Defining ‘elderly’ in clinical practice guidelines for pharmacotherapy
Objective: To identify how ‘elderly’ patients are defined and considered within Australian clinical guidelines for the use of pharmacotherapy.
Method: Guidelines pertaining to the use of pharmacotherapy, focusing on conditions described in National Health Priority Areas, were identified using databases (Medline, Google Scholar) and organisation websites (Department of Health and Ageing, National Heart Foundation, National Health and Medical Research Council). Guidelines were reviewed and qualitatively analysed to identify any references or definitions of ‘elderly’ persons.
Results: Among the 20 guidelines reviewed, 3 defined ‘elderly’ by chronological age (i.e., years since birth) while the remaining 17 guidelines did not define ‘elderly’ in any way. All 20 guidelines used the term ‘elderly’, whilst some guidelines provided age (chronological)-based dosage recommendations suggesting an ageist or generalist approach in their representation of ‘elderly’, for which rationale was seldom provided. Thematic analysis of the statements revealed five key themes regarding how ‘elderly’ was considered within the guidelines, broadly describing ‘elderly’ persons as being frail and with altered pharmacology. Some guidelines also highlighted the limited evidence base to direct clinical decision-making. A continuum of perceptions of ageing also emerged out of the identified themes.
Conclusion: Clinical practice guidelines currently do not adequately define ‘elderly’ persons and provide limited guidance on how to apply treatment recommendations to older persons. The representation of ‘elderly’ in guidelines needs to be less based on chronological age or generic definitions focusing more on establishing a direct link between an individual patient’s characteristics and the pharmacology of their prescribed medication. Clinical guidelines that do not offer any practical descriptions of the features of ageing that are specifically related to the use of pharmacotherapy, or how to assess these in individual patients, render decision-making challenging.
2. Cherubini A, Corsonello A, Lattanzio F. Underprescription of Beneficial Medicines in Older People. Drugs Aging. 2012;29(6):463-475. doi: 10.2165/11631750-000000000-00000
3. Nyborg G, Straand J, Brekke M. Inappropriate prescribing for the elderly - a modern epidemic? Eur J Clin Pharmacol. 2012;68(7):1085-1094. doi: 10.1007/s00228-012-1223-8
4. Hubbard RE, O'Mahony MS, Woodhouse KW. Medication prescribing in frail older people. Eur J Clin Pharmacol. 2013;69(3):319-326. doi: 10.1007/s00228-012-1387-2
5. Hanlon JT, Wang X, Castle NG, Stone RA, Handler SM, Semla TP, Pugh MJ, Berlowitz DR, Dysken MW. Potential underuse, overuse, and inappropriate use of antidepressants in older veteran nursing home residents. J Am Geriatr Soc. 2011;59(8):1412-1420. doi: 10.1111/j.1532-5415.2011.03522.x
6. Tran CTT, Laupacis A, Mamdani MM, Tu JV. Effect of age on the use of evidence-based therapies for acute myocardial infarction. Am Heart J. 2004;148(5):834-841. doi: 10.1016/j.ahj.2003.11.028
7. Jacobson TA. Overcoming 'ageism' bias in the treatment of hypercholesterolaemia : a review of safety issues with statins in the elderly. Drug Saf. 2006;29(5):421-448.
8. Boyles PJ, Peterson GM, Bleasel MD, Vial JH. Undertreatment of congestive heart failure in an Australian setting. J Clin Pharm Ther. 2004;29(1):15-22. doi:10.1046/j.1365-2710.2003.00531.x
9. Krass I, Ogle SJ, Duguid MJ, Shenfield GM, Bajorek BV. The impact of age on antithrombotic use in elderly patients with non-valvular atrial fibrillation. Australas J Ageing. 2002;21(1):36-41. doi:10.1111/j.1741-6612.2002.tb00413.x
10. Fraenkel L, Rabidou N, Dhar R. Are rheumatologists' treatment decisions influenced by patients' age? Rheumatology (Oxford). 2006;45(12):1555-1557. doi:10.1093/rheumatology/kel144
11. Harries C, Forrest D, Harvey N, McClelland A, Bowling A. Which doctors are influenced by a patient’s age? A multi-method study of angina treatment in general practice, cardiology and gerontology. Qual Saf Health Care. 2007;16(1):23-27. doi:10.1136/qshc.2006.018036
12. World Health Organisation. Definition of an older or elderly person. WHO, Geneva, Switzerland. 2010. http://www.who.int/healthinfo/survey/ageingdefnolder/en/index.html (accessed 12/11/2013).
13. Orimo H, Ito H, Suzuki T, Araki A, Hosoi T, Sawabe M. Reviewing the definition of “elderly”. Geriatrics & gerontology international. 2006;6(3):149-158. doi: 10.1111/j.1447-0594.2006.00341.x
14. Levine ME. Modeling the Rate of Senescence: Can Estimated Biological Age Predict Mortality More Accurately Than Chronological Age? J Gerontol A Biol Sci Med Sci. 2013;68(6):667-674. doi: 10.1093/gerona/gls233
15. Ferguson LM, Ward H, Card S, Sheppard S, McMurtry J. Putting the ‘patient’ back into patient-centred care: An education perspective. Nurse Educ Pract. 2013;13(4):283-287. doi: 10.1016/j.nepr.2013.03.016
16. Lesko LJ, Schmidt S. Individualization of drug therapy: history, present state, and opportunities for the future. Clin Pharmacol Ther. 2012;92(4):458-466. doi: 10.1038/clpt.2012.113
17. Zhao P, Zhang L, Grillo JA, Liu Q, Bullock JM, Moon YJ, Song P, Brar SS, Madabushi R, Wu TC, Booth BP, Rahman NA, Reynolds KS, Gil Berglund E, Lesko LJ, Huang SM. Applications of Physiologically Based Pharmacokinetic (PBPK) Modeling and Simulation During Regulatory Review. Clin Pharmacol Ther. 2011;89(2):259-67. doi: 10.1038/clpt.2010.298
18. Hamberg AK, Wadelius M, Lindh JD, Dahl ML, Padrini R, Deloukas P, Rane A, Jonsson EN. A Pharmacometric Model Describing the Relationship Between Warfarin Dose and INR Response With Respect to Variations in CYP2C9, VKORC1, and Age. Clin Pharmacol Ther. 2010;87(6):727-734. doi: 10.1038/clpt.2010.37
19. Field MJ, Lohr KN. Clinical Practice Guidelines: directions for a new program. Washington, DC: Institute of Medicine, National Academy Press; 1990.
20. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;301(8):831-841. doi: 10.1001/jama.2009.205
21. Farquhar CM, Kofa EW, Slutsky JR. Clinicians' attitudes to clinical practice guidelines: a systematic review. Med J Aust. 2002;177(9):502-506.
22. AIHW, Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lapez A. The burden of disease and injury in Australia 2003. 2007. http://www.aihw.gov.au/publication-detail/?id=6442467990 (accessed 8/10/2014).
23. Clinical Practice Guidelines Portal. https://www.clinicalguidelines.gov.au/ (accessed 23/10/2014).
24. Joffe H, Yardley L. Content and thematic analysis. In: Research methods for clinical and health psychology. London; SAGE; 2004. ISBN: 9780761971917
25. RHD Australia (ARF/RHD writing group) National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Australian guideline for prevention, diagnosis and mangement of acute rheumatic fever and rheumatic heart disease. 2012. http://www.rhdaustralia.org.au/sites/default/files/guideline_0.pdf (accessed 14/03/2014).
26. National Health and Medical Research Council. Clinical practice guideline for the prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to Australian hospitals. Melbourne: National Health and Medical Research Council. 2009. http://www.nhmrc.gov.au/_files_nhmrc/file/nics/programs/vtp/guideline_prevention_venous_thromboembolism.pdf (accessed 18/03/2014).
27. Australian and New Zealand Clinical practice Guideline for Prevention and Management of Venous Leg Ulcers. http://www.awma.com.au/publications/2011_awma_vlug.pdf (accessed 22/03/2014).
28. Australian Cancer Network Management of Metastatic Prostate Cancer Working Party. Clinical Practice Guidelines for the Management of Locally Advanced and Metastatic Prostate Cancer. Cancer Council Australia and Australian Cancer Network, Sydney. 2010. http://www.cancer.org.au/content/pdf/HealthProfessionals/ClinicalGuidelines/FINAL_Advanced_Prostate_Cancer_Guidelines.pdf (accessed 05/03/2014).
29. Guideline for the non-surgical management of hip and knee osteoarthritis. 2009. http://www.racgp.org.au/download/documents/Guidelines/Musculoskeletal/racgp_oa_guideline.pdf (accessed 03/03/2014).
30. National Stroke Foundation. Clinical Guidelines for Stroke Management. Melbourne Australia. 2010. http://strokefoundation.com.au/site/media/clinical_guidelines_stroke_managment_2010_interactive.pdf (accessed 10/03/2014).
31. Clinical guideline for the diagnosis and management of early rheumatoid arthritis. 2009. http://www.racgp.org.au/download/documents/Guidelines/Musculoskeletal/racgp_ra_guideline.pdf (accessed 16/02/2014).
32. National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee). Guide to management of hypertension 2008. Updated December 2010. 2008. http://www.heartfoundation.org.au/SiteCollectionDocuments/HypertensionGuidelines2008to2010Update.pdf (accessed 28/02/2014).
33. Diabetes Management in General Practice 2011/12. http://www.racgp.org.au/download/documents/Guidelines/Diabetes/201107diabetesmanagementingeneralpractice.pdf (accessed 13/03/2014).
34. Western Australian Therapeutic Advisory Group. Guidelines for the Treatment of Neuropathic Pain. 2013. http://www.watag.org.au/watag/docs/130717_Advisory%20Note_Neuropathic%20Pain%20Guidelines%20ver2.pdf (accessed 13/03/2014).
35. The Australian Cancer Network. Clinical Practice Guidelines for the Prevention, Diagnosis and Management of Lung Cancer. 2004. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp97.pdf (accessed 13/03/2014).
36. Dodd S, Malhi GS, Tiller J, Schweitzer I, Hickie I, Khoo JP, Bassett DL, Lyndon B, Mitchell PB, Parker G, Fitzgerald PB, Udina M, Singh A, Moylan S, Giorlando F, Doughty C, Davey CG, Theodoros M, Berk M. A Consensus Statement for Safety Monitoring Guidelines of Treatments for Major Depressive Disorder. Aust N Z J Psychiatry. 2011;45(9):712-725. doi: 10.3109/00048674.2011.595686
37. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012. http://strokefoundation.com.au/site/media/AbsoluteCVD_GL_webready.pdf (accessed 13/03/2014).
38. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. 2013. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n57_obesity_guidelines_131003.pdf (accessed 15/03/2014).
39. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Reducing risk in heart disease: an expert guide to clinical practice for secondary prevention of coronary heart disease., Melbourne: National Heart Foundation of Australia. 2012. http://www.heartfoundation.org.au/SiteCollectionDocuments/Reducing-risk-in-heart-disease.pdf (accessed 13/03/2014).
40. Frith PA. The COPDX Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease 2003. Med J Aust. 2003;178(Suppl):S7-S39.
41. Clinical guieline for the prevention and treatment of osteoporosis in postmenopausal women and older men. 2010. http://www.racgp.org.au/download/documents/Guidelines/Musculoskeletal/racgp_osteo_guideline.pdf (accessed 15/03/2014).
42. Mant J, Hobbs FDR, Fletcher K, Roalfe A, Fitzmaurice D, Lip GYH, Murray E. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet.370(9586):493-503. doi: 10.1016/S0140-6736(07)61233-1
43. Carlsson J, Tebbe U, Rox J, Harmjanz D, Haerten K, Neuhaus K-L, Seidel F, Niederer W, Miketic S. Cardioversion of atrial fibrillation in the elderly. Am J Cardiol. 1996;78(12):1380-1384. doi: 10.1016/S0002-9149(96)00647-9
44. Guiot A, Jongnarangsin K, Chugh A, Suwanagool A, Latchamsetty R, Myles JD, Jiang Q, Crawford T, Good E, Pelosi F Jr, Bogun F, Morady F, Oral H. Anticoagulant Therapy and Risk of Cerebrovascular Events After Catheter Ablation of Atrial Fibrillation in the Elderly. J Cardiovasc Electrophysiol. 2012;23(1):36-43. doi: 10.1111/j.1540-8167.2011.02141.x
45. Kraft K, Hoffmann W. Challenge of evidence in individualized medicine. Per Med. 2012;9(1):65-71.
46. Cho S, Lau S, Tandon V, Kumi K, Pfuma E, Abernethy DR. Geriatric drug evaluation: where are we now and where should we be in the future? Arch Intern Med. 2011;171(10):937-940. doi:10.1001/archinternmed.2011.152
47. Jacobs JM, Maaravi Y, Cohen A, Bursztyn M, Ein-Mor E, Stessman J. Changing Profile of Health and Function from Age 70 to 85 Years. Gerontology. 2012;58(4):313-321. doi: 10.1159/000335238
48. Goggins WB, Woo J, Sham A, Ho SC. Frailty Index as a Measure of Biological Age in a Chinese Population. J Gerontol A Biol Sci Med Sci. 2005;60(8):1046-1051. doi:10.1093/gerona/60.8.1046.
49. Mitnitski AB, Graham JE, Mogilner AJ, Rockwood K. Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatr. 2002;2:1.
50. Guidelines for the ethical management of people with advanced chronic or terminal conditions in the final months of life. 2011. https://www.nhmrc.gov.au/guidelines/publications/rec31 (accessed 28/05/2014).
51. Carlsen B, Glenton C, Pope C. Thou shalt versus thou shalt not: a meta-synthesis of GPs' attitudes to clinical practice guidelines. Br J Gen Pract. 2007;57(545):971-978. doi: 10.3399/096016407782604820
52. O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, O’Connor M, Kennedy J. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. Eur Geriatr Med. 2010;1(1):45-51. doi: 10.1016/j.eurger.2010.01.007.
53. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631. doi: 10.1111/j.1532-5415.2012.03923.x
54. Vinks THAM, Egberts TCG, De Lange TM, De Koning FHP. Pharmacist-based medication review reduces potential drug-related problems in the elderly: the SMOG controlled trial. Drugs Aging. 2009;26(2):123-133. doi: 10.2165/0002512-200926020-00004
55. Castelino RL, Bajorek BV, Chen TF. Are interventions recommended by pharmacists during Home Medicines Review evidence-based? J Eval Clin Pract. 2011;17(1):104-110. doi: 10.1111/j.1365-2753.2010.01375.x
56. National Health and Medical Research Council. 2014 Annual Report on Australian Clinical Practice Guidelines. 2014. https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/nh165_2014_nhmrc_clinical_guidelines_annual_report_140805.pdf (accessed 10/10/2014).
57. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Aust N Z J Psychiatry. 2005;39(1-2):1-30. doi: 10.1080/j.1440-1614.2005.01516.x
58. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (Chronic Heart Failure Guidelines Expet Writing Panel). Guidelines for the prevention , detection and mangement of chronic heart failure in Australia. In: Updated October 2011. http://www.heartfoundation.org.au/SiteCollectionDocuments/Chronic_Heart_Failure_Guidelines_2011.pdf (accessed 23/03/2014).
59. iSource National Breast Cancer Centre. Clinical practice guidelines for the management of early breast cancer: Second edition. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp74.pdf (accessed 13/03/2014).
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