Systematic review of clinical practice guidelines recommendations about primary cardiovascular disease prevention for older adults

Abstract

BackgroundClinical care for older adults is complex and represents a growing problem. They are a diverse patient group with varying needs, frequent presence of multiple comorbidities, and are more susceptible to treatment harms. Thus Clinical Practice Guidelines (CPGs) need to carefully consider older adults in order to guide clinicians. We reviewed CPG recommendations for primary cardiovascular disease (CVD) prevention and examined the extent to which CPGs address issues important for older people identified in the literature.MethodsWe searched: 1) two systematic reviews on CPGs for CVD prevention and 2) the National CPG Clearinghouse, G-I-N International CPG Library and Trip databases for CPGs for CVD prevention, hypertension and cholesterol. We conducted our search between April and December 2013. We excluded CPGs for diabetes, chronic kidney disease, HIV, lifestyle, general screening/prevention, and pregnant or pediatric populations. Three authors independently screened citations for inclusion and extracted data. The primary outcomes were presence and extent of recommendations for older people including discussion of: (1) available evidence, (2) barriers to implementation of the CPG, and (3) tailoring management for this group.ResultsWe found 47 eligible CPGs. There was no mention of older people in 4 (9 %) of the CPGs. Benefits were discussed more frequently than harms. Twenty-three CPGs (49 %) discussed evidence about potential benefits and 18 (38 %) discussed potential harms of CVD prevention in older people. Most CPGs addressed one or more barriers to implementation, often as a short statement. Although 27 CPGs (58 %) mentioned tailoring management to the older patient context (e.g. comorbidities), concrete guidance was rare.ConclusionAlthough most CVD prevention CPGs mention the older population to some extent, the information provided is vague and very limited. Older adults represent a growing proportion of the population. Guideline developers must ensure they consider older patients’ needs and provide appropriate advice to clinicians in order to support high quality care for this group. CPGs should at a minimum address the available evidence about CVD prevention for older people, and acknowledge the importance of patient involvement.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0310-1) contains supplementary material, which is available to authorized users.

General Practitioners’ Decision Making about Primary Prevention of Cardiovascular Disease in Older Adults: A Qualitative Study

“…Due to the close balance between benefits and harms, shared decision making has been promoted in primary CVD prevention for older people [25, 40]. However, in line with previous work [48], our interviews suggest that few GPs use a shared decision making approach and many refer to challenges associated with older patient involvement, including: third party involvement, a perception that older patients prefer a paternalistic relationship with their GP, and cognitive impairment.…”

“…It is not surprising that there is substantial variation in GP practice. Two recent reviews independently showed that clinical practice guidelines are highly disease specific and tend to ignore patient context [28], often recommending the initiation of preventive medication therapy without consideration of multimorbidity, advanced illness, or limited life expectancy [25]. …”

“…Key in all of these approaches is optimising care by carefully tailoring treatment to the context and preferences of the individual (older) patient with multimorbidity. However, systematic reviews suggest that these principles are generally poorly applied in guidelines for this group [25–28]. One review looked at primary CVD prevention in older people specifically, and showed that only a handful of clinical practice guidelines adequately addressed evidence about potential benefits and harms of CVD prevention in older people or how to tailor CVD management to multimorbidity and limited life expectancy [25].…”

Improving the applicability of guidelines on nonmelanoma skin cancer in frail older adults: a multidisciplinary expert consensus and systematic review of current guidelines

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Hospital pharmacists' beliefs about optimising statin therapy in older inpatients

“…found that patients who had received pharmacist‐led dyslipidaemia management and interventions in a primary care setting were more likely to receive changes in therapy to optimise their statin use . However, current practice guidelines provide little decision support to practitioners and pharmacists in identifying individuals or population groups who may benefit from statin deprescribing interventions, as guidelines are currently limited to making recommendations on when to initiate therapy . This was highlighted in a recent study, which identified the need for statin deprescribing guidelines as 1 of the top 5 deprescribing priorities for older patients …”