). interventions.
Thus one of the applications of critical discourse analysis
is to enable the scrutiny of power and constructions of
truths so that these can be used to rethink or reconfigure Supplementary Material
roles, relationships, or institutional practices. The current Supplementary data is available at The Gerontologist
study highlights two dominant discourse resources which online.
health professionals draw upon to either sanction the pre-
scribing of antipsychotics or to distance them from such
prescribing. Regardless of what the speaker is doing with Acknowledgments
their speech, they reflect a shared understanding that anti-
S. Almutairi completed the data collection and revised the manu-
psychotic prescribing is a choice that is taken. Identifying
script critically for important intellectual content. D.Gill completed
these interpretative repertoires can inform health profes- the analysis and revised the manuscript critically for important intel-
sionals to their own and others intentions when they con- lectual content. P.Donyai designed and managed the study, including
template prescribing decisions. When prescribers draw on analysis and interpretation of data and drafted the manuscript. All
the lesser of two evils paradigm to endorse the inappro- authors approved the final version to be published.
priate prescribing of antipsychotics, implicit assumptions
about these medications as being the less harmful of two
bad choices need to be challenged. Future studies could Funding
focus on challenging the common repertoires that con- The PhD student, Saleh Almutairi, was sponsored and funded by
struct and validate inappropriate antipsychotic prescribing the Medical Services Department of the Ministry of Defence, Saudi
and use in dementia. Recall that interpretative repertoires Arabia.
examine the common-sense way in which people talk about
the world, and are composed of the lexicon of common
knowledge which people draw on to build explanations, Conflict of Interest
descriptions, accounts and arguments. Therefore from a None reported.
behavioral change perspective (Abraham & Michie, 2008)
a future intervention would focus on changing norma-
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