According to an article in JAMA, clinicians lack guidelines for treating the elderly with many illnesses.
The aging of the population and the increasing prevalence of chronic diseases pose challenges to the development and application of clinical practice guidelines (CPGs Clinical practice guidelines are based on clinical evidence // and expert consensus to help decision making about treating specific diseases. Most CPGs address single diseases in accordance with modern medicine’s focus on disease and pathophysiology. However, physicians who care for older adults with multiple diseases must strike a balance between following CPGs and adjusting recommendations for individual patients’ circumstances. Difficulties escalate with the number of diseases the patient has.
Researchers from Johns Hopkins University, Baltimore had examined how CPGs address co-morbidity in older patients and explored what happens when multiple single-disease CPGs are applied to a hypothetical 79-year-old woman with 5 common chronic diseases.
Two investigators independently assessed whether each CPG addressed older patients with co-morbidities, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life. For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, the authors aggregated the recommendations from the relevant CPGs.
The researchers found that most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple co-morbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costi
ng her $406 per month) and a complicated non-pharmacological regimen. Adverse interactions between drugs and diseases could result.
For the present, widely used CPGs offer little guidance to clinicians caring for older patients with several chronic diseases. The use of CPGs as the basis for pay-for-performance initiatives that focus on specific treatments for single diseases may be particularly unsuited to the care of older individuals with multiple chronic diseases. Quality improvement and pay-for-performance initiatives within the medical care system should be designed to improve the quality of care for older patients with multiple chronic diseases; a critical first step is research to define measures of the quality of care needed by this population, including care coordination, education, empowerment for self-management, and shared decision making based on the individual circumstances of older patients, said the authors.
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