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Wallis KA, Taylor DA, Fanueli EF, Saravanakumar P, Wells S. Older peoples' views on cardiovascular disease medication: a qualitative study. Fam Pract 2022; 39:897-902. [PMID: 35078221 DOI: 10.1093/fampra/cmab186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is increasing evidence for the potential benefits and harms of cardiovascular disease (CVD) medications in older people (>75 years) prompting updating of clinical guidelines. We explored the views of older people about CVD medication to inform guideline development. METHODS Qualitative study using semistructured interviews and focus groups. An ethnically diverse group of community dwelling older people were purposefully recruited from northern New Zealand using flyers in primary care clinics, local libraries, social groups, and places of worship, and by word of mouth. Interviews and focus groups were digitally recorded, transcribed verbatim, and analysed using an iterative and inductive approach to thematic analysis. RESULTS Thirty-nine participants from 4 ethnic groups were recruited (mean 74 years; range 61-91 years; Māori (7), South Asian (8), European (9), and Pasifika (15)). Most participants were taking CVD medication/s. Four main themes emerged: (i) emphasizing the benefits of CVD medication and downplaying the harms; (ii) feeling compelled to take medication; (iii) trusting "my" doctor; and (iv) expecting medication to be continued. CONCLUSION Findings raise questions about older people's agency in decision-making regarding CVD medication. CVD risk management guidelines for older people could include strategies to support effective communication of the potential benefits and harms of CVD medication in older people, balancing life expectancy, and the expected duration of therapy.
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Affiliation(s)
- Katharine A Wallis
- School of Population Health, The University of Auckland, Auckland, New Zealand
- General Practice Clinical Unit, The University of Queensland, Level 8, Health Sciences Building, Brisbane, Qld, Australia
| | | | - Elizabeth F Fanueli
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | | | - Susan Wells
- School of Population Health, The University of Auckland, Auckland, New Zealand
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2
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McCormack J, Lindblad AJ, Korownyk C. Clinical practice guidelines have big problems: The fix is simple. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- James McCormack
- Faculty of Pharmaceutical Sciences University of British Columbia Vancouver British Columbia Canada
| | - Adrienne J. Lindblad
- Faculty of Medicine and Dentistry, Department of Family Medicine University of Alberta Edmonton Alberta Canada
| | - Christina Korownyk
- Faculty of Medicine and Dentistry, Department of Family Medicine University of Alberta Edmonton Alberta Canada
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3
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van der Ploeg MA, Poortvliet RKE, Achterberg WP, Mooijaart SP, Gussekloo J, Drewes YM. Assessment of the appropriateness of cardiovascular preventive medication in older people: using the RAND/UCLA Appropriateness Method. BMC Geriatr 2022; 22:394. [PMID: 35513798 PMCID: PMC9069851 DOI: 10.1186/s12877-022-03082-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 04/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background In clinical practice and science, there is debate for which older adults the benefits of cardiovascular preventive medications (CPM) still outweigh the risks in older age. Therefore, we aimed to assess how various clinical characteristics influence the judgement of appropriateness of CPM in older adults. Method We assessed the appropriateness of CPM for adults ≥75 years with regard to clinical characteristics (cardiovascular variables, complexity of health problems, age, side effects and life expectancy) using the RAND/ University of California at Los Angeles Appropriateness Method. A multidisciplinary panel, including 11 medical professionals and 3 older representatives of the target population, received an up-to-date overview of the literature. Using 9-point Likert scales (1 = extremely inappropriate; 9 = extremely appropriate), they assessed the appropriateness of starting and stopping cholesterol lowering medication, antihypertensives and platelet aggregation inhibitors, for various theoretical clinical scenarios. There were two rating rounds, with one face-to-face discussion in between. The overall appropriateness judgments were based on the median panel ratings of the second round and level of disagreement. Results The panelists emphasized the importance of the individual context of the patient for appropriateness of CPM. They judged that in general, a history of atherosclerotic cardiovascular disease strongly adds to the appropriateness of CPM, while increasing complexity of health problems, presence of hindering or severe side effects, and life expectancy < 1 year all contribute to the inappropriateness of CPM. Age had only minor influence on the appropriateness judgments. The appropriateness judgments were different for the three types of CPM. The literature, time-to-benefit, remaining life expectancy, number needed to treat, and quality of life, were major themes in the panel discussions. The considerations to stop CPM were different from the considerations not to start CPM. Conclusion Next to the patients’ individual context, which was considered decisive in the final decision to start or stop CPM, there were general trends of how clinical characteristics influenced the appropriateness, according to the multidisciplinary panel. The decision to stop, and not start CPM, appeared to be two distinct concepts. Results of this study may be used in efforts to support clinical decision making about CPM in older adults. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03082-8.
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Affiliation(s)
- Milly A van der Ploeg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.,Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvonne M Drewes
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands.
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4
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Bogaerts JMK, von Ballmoos LM, Achterberg WP, Gussekloo J, Streit S, van der Ploeg MA, Drewes YM, Poortvliet RKE. Do we AGREE on the targets of antihypertensive drug treatment in older adults: a systematic review of guidelines on primary prevention of cardiovascular diseases. Age Ageing 2022; 51:6410447. [PMID: 34718378 PMCID: PMC8753036 DOI: 10.1093/ageing/afab192] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 06/09/2021] [Indexed: 12/11/2022] Open
Abstract
Background translation of the available evidence concerning primary cardiovascular prevention into clinical guidance for the heterogeneous population of older adults is challenging. With this review, we aimed to give an overview of the thresholds and targets of antihypertensive drug therapy for older adults in currently used guidelines on primary cardiovascular prevention. Secondly, we evaluated the relationship between the advised targets and guideline characteristics, including guideline quality. Methods we systematically searched PubMed, Embase, Emcare and five guideline databases. We selected guidelines with (i) numerical thresholds for the initiation or target values of antihypertensive drug therapy in context of primary prevention (January 2008–July 2020) and (ii) specific advice concerning antihypertensive drug therapy in older adults. We extracted the recommendations and appraised the quality of included guidelines with the AGREE II instrument. Results thirty-four guidelines provided recommendations concerning antihypertensive drug therapy in older adults. Twenty advised a higher target of systolic blood pressure (SBP) for octogenarians in comparison with the general population and three advised a lower target. Over half of the guidelines (n = 18) recommended to target a SBP <150 mmHg in the oldest old, while four endorsed targets of SBP lower than 130 or 120 mmHg. Although many guidelines acknowledged frailty, only three gave specific thresholds and targets. Guideline characteristics, including methodological quality, were not related with the recommended targets. Conclusion the ongoing debate concerning targets of antihypertensive treatment in older adults, is reflected in an inconsistency of recommendations across guidelines. Recommended targets are largely set on chronological rather than biological age.
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Affiliation(s)
- Jonathan M K Bogaerts
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
| | - Leonie M von Ballmoos
- Institute of Primary Health Care (BIHAM), University of Bern, Bern CH-3012, Switzerland
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern CH-3012, Switzerland
| | - Milly A van der Ploeg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
| | - Yvonne M Drewes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden 2300 RC, The Netherlands
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5
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Wells S, Choi Y, Jackson R, Parwaiz M, Mehta S, Selak V, Harwood M, Grey C, Kerse N, Poppe K. Cardiovascular disease preventive medication dispensing for almost every New Zealander 65 years and over: a preventive treatment paradox? Age Ageing 2022; 51:6514237. [PMID: 35077560 DOI: 10.1093/ageing/afab265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/15/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe the dispensing of cardiovascular disease (CVD) preventive medications among older New Zealanders with and without prior CVD or diabetes. METHODS New Zealanders aged ≥65 years in 2013 were identified using anonymised linkage of national administrative health databases. Dispensing of blood pressure lowering (BPL), lipid lowering (LL) or antithrombotic (AT) medications, was documented, stratified by age and by history of CVD, diabetes, or neither. RESULTS Of the 593,549 people identified, 32% had prior CVD, 14% had diabetes (of whom half also had prior CVD) and 61% had neither diagnosis. For those with prior CVD, between 79-87% were dispensed BPL and 73-79% were dispensed AT medications, across all age groups. In contrast, LL dispensing was lower than either BPL or AT in every age group, falling from 75% at age 65-69 years to 43% at 85+ years. For people with diabetes, BPL and LL dispensing was similar to those with prior CVD, but AT dispensing was approximately 20% lower. Among people without prior CVD or diabetes, both BPL and AT dispensing increased with age (from 39% and 17% at age 65-69 years to 56% and 35% at 85+ years respectively), whereas LL dispensing was 26-31% across the 65-84 year age groups, falling to 17% at 85+ years. CONCLUSION The much higher dispensing of BPL and AT compared to LL medications with increasing age suggests a preventive treatment paradox for older people, with the medications most likely to cause adverse effects being dispensed most often.
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Travassos A, Osório NB, Avelino-dos-Santos C, Figueiredo AB, Nunes DP, Rosa TDS, Frauzino FC, Vidal-de-Santana W, Sesti LF, Nunes GF, Ribeiro EM, Pontes-Silva A, Maciel EDS, Quaresma FRP, Sera EAR, Silva-Neto LS. Hemodynamics and functional outcomes after resistance training in hypertensive and normotensive elderly: An experimental study. MOTRIZ: REVISTA DE EDUCACAO FISICA 2022. [DOI: 10.1590/s1980-657420220020021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - André Pontes-Silva
- Universidade Federal de São Carlos, Brazil; Universidade Federal do Maranhão, Brazil
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Taylor CJ, Lay-Flurrie SL, Ordóñez-Mena JM, Goyder CR, Jones NR, Roalfe AK, Hobbs FR. Natriuretic peptide level at heart failure diagnosis and risk of hospitalisation and death in England 2004-2018. Heart 2021; 108:543-549. [PMID: 34183432 PMCID: PMC8921592 DOI: 10.1136/heartjnl-2021-319196] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 05/19/2021] [Indexed: 12/23/2022] Open
Abstract
Objective Heart failure (HF) is a malignant condition requiring urgent treatment. Guidelines recommend natriuretic peptide (NP) testing in primary care to prioritise referral for specialist diagnostic assessment. We aimed to assess association of baseline NP with hospitalisation and mortality in people with newly diagnosed HF. Methods Population-based cohort study of 40 007 patients in the Clinical Practice Research Datalink in England with a new HF diagnosis (48% men, mean age 78.5 years). We used linked primary and secondary care data between 1 January 2004 and 31 December 2018 to report one-year hospitalisation and 1-year, 5-year and 10-year mortality by NP level. Results 22 085 (55%) participants were hospitalised in the year following diagnosis. Adjusted odds of HF-related hospitalisation in those with a high NP (NT-proBNP >2000 pg/mL) were twofold greater (OR 2.26 95% CI 1.98 to 2.59) than a moderate NP (NT-proBNP 400–2000 pg/mL). All-cause mortality rates in the high NP group were 27%, 62% and 82% at 1, 5 and 10 years, compared with 19%, 50% and 77%, respectively, in the moderate NP group and, in a competing risks model, risk of HF-related death was 50% higher at each timepoint. Median time between NP test and HF diagnosis was 101 days (IQR 19–581). Conclusions High baseline NP is associated with increased HF-related hospitalisation and poor survival. While healthcare systems remain under pressure from the impact of COVID-19, research to test novel strategies to prevent hospitalisation and improve outcomes—such as a mandatory two-week HF diagnosis pathway—is urgently needed.
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Affiliation(s)
- Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah L Lay-Flurrie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - José M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare R Goyder
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrea K Roalfe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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8
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Cardiovascular disease risk prediction in older people: a qualitative study. Br J Gen Pract 2021; 71:e772-e779. [PMID: 34019484 PMCID: PMC8436778 DOI: 10.3399/bjgp.2020.1038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 05/12/2021] [Indexed: 12/25/2022] Open
Abstract
Background Despite cardiovascular disease (CVD) risk prediction equations becoming more widely available for people aged ≥75 years, views of older people on CVD risk assessment are unknown. Aim To explore older people’s views on CVD risk prediction and its assessment. Design and setting Qualitative study of community-dwelling older people in New Zealand. Method A diverse group of older people was purposively recruited. Semi-structured interviews and focus groups were conducted, transcribed verbatim, and thematically analysed. Results Thirty-nine participants (mean age 74 years) of Māori, Pacific, South Asian, and European ethnicities participated in one of 26 interviews or one of three focus groups. Three key themes emerged: poor knowledge and understanding of CVD and its risk assessment; acceptability and perceived benefit of knowing and receiving advice on managing personal CVD risk; and distinguishing between CVD outcomes — stroke and heart attack are not the same. Most participants did not understand CVD terms, but were familiar with the terms ‘heart attack’ and ‘stroke’, and understood lifestyle risk factors for these events. Participants valued CVD outcomes differently, fearing stroke and disability — which might adversely affect independence and quality of life — but were less concerned about a heart attack, which was perceived as causing less disability or swifter death. These findings and preferences were similar across ethnic groups. All but two participants wanted to know their CVD risk, how to manage it, and distinguish between CVD outcomes. Those who did not wish to know perceived this as something only their God could decide. Conclusion To inform clinical decision making for older people, consideration of an individual’s wish to know their risk is important, and risk prediction tools should provide separate event types rather than just composite outcomes.
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9
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Leśniak W, Morbidoni L, Dicker D, Marín-León I. Clinical practice guidelines adaptation for internists - An EFIM methodology. Eur J Intern Med 2020; 77:1-5. [PMID: 32482600 DOI: 10.1016/j.ejim.2020.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 01/09/2023]
Abstract
The rising number of clinical guidelines poses a new challenge to the internists. The main problems are: 1) available documents suffer from heterogeneous methodological quality, and 2) most of clinical guidelines target an 'ideal' patient affected by a single condition, while in real practice internists must face with comorbid patients typically undergoing a polypharmacy. To help address this challenge, EFIM Clinical Practice Working Group started a project aimed to answer a series of relevant clinical questions, by selecting the best available guidance containing recommendations applicable to complex patients under polypharmacy. The project started with the creation of a research protocol containing details about all the steps needed to write the Clinical Practice Guideline Summary. In particular, this methodological document specifies the rules: 1) to select topics and clinical questions; 2) to build up a panel of experts, carefully managing eventual conflict of interests; 3) to critically appraise clinical guidelines (using a validated tool as AGREE II), selecting the most valid and applicable to the common clinical practice (using ADAPTE; 4) to address and solve potential disagreements among the selected documents.
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Affiliation(s)
- Wiktoria Leśniak
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Laura Morbidoni
- Department of Internal Medicine, Senigallia Hospital, Ancona, Italy
| | - Dror Dicker
- Department of Internal Medicine D and Obesity Clinic, Hasharon Hospital Rabin Medical Center, Sackler School Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ignacio Marín-León
- CIBERESP-IBIS-ROCIO-University Hospital; Fundación Enebro, Seville, Spain.
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Klinger JR, Elliott G, Levine DJ, Bossone E, Duvall L, Fagan K, Frantsve-Hawley J, Kawut SM, Ryan JJ, Rosenzweig EB, Sederstrom N, Steen VD, Badesch DB. Response. Chest 2020; 156:187-188. [PMID: 31279370 DOI: 10.1016/j.chest.2019.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 03/30/2019] [Indexed: 11/18/2022] Open
Affiliation(s)
- James R Klinger
- Department of Medicine, Rhode Island Hospital, Providence, RI
| | - Gregory Elliott
- Department of Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah, Murray, UT
| | - Deborah J Levine
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, TX
| | | | - Laura Duvall
- Department of Pharmacy, OhioHealth, Columbus, OH
| | - Karen Fagan
- Division of Pulmonary and Critical Care, University of South Alabama, Mobile, AL
| | | | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - John J Ryan
- Department of Medicine, University of Utah, Salt Lake City, UT
| | - Erika B Rosenzweig
- Department of Pediatric Cardiology, Columbia University Medical Center, New York, NY
| | - Nneka Sederstrom
- Clinical Ethics Department, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Virginia D Steen
- Department of Medicine, Georgetown University School of Medicine, Washington, DC
| | - David B Badesch
- Department of Medicine, University of Colorado Health Sciences Center, Aurora, CO.
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11
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van Bussel EF, Hoevenaar-Blom MP, Poortvliet RKE, Gussekloo J, van Dalen JW, van Gool WA, Richard E, Moll van Charante EP. Predictive value of traditional risk factors for cardiovascular disease in older people: A systematic review. Prev Med 2020; 132:105986. [PMID: 31958478 DOI: 10.1016/j.ypmed.2020.105986] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/08/2020] [Accepted: 01/12/2020] [Indexed: 01/21/2023]
Abstract
With increasing age, associations between traditional risk factors (TRFs) and cardiovascular disease (CVD) shift. It is unknown which mid-life risk factors remain relevant predictors for CVD in older people. We systematically searched PubMed and EMBASE on August 16th 2019 for studies assessing predictive ability of >1 of fourteen TRFs for fatal and non-fatal CVD, in the general population aged 60+. We included 12 studies, comprising 11 unique cohorts. TRF were evaluated in 2 to 11 cohorts, and retained in 0-70% of the cohorts: age (70%), diabetes (64%), male sex (57%), systolic blood pressure (SBP) (50%), smoking (36%), high-density lipoprotein cholesterol (HDL) (33%), left ventricular hypertrophy (LVH) (33%), total cholesterol (22%), diastolic blood pressure (20%), antihypertensive medication use (AHM) (20%), body mass index (BMI) (0%), hypertension (0%), low-density lipoprotein cholesterol (0%). In studies with low to moderate risk of bias, systolic blood pressure (SBP) (80%), smoking (80%) and HDL cholesterol (60%) were more often retained. Model performance was moderate with C-statistics ranging from 0.61 to 0.77. Compared to middle-aged adults, in people aged 60+ different risk factors predict CVD and current prediction models perform only moderate at best. According to most studies, age, sex and diabetes seem valuable predictors of CVD in old-age. SBP, HDL cholesterol and smoking may also have predictive value. Other blood pressure and cholesterol related variables, BMI, and LVH seem of very limited or no additional value. Without competing risk analysis, predictors are overestimated.
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Affiliation(s)
- E F van Bussel
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1100DD Amsterdam, the Netherlands.
| | - M P Hoevenaar-Blom
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1100 DD Amsterdam, the Netherlands; Department of Neurology, Donders Centre for Brain, Behaviour and Cognition, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA Nijmegen, the Netherlands.
| | - R K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.
| | - J Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands; Department of Gerontology and Geriatrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.
| | - J W van Dalen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1100 DD Amsterdam, the Netherlands; Department of Neurology, Donders Centre for Brain, Behaviour and Cognition, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA Nijmegen, the Netherlands.
| | - W A van Gool
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1100 DD Amsterdam, the Netherlands.
| | - E Richard
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1100 DD Amsterdam, the Netherlands; Department of Neurology, Donders Centre for Brain, Behaviour and Cognition, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA Nijmegen, the Netherlands.
| | - E P Moll van Charante
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1100DD Amsterdam, the Netherlands.
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12
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van der Ploeg MA, Floriani C, Achterberg WP, Bogaerts JMK, Gussekloo J, Mooijaart SP, Streit S, Poortvliet RKE, Drewes YM. Recommendations for (Discontinuation of) Statin Treatment in Older Adults: Review of Guidelines. J Am Geriatr Soc 2019; 68:417-425. [PMID: 31663610 PMCID: PMC7027549 DOI: 10.1111/jgs.16219] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/12/2019] [Accepted: 09/15/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVES As a person's age increases and his/her health status declines, new challenges arise that may lead physicians to consider deprescribing statins. We aimed to provide insight into recommendations available in international cardiovascular disease prevention guidelines regarding discontinuation of statin treatment applicable to older adults. DESIGN We systematically searched PubMed, EMBASE, EMCARE, and the websites of guideline development organizations and online guideline repositories for cardiovascular disease prevention guidelines aimed at the general population. We selected all guidelines with recommendations (instructions and suggestions) on discontinuation of statin treatment applicable to older adults, published between January 2009 and April 2019. In addition, we performed a synthesis of information from all other recommendations for older adults regarding statin treatment. Methodological quality of the included guidelines was appraised using the appraisal of guidelines for research & evaluation II (AGREE II) instrument. RESULTS Eighteen international guidelines for cardiovascular disease prevention in the general adult population provided recommendations for statin discontinuation that were applicable to older adults. We identified three groups of instructions for statin discontinuation related to statin intolerance, and none was specifically aimed at older adults. Three guidelines also included suggestions to consider statin discontinuation in patients with poor health status. Of the 18 guidelines included, 16 made recommendations regarding statin treatment in older adults, although details on how to implement these recommendations in practice were not provided. CONCLUSION Current international cardiovascular disease prevention guidelines provide little specific guidance for physicians who are considering statin discontinuation in older adults in the context of declining health status and short life expectancy. J Am Geriatr Soc 68:417–425, 2020
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Affiliation(s)
- Milly A van der Ploeg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Carmen Floriani
- Institute of Primary Health Care (Berner Institut für Hausarztmedizin, BIHAM), University of Bern, Bern, Switzerland
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jonathan M K Bogaerts
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sven Streit
- Institute of Primary Health Care (Berner Institut für Hausarztmedizin, BIHAM), University of Bern, Bern, Switzerland
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvonne M Drewes
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
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13
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Patient Characteristics and General Practitioners' Advice to Stop Statins in Oldest-Old Patients: a Survey Study Across 30 Countries. J Gen Intern Med 2019; 34:1751-1757. [PMID: 30652277 PMCID: PMC6711940 DOI: 10.1007/s11606-018-4795-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/29/2018] [Accepted: 11/15/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Statins are widely used to prevent cardiovascular disease (CVD). With advancing age, the risks of statins might outweigh the potential benefits. It is unclear which factors influence general practitioners' (GPs) advice to stop statins in oldest-old patients. OBJECTIVE To investigate the influence of a history of CVD, statin-related side effects, frailty and short life expectancy, on GPs' advice to stop statins in oldest-old patients. DESIGN We invited GPs to participate in this case-based survey. GPs were presented with 8 case vignettes describing patients > 80 years using a statin, and asked whether they would advise stopping statin treatment. MAIN MEASURES Cases varied in history of CVD, statin-related side effects and frailty, with and without shortened life expectancy (< 1 year) in the context of metastatic, non-curable cancer. Odds ratios adjusted for GP characteristics (ORadj) were calculated for GPs' advice to stop. KEY RESULTS Two thousand two hundred fifty GPs from 30 countries participated (median response rate 36%). Overall, GPs advised stopping statin treatment in 46% (95%CI 45-47) of the case vignettes; with shortened life expectancy, this proportion increased to 90% (95CI% 89-90). Advice to stop was more frequent in case vignettes without CVD compared to those with CVD (ORadj 13.8, 95%CI 12.6-15.1), with side effects compared to without ORadj 1.62 (95%CI 1.5-1.7) and with frailty (ORadj 4.1, 95%CI 3.8-4.4) compared to without. Shortened life expectancy increased advice to stop (ORadj 50.7, 95%CI 45.5-56.4) and was the strongest predictor for GP advice to stop, ranging across countries from 30% (95%CI 19-42) to 98% (95% CI 96-99). CONCLUSIONS The absence of CVD, the presence of statin-related side effects, and frailty were all independently associated with GPs' advice to stop statins in patients aged > 80 years. Overall, and within all countries, cancer-related short life expectancy was the strongest independent predictor of GPs' advice to stop statins.
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van Bussel E, Reurich L, Pols J, Richard E, Moll van Charante E, Ligthart S. Hypertension management: experiences, wishes and concerns among older people-a qualitative study. BMJ Open 2019; 9:e030742. [PMID: 31427342 PMCID: PMC6701601 DOI: 10.1136/bmjopen-2019-030742] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Sixty-five per cent of older people have hypertension, but little is known about their preferences and concerns regarding hypertension management. Guidelines on hypertension lack consensus on how to treat older people without previous cardiovascular disease (CVD). This asks for explicit consideration of patient preferences in decision making. Therefore, the aim of this study was to explore older peoples' experiences, preferences, concerns and perceived involvement regarding hypertension management. DESIGN Qualitative interview study. SETTING Participants were selected from 11 general practitioner (GP) practices in the Netherlands and purposively sampled until data saturation was achieved. Semistructured interviews were conducted, audio recorded and analysed by two researchers using thematic analysis. PARTICIPANTS Fifteen community dwelling older people aged 74-93 years with hypertension and without previous CVD participated. RESULTS Interviewees rarely started the conversation about hypertension management with their GP, although they did have concerns. Reasons for not discussing the subject included low priority of hypertension concerns, reliance on GPs or trust in GPs to make the right decision on their behalf. Also, interviewees anticipated regret of reducing medication, fearing vascular incidents. Interviewees would like to discuss tailoring treatment to their needs, deprescription of medication and ways to reduce side effects. They expected GPs to be more transparent on treatment effects. CONCLUSION Older people describe having little involvement in hypertension management, although they have several concerns. Since GPs are also known to be hesitant to bring up this subject, we signal a conspiracy of silence about antihypertensive medication. Through breaking this silence, GPs can facilitate shared decision-making on hypertension management and better tailored care.
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Affiliation(s)
- Emma van Bussel
- Department of Primary Care and Medical Ethics, Amsterdam UMC, AMC, Amsterdam, Netherlands
| | - Leony Reurich
- Department of Primary Care and Medical Ethics, Amsterdam UMC, AMC, Amsterdam, Netherlands
| | - Jeannette Pols
- Department of Primary Care and Medical Ethics, Amsterdam UMC, AMC, Amsterdam, Netherlands
| | - Edo Richard
- Department of Neurology, Amsterdam UMC, AMC, Amsterdam, Netherlands
- Department of Neurology, Radbout University Medical Center, Nijmegen, Netherlands
| | - Eric Moll van Charante
- Department of Primary Care and Medical Ethics, Amsterdam UMC, AMC, Amsterdam, Netherlands
| | - Suzanne Ligthart
- Department of Primary and Community Care, Radbout University Medical Center, Nijmegen, Netherlands
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Jansen J, McKinn S, Bonner C, Muscat DM, Doust J, McCaffery K. Shared decision-making about cardiovascular disease medication in older people: a qualitative study of patient experiences in general practice. BMJ Open 2019; 9:e026342. [PMID: 30898831 PMCID: PMC6475217 DOI: 10.1136/bmjopen-2018-026342] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To explore older people's perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention. DESIGN, SETTING AND PARTICIPANTS Semi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol) or had received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis. RESULTS Twenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication. CONCLUSIONS Results demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general.
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Affiliation(s)
- Jesse Jansen
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Shannon McKinn
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Danielle Marie Muscat
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
| | - Jenny Doust
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kirsten McCaffery
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
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Barbera M, Mangialasche F, Jongstra S, Guillemont J, Ngandu T, Beishuizen C, Coley N, Brayne C, Andrieu S, Richard E, Soininen H, Kivipelto M. Designing an Internet-Based Multidomain Intervention for the Prevention of Cardiovascular Disease and Cognitive Impairment in Older Adults: The HATICE Trial. J Alzheimers Dis 2019; 62:649-663. [PMID: 29480185 DOI: 10.3233/jad-170858] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Many dementia and cardiovascular disease (CVD) cases in older adults are attributable to modifiable vascular and lifestyle-related risk factors, providing opportunities for prevention. In the Healthy Aging Through Internet Counselling in the Elderly (HATICE) randomized controlled trial, an internet-based multidomain intervention is being tested to improve the cardiovascular risk (CVR) profile of older adults. OBJECTIVE To design a multidomain intervention to improve CVR, based on the guidelines for CVR management, and administered through a coach-supported, interactive, platform to over 2500 community-dwellers aged 65+ in three European countries. METHODS A comparative analysis of national and European guidelines for primary and secondary CVD prevention was performed. Results were used to define the content of the intervention. RESULTS The intervention design focused on promoting awareness and self-management of hypertension, dyslipidemia, diabetes mellitus, and overweight, and supporting smoking cessation, physical activity, and healthy diet. Overall, available guidelines lacked specific recommendations for CVR management in older adults. The comparative analysis of the guidelines showed general consistency for lifestyle-related recommendations. Key differences, identified mostly in methods used to assess the overall CVR, did not hamper the intervention design. Minor country-specific adaptations were implemented to maximize the intervention feasibility in each country. CONCLUSION Despite differences in CVR management within the countries considered, it was possible to design and implement the HATICE multidomain intervention. The study can help define preventative strategies for dementia and CVD that are applicable internationally.
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Affiliation(s)
- Mariagnese Barbera
- Institute of Clinical Medicine, Neurology, University of Eastern Finland, Kuopio, Finland
| | - Francesca Mangialasche
- Department of Neurobiology, Aging Research Center, Health Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Susan Jongstra
- Department of Neurology, Academic Medical Center, University of Amsterdam, The Netherlands
| | | | - Tiia Ngandu
- Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Cathrien Beishuizen
- Department of Neurology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Nicola Coley
- INSERM, University of Toulouse UMR 1027, Toulouse, France.,Department of Epidemiology and Public Health, Toulouse University Hospital, Toulouse, France
| | | | - Sandrine Andrieu
- INSERM, University of Toulouse UMR 1027, Toulouse, France.,Department of Epidemiology and Public Health, Toulouse University Hospital, Toulouse, France
| | - Edo Richard
- Department of Neurology, Academic Medical Center, University of Amsterdam, The Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hilkka Soininen
- Institute of Clinical Medicine, Neurology, University of Eastern Finland, Kuopio, Finland.,Neurocenter, Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Miia Kivipelto
- Institute of Clinical Medicine, Neurology, University of Eastern Finland, Kuopio, Finland.,Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland.,Department of Neurobiology, Division of Clinical Geriatrics, Care Sciences and Society, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.,Stockholms Sjukhem, R&D unit, Stockholm Sweden
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Okeowo D, Patterson A, Boyd C, Reeve E, Gnjidic D, Todd A. Clinical practice guidelines for older people with multimorbidity and life-limiting illness: what are the implications for deprescribing? Ther Adv Drug Saf 2018; 9:619-630. [PMID: 30479737 PMCID: PMC6243426 DOI: 10.1177/2042098618795770] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/07/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The aim of this study was (1) to apply the current United Kingdom (UK) National Institute for Health and Care Excellence (NICE) clinical practice guidelines to a hypothetical older patient with multimorbidity and life-limiting illness; (2) consider how treatment choices could be influenced by NICE guidance specifically related to multimorbidity; and, (3) ascertain if such clinical practice guidelines describe how and when medication should be reviewed, reduced and stopped. METHODS Based upon common long-term conditions in older people, a hypothetical older patient was constructed. Relevant NICE guidelines were applied to the hypothetical patient to determine what medication should be initiated in three treatment models: a new patient model, a treatment-resistant model, and a last-line model. Medication complexity for each model was assessed according to the medication regimen complexity index (MRCI). RESULTS The majority of the guidelines recommended the initiation of medication in the hypothetical patient; if the initial treatment approach was unsuccessful, each guideline advocated the use of more medication, with the regimen becoming increasingly complex. In the new patient model, 4 separate medications (9 dosage units) would be initiated per day; for the treatment-resistant model, 6 separate medications (15 dosage units); and, for the last-line model, 11 separate medications (20 dosage units). None of the guidelines used for the hypothetical patient discussed approaches to stopping medication. CONCLUSIONS In a UK context, disease-specific clinical practice guidelines routinely advocate the initiation of medication to manage long-term conditions, with medication regimens becoming increasingly complex through the different steps of care. There is often a lack of information regarding specific treatment recommendations for older people with life-limiting illness and multimorbidity. While guidelines frequently explain how and when a medication should be initiated, there is often no information concerning when and how the medications should be reduced or stopped.
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Affiliation(s)
- Daniel Okeowo
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Alastair Patterson
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily Reeve
- NHMRC-Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada College of Pharmacy, Faculty of Health, Dalhousie University, NS, Canada
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Adam Todd
- Faculty of Medical Sciences, School of Pharmacy, Newcastle University, Rm G.66, King George VI Building, Queen Victoria Road, Newcastle upon Tyne, NE1 7RU, UK
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18
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Mantelli S, Jungo KT, Rozsnyai Z, Reeve E, Luymes CH, Poortvliet RKE, Chiolero A, Rodondi N, Gussekloo J, Streit S. How general practitioners would deprescribe in frail oldest-old with polypharmacy - the LESS study. BMC FAMILY PRACTICE 2018; 19:169. [PMID: 30314468 PMCID: PMC6186124 DOI: 10.1186/s12875-018-0856-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/03/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Many oldest-old (> 80-years) with multimorbidity and polypharmacy are at high risk of inappropriate use of medication, but we know little about whether and how GPs would deprescribe, especially in the frail oldest-old. We aimed to determine whether, how, and why Swiss GPs deprescribe for this population. METHODS GPs took an online survey that presented case-vignettes of a frail oldest-old patient with and without history of cardiovascular disease (CVD) and asked if they would deprescribe any of seven medications. We calculated percentages of GPs willing to deprescribe at least one medication in the case with CVD and compared these with the case without CVD using paired t-tests. We also included open-ended questions to capture reasons for deprescribing and asked which factors could influence their decision to deprescribe by asking for their agreement on a 5-point-Likert-scale. RESULTS Of the 282 GPs we invited, 157 (56%) responded: 73% were men; mean age was 56. In the case-vignette without CVD, 98% of GPs deprescribed at least one medication (usually cardiovascular preventive medications) stating it had no indication nor benefit. They would lower the dose or prescribe pain medication as needed to reduce side effects. Their response was much the same when the patient had a history of CVD. GPs reported they were influenced by 'risk' and 'benefit' of medications, 'quality of life', and 'life expectancy', and prioritized the patient's wishes and priorities when deprescribing. CONCLUSION Swiss GPs were willing to deprescribe cardiovascular preventive medication when it lacked indication but tended to retain pain medication. Developing tools for GPs to assist them in balancing the risks and benefits of medication in the context of patient values may improve deprescribing activities in practice.
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Affiliation(s)
- Sophie Mantelli
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Katharina Tabea Jungo
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Zsofia Rozsnyai
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Geriatric Medicine Research, Dalhousie University and Nova Scotia Health Authority, Halifax, NS Canada
- College of Pharmacy, Dalhousie University, Halifax, NS Canada
| | - Clare H. Luymes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Arnaud Chiolero
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Nicolas Rodondi
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Sven Streit
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
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Hoffmann T, Jansen J, Glasziou P. The importance and challenges of shared decision making in older people with multimorbidity. PLoS Med 2018; 15:e1002530. [PMID: 29534067 PMCID: PMC5849298 DOI: 10.1371/journal.pmed.1002530] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
In a Perspective, Tammy Hoffmann and colleagues discuss medical decision making for elderly patients with multimorbidity.
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Affiliation(s)
- Tammy Hoffmann
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Jesse Jansen
- Wiser Healthcare Program, Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, Australia
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
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20
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Herrod PJJ, Doleman B, Blackwell JEM, O'Boyle F, Williams JP, Lund JN, Phillips BE. Exercise and other nonpharmacological strategies to reduce blood pressure in older adults: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2018; 12:248-267. [PMID: 29496468 DOI: 10.1016/j.jash.2018.01.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 12/12/2017] [Accepted: 01/18/2018] [Indexed: 12/16/2022]
Abstract
The incidence of hypertension increases with advancing age and represents a significant burden of disease. Lifestyle modification represents the first-line intervention in treatment algorithms; however, the majority of evidence for this comes from studies involving young participants using interventions that may not always be feasible in the elderly. This manuscript presents a systematic review of all randomized controlled trials involving participants with a mean age of 65 or over investigating nonpharmacological strategies to reduce blood pressure (BP). Fifty-three randomized controlled trials were included. The majority of interventions described aerobic exercise training, dynamic resistance exercise training, or combined aerobic and dynamic resistance exercise training (COM), with limited studies reporting isometric exercise training or alternative lifestyle strategies. Aerobic exercise training, dynamic resistance exercise training, COM, and isometric exercise training all elicited significant reductions in both systolic and diastolic BP, with no additional benefit of COM compared with single modality exercise training. Three months of traditional exercise-based lifestyle intervention may produce a reduction in BP of approximately 5 mmHg systolic and 3 mmHg diastolic in older individuals, similar to that expected in younger individuals.
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Affiliation(s)
- Philip J J Herrod
- Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; Royal Derby Hospital, Derby, United Kingdom
| | - Brett Doleman
- Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; Royal Derby Hospital, Derby, United Kingdom
| | - James E M Blackwell
- Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; Royal Derby Hospital, Derby, United Kingdom
| | | | - John P Williams
- Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; Royal Derby Hospital, Derby, United Kingdom
| | - Jonathan N Lund
- Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom; Royal Derby Hospital, Derby, United Kingdom.
| | - Bethan E Phillips
- Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom
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Jokanovic N, Jamsen KM, Tan ECK, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and Variability in Medications Contributing to Polypharmacy in Long-Term Care Facilities. Drugs Real World Outcomes 2017; 4:235-245. [PMID: 29110295 PMCID: PMC5684050 DOI: 10.1007/s40801-017-0121-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Research into which medications contribute to polypharmacy and the variability in these medications across long-term care facilities (LTCFs) has been minimal. Objective Our objective was to investigate which medications were more prevalent among residents with polypharmacy and to determine the variability in prescribing of these medications across LTCFs. Methods This was a cross-sectional study of 27 LTCFs in regional and rural Victoria, Australia. An audit of the medication charts and medical records of 754 residents was performed in May 2015. Polypharmacy was defined as nine or more regular medications. Logistic regression was performed to determine the association between medications and resident characteristics with polypharmacy. Analyses were adjusted for age, sex and Charlson’s comorbidity index. Variability in the use of the ten most prevalent medication classes was explored using funnel plots. Characteristics of LTCFs with low (< 30%), moderate (30–49%) and high (≥ 50%) polypharmacy prevalence were compared. Results Polypharmacy was observed in 272 (36%) residents. In adjusted analyses, each of the top ten most prevalent medication classes, with the exception of antipsychotics, were associated with polypharmacy. Between 7 and 23% of LTCFs fell outside the 95% control limits for each of the ten most prevalent medications. LTCFs with ≥ 50% polypharmacy prevalence were predominately smaller. Conclusion Polypharmacy was associated with nine of the ten most prevalent medication classes. There was greater than fourfold variability in nine of the ten most prevalent medications across LTCFs. Further studies are needed to investigate the clinical appropriateness of the variability in polypharmacy.
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Affiliation(s)
- Natali Jokanovic
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia.
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia.
| | - Kris M Jamsen
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
| | - Edwin C K Tan
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Michael J Dooley
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia
| | - Carl M Kirkpatrick
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
| | - J Simon Bell
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University (Parkville Campus), 407 Royal Parade, Parkville, VIC, 3052, Australia
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Yong J, Lin D, Tan XR. Primary prevention of cardiovascular disease in older adults in China. World J Clin Cases 2017; 5:349-359. [PMID: 29026833 PMCID: PMC5618113 DOI: 10.12998/wjcc.v5.i9.349] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 05/22/2017] [Accepted: 06/13/2017] [Indexed: 02/05/2023] Open
Abstract
Over the past two decades, the percentage of Chinese who is 60 years or older has increased from 5.2% in 1995 to 10.5% in 2015. Approximately 16% of the population in China was 60 years old and above in 2015. Since 1990, cardiovascular disease (CVD) has been the leading cause of death in China. Cardiovascular medications of older adults are usually more complicated than younger age groups due to polypharmacy, the presence of comorbidities and more susceptible to treatment-related adverse outcomes. Therefore, effective primary prevention of CVD for older adults is important in sustaining the health of older adults and reducing the burden of the healthcare system. Proper management of CVD-related risk factors, such as hypertension, dyslipidemia, diabetes and obesity, can remarkably reduce risks of CVDs in older Chinese. These risk factors can be modified by managing blood pressure, glucose and lipids via lifestyle modifications or receiving medications. Smoking cessation, healthy diets, strict alcohol intake and moderate physical exercise are examples of recommended lifestyle changes for remarkably recovering health conditions of older adults who have hypertension, dyslipidemia, obesity, diabetes or complications. Treatment prescriptions of older adults, in general, are recommended to be individualized and to be initiated at a low dose. The future directions for better primary CVD prevention in older adults include establishing guidelines for primary prevention of CVD for different older adults and further research on better management strategies of CVD risks for elderly Chinese.
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Affiliation(s)
- Jian Yong
- First Affiliated Hospital of Shantou University Medical College, Shantou 515041, Guangdong Province, China
| | - Dong Lin
- First Affiliated Hospital of Shantou University Medical College, Shantou 515041, Guangdong Province, China
| | - Xue-Rui Tan
- First Affiliated Hospital of Shantou University Medical College, Shantou 515041, Guangdong Province, China
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Abstract
Hypertension is common among adults and is associated with significant morbidity and mortality and should be routinely addressed in primary care practice. Optimal blood pressure targets have evolved in the past decade with the release of large studies including older persons. However, controversy remains regarding the treatment of older and frail patients. The relationship between blood pressure treatment and falls or cognitive impairment is still an area of concern and debate. A strategy to address hypertension in older persons should consider an individual's fitness and the likelihood of adverse effects and worsening of conditions that adversely affect quality of life.
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Affiliation(s)
- Belinda Setters
- Department of Internal Medicine, Robley Rex VAMC, University of Louisville School of Medicine, 800 Zorn Avenue, 6 West - GEC #627, Louisville, KY 40206, USA; Inpatient Geriatrics, Department of Family & Geriatric Medicine, Robley Rex VAMC, University of Louisville School of Medicine, 800 Zorn Avenue, 6 West - GEC #627, Louisville, KY 40206, USA
| | - Holly M Holmes
- Geriatric & Palliative Medicine, Department of Internal Medicine, University of Texas Houston McGovern Medical School, 6431 Fannin, MBS 5.111, Houston, TX 77030, USA.
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Application of the 2014 NICE cholesterol guidelines in the English population: a cross-sectional analysis. Br J Gen Pract 2017; 67:e598-e608. [PMID: 28760741 DOI: 10.3399/bjgp17x692141] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 04/05/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The 2014 guidelines on cardiovascular risk assessment and lipid modification from the National Institute for Health and Care Excellence (NICE) recommend statin therapy for adults with prevalent cardiovascular disease (CVD), and for adults with a 10-year CVD risk of ≥10%, estimated using the QRISK2 algorithm. AIM To determine risk factor levels required to exceed the risk threshold for statin therapy, and to estimate the number of adults in England who would require statin therapy under the guidelines. DESIGN AND SETTING Cross-sectional study using a sample representative of the English population aged 30-84 years. METHOD To estimate 10-year CVD risk different combinations of risk factor levels were entered into the QRISK2 algorithm. The NICE guidelines were applied to the sample using data from the Health Survey for England 2011. RESULTS Even with optimal risk factor levels, males of different ethnicities would exceed the 10% risk threshold between the ages of 60 and 70 years, and females would exceed the threshold between 65 and 75 years. Under the NICE guidelines, 11.8 million males and females (37% of the adults aged 30-84 years) would require statin therapy, most of them (9.8 million) for primary prevention. When analysed by age, 95% of males and 66% of females without CVD in ages 60-74 years, including all males and females in ages 75-84 years, would require statin therapy. CONCLUSION Under the 2014 NICE guidelines, 11.8 million (37%) adults in England aged 30-84 years, including almost all males >60 years in all females >75 years, require statin therapy.
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Wu A, Reeve E, Hilmer S, Gnjidic D. Hospital pharmacists' beliefs about optimising statin therapy in older inpatients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Angela Wu
- Faculty of Pharmacy; University of Sydney; Sydney Australia
| | - Emily Reeve
- Sydney Medical School; University of Sydney; Sydney Australia
- Cognitive Decline Partnership Centre; Kolling Institute of Medical Research; Northern Clinical School; University of Sydney; St Leonards Australia
| | - Sarah Hilmer
- Sydney Medical School; University of Sydney; Sydney Australia
- Cognitive Decline Partnership Centre; Kolling Institute of Medical Research; Northern Clinical School; University of Sydney; St Leonards Australia
- Departments of Clinical Pharmacology and Aged Care; Royal North Shore Hospital; Sydney Australia
| | - Danijela Gnjidic
- Faculty of Pharmacy; University of Sydney; Sydney Australia
- Sydney Medical School; University of Sydney; Sydney Australia
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Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med 2017; 38:3-11. [PMID: 28063660 DOI: 10.1016/j.ejim.2016.12.021] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/21/2016] [Accepted: 12/25/2016] [Indexed: 12/17/2022]
Abstract
Deprescribing can be defined as the process of withdrawal or dose reduction of medications which are considered inappropriate in an individual. The aim of this narrative review is to provide an overview of "deprescribing"; firstly discussing the potential benefits and harms followed by the barriers to and enablers of deprescribing. We also provide practical recommendations to recognise opportunities and strategies for deprescribing in practice. Studies focused on minimizing polypharmacy indicate that deprescribing may be associated with potential benefits including resolution of adverse drug reactions, improved quality of life and medication adherence and a reduction in drug costs. While the data on the benefits is inconsistent, deprescribing appears to be safe. There are, however, potential harms including return of medical conditions or symptoms and adverse drug withdrawal reactions which emphasise the need for the process to be supervised and monitored by a health care professional. Taking action on deprescribing can be facilitated by knowledge of potential barriers, implementing a deprescribing process (utilising developed tools and resources) and identifying opportunities for deprescribing through engaging with patients and caregivers and other health care professionals and considering deprescribing in a variety of populations. Important areas for future research include the suitability of deprescribing of certain medications in specific populations, how to implement deprescribing processes into clinical care in a feasible and cost effective manner and how to engage consumers throughout the process to achieve positive health and quality of life outcomes.
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Affiliation(s)
- Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine, University of Sydney, NSW, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Capital Health, Nova Scotia Health Authority, NS, Canada.
| | - Wade Thompson
- Bruyère Research Institute, Ottawa, ON, Canada; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, ON, Canada
| | - Barbara Farrell
- Bruyère Research Institute, Ottawa, ON, Canada; Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada; School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
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Jansen J, McKinn S, Bonner C, Irwig L, Doust J, Glasziou P, Bell K, Naganathan V, McCaffery K. General Practitioners' Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study. PLoS One 2017; 12:e0170228. [PMID: 28085944 PMCID: PMC5234831 DOI: 10.1371/journal.pone.0170228] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 12/30/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs' decision making about primary CVD prevention in patients aged 75 years and older. METHOD 25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used. RESULTS Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear. CONCLUSION Older patients receive different care depending on their GP's perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.
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Affiliation(s)
- Jesse Jansen
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
- * E-mail:
| | - Shannon McKinn
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Les Irwig
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jenny Doust
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Paul Glasziou
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Katy Bell
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Ageing and Alzheimer’s Institute, Concord Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Screening and Test Evaluation Program (STEP), Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
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Lubeek SFK, Borgonjen RJ, van Vugt LJ, Olde Rikkert MG, van de Kerkhof PCM, Gerritsen MJP. Improving the applicability of guidelines on nonmelanoma skin cancer in frail older adults: a multidisciplinary expert consensus and systematic review of current guidelines. Br J Dermatol 2016; 175:1003-1010. [PMID: 27484632 DOI: 10.1111/bjd.14923] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Balancing treatment decisions in frail older adults with nonmelanoma skin cancer (NMSC) can be challenging. Clinical practice guidelines (CPGs) could provide assistance. OBJECTIVES To collect and prioritize items related to frail older adults with NMSC for integration into CPGs and to assess the current extent of this integration. METHODS Items were collected and prioritized by a multidisciplinary working group (29 members) using a modified Delphi procedure and a five-point Likert scale. To assess current integration of these items in CPGs, a systematic review was subsequently performed by two independent reviewers using five medical databases (PubMed, Embase, Cochrane Library, SUMsearch and Trip Database), websites of guideline developers/databases, and (inter)national dermatological societies. RESULTS Prioritization of a final 13-item list showed that 'limited life expectancy' (4·5 ± 0·9) and 'treatment goals other than cure' (4·4 ± 0·7) were most desired to be integrated into CPGs; both were included in six (46%) of the CPGs found (n = 13). Attention to 'tumour characteristics' and 'comorbidities' were included in CPGs most often (100% and 77%, respectively). CONCLUSIONS More attention to items related to frail older adults in NMSC CPGs is broadly desired, but CPG integration of these items is currently limited. More integration might stimulate more holistic, personalized and patient-centred care in frail older adults.
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Affiliation(s)
- S F K Lubeek
- Department of Dermatology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - R J Borgonjen
- Department of Dermatology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - L J van Vugt
- Department of Dermatology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - M G Olde Rikkert
- Department of Geriatrics, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - P C M van de Kerkhof
- Department of Dermatology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - M J P Gerritsen
- Department of Dermatology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
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