American College of Physicians: Internal Medicine — Doctors for Adults ®


Geriatric guidelines help—until there are too many

From the June ACP Observer, copyright 2007 by the American College of Physicians.

By Ryan DuBosar

SAN DIEGO—It's a busy day in the office for Louise C. Walter, ACP Member. Amid the hubbub, she's examining two elderly patients for cancer screening.

Louise C. Walter, MD

Louise C. Walter, MD

The first is a 70-year-old woman with Alzheimer’s dementia who is functionally dependent in many areas of daily living. She hasn't seen a doctor in several years, so her daughter brought her in for a routine check-up. The second is an 82-year-old woman with a history of osteoarthritis who walks two miles a day and cares for her older sister. She, too, has not seen a doctor recently and has come in for a routine check-up.

A strict adherence to current guidelines would have Dr. Walter screen both patients for cancer, but that's not always in the best interests of older patients, said Dr. Walter, an internist in the division of geriatrics at the San Francisco VA Medical Center, who led a session on Guidelines and the Older Patient.

Instead, she recommended weighing the benefits and risks of screening in the context of life expectancy and individual patient values and preferences. In the two cases above, after considering these factors, Dr. Walter decided to recommend screening to the second woman but decided to recommend against it for the first.

“What’s best for the disease is not always what’s best for the patient,” she said.

The studies used to create guidelines don’t always include elderly patients, explained Dr. Walter, who also practices at the University of California, San Francisco. And there are so many guidelines that they create a “complex rubric” of treatments and interventions that can overwhelm patients. Following guidelines to the letter could mean that a patient with five comorbidities might merit a prescription regimen of 19 drugs taken at five times throughout the day.

“The majority of patients in my clinic cannot take a four-times-a-day drug,” Dr. Walter said. “I have to think of something else.”

Considering criteria

Guidelines are based on clinical evidence and expert consensus to help clinicians manage a specific disease, and usually a single disease, Dr. Walter said. However, they are increasingly being used as quality of care benchmarks to reduce practice pattern variations and set universal standards.

The problem is that there's little evidence on the applicability of current guidelines to older persons with multiple diseases, Dr. Walter said. Most guidelines are based on studies that don't include patients over age 75 or those with multiple diseases. And there is no data on the effect of a seventh drug on a patient's life expectancy or the benefit of cancer screening in an elderly person with multiple diseases.

That's worrisome considering that 48% of Medicare beneficiaries have three or more chronic conditions and half of Medicare beneficiaries take five or more medications.

With these issues in mind, Dr. Walter decided to weigh the cancer screening guidelines against other factors in considering how to evaluate her two older female patients.

The first patient was younger than the second but had severe dementia and functional dependency, so life expectancy was less than five years. She had avoided doctors and became agitated if anything interrupted her daily routine. Testing may have caused distress and led to treatment and complications from identifying clinically insignificant disease and there was little chance of benefit, Dr. Walter said.

However, cancer screening did make sense for the second patient, whose life expectancy was more than 13 years, she said. In addition, the patient understood and accepted the risks of tests. She worried about her health and had requested a mammogram, fecal occult blood test and Pap smear.

One-size-fits none

A "one-size-fits-all" approach to medical care does not work in the diverse elderly population, Dr. Walter said. Good medical care involves individualized decision-making where risks and benefits are weighed and patient preferences are considered.

Dr. Walter cited another hypothetical scenario of a 79-year-old woman with five chronic conditions of moderate severity: COPD, hypertension, diabetes osteoporosis and osteoarthritis.

She generated an aggregate treatment regimen that follows all evidence-based guidelines, is relatively simple and inexpensive, and that applies generics and once-daily dosing when possible.

The resulting prescription regimen involved 12 medications:

  • COPD: ipratropium bromide, albuterol
  • hypertension: hydrochlorothiazide, ACE inhibitor
  • diabetes: sulfonylurea, metformin, acetylsalicylic acid, statin
  • osteoporosis: calcium/vitamin D, bisphosphonate
  • osteoarthritis: NSAID, proton pump inhibitor

Problems arise with adherence: The regimen requires 19 doses per day, taken at five times during the day, and there are 14 nonpharmacologic recommendations. Potential drug interactions are also an issue, with 20 possible drug-drug or drug-disease interactions. In addition, hydrochlorothiazide can decrease effectiveness of glyburide and NSAIDs worsen hypertension.

Such complexity decreases quality of life and adherence, while increasing undesirable drug interactions and costs.

Impact on clinicians

The challenge now for many physicians who care for the elderly is to maintain individualized care and targeted interventions despite pressure to score well on performance measures that largely do not consider the particular needs of older patients.

In 2002, San Francisco VA clinicians were frustrated by just such a challenge, recalled Dr. Walter. Their colorectal cancer screening rate of 58% failed to meet the national target rate of 65%, and the clinicians were told to screen more patients or face financial penalties. The medical staff decided to assess how well the quality indicator reflected medical care.

External auditors conducted a chart review to compute the percentage of eligible patients who received timely colorectal cancer screening. To be eligible, patients had to be 52 years or older without cancer of the liver, pancreas or esophagus, and have a life expectancy of more than six months.

Auditors over-sampled patients with specific comorbid illnesses, such as congestive heart failure and ischemic heart disease and diabetes. The resulting group included 229 patients used by auditors to compute the 2002 colorectal cancer screening quality indicator.

Researchers found that 90% of patients classified as receiving poor quality care for not being screened had valid reasons, such as poor prognosis or individual preferences. Dr. Walter said.

"The administration thought we were just complaining when we said it was a bad measure," Dr. Walter noted. But it became clear that the quality indicators being used to measure colorectal cancer screening minimized the importance of individual decisions and led to inaccurate judgments of clinicians and organizations caring for older patients.


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