Applying Clinical Experiences and Data from Other Settings

Although seniors are the main consumers of medications and healthcare services, they continue to be excluded from clinical trials. A recent study published in the Journal of General Internal Medicine (www.ncbi.nlm.nih.gov/pubmed/21286840) found that 20% of 109 surveyed clinical trials excluded patients above a specified age and 46% excluded individuals with conditions that are commonly encountered in elderly patients (eg, physical disability). In addition, only one in four trials (27%) examined outcomes that are considered highly relevant to older adults, such as health status or quality of life. This is disconcerting given that the elderly population continues to increase and is expected to make up approximately 25% of the U.S. population by 2030.

Since the majority of clinical trials exclude older adults, physicians often have limited data from which they can draw when caring for these individuals. As a result, healthcare providers caring for older adults may need to apply data or extrapolate findings from other settings and populations. They may also need to adapt treatments based on their own observations in clinical practice, rather than following clinical guidelines, which may not be applicable to every older adult.

Several of the articles in this month’s issue of Annals of Long-Term Care: Clinical Care and Aging (ALTC) demonstrate various ways in which clinicians may apply their experiences and data from other settings to improve the care of their patients.

In “Helping Families in Long-Term Care Facing Complex Decisions: Applying the Evidence about Family Meetings from Other Settings,” the authors discuss how to conduct effective family meetings in long-term care. This report is based on their review of studies that assessed structured communication processes in intensive care units and palliative care settings. They note that the communication strategies outlined in these settings may also be effective in long-term care because of key similarities between each of these settings (eg, complex medical needs, frequent reliance on surrogate decision-makers, prognostic uncertainty). The authors emphasize that research assessing these strategies in long-term care is needed, as effective communication is instrumental in improving family satisfaction and the quality of care for residents facing complex medical decisions.

In “Scheduled Low-Dose Risperidone for Agitation in Elderly Patients,” the authors recommend the use of scheduled, low-dose, routine antipsychotics versus the use of high-dose antipsychotics given on an as-needed basis to treat agitation in elderly patients with delirium, dementia, or both. This recommendation is based on the authors’ clinical experience, and they provide two case reports that demonstrate the efficacy of their regimen. While the benefits of such a regimen would have to be assessed in a randomized clinical trial to prove its superiority over other treatments, the recommendation is not without merit. Michael Keys, MD, who provides a commentary on the article, notes that the authors’ recommendation highlights “[several] principles that serve as helpful clinical guides in managing, and, perhaps, give balance to, the clinical use of antipsychotics in frail elderly patients with delirium.” In some cases, even when abundant literature exists, clinicians may not be aware of it or may not think to apply its findings to their patients.

In “Torsades de Pointes After Fluoroquinolone Therapy in an Elderly Patient with Comorbidities,” the authors report the case of an elderly man who developed QT interval prolongation and torsades de pointes shortly after receiving a fluoroquinolone for bronchopneumonia. The authors note that although the proarrhythmic effects of these drugs are well documented in the literature, awareness of these effects appears to be lacking in routine clinical practice. They note that clinicians treating patients at risk for QT prolongation, such as the elderly, should carefully consider the risks versus benefits of these agents before prescribing them to these patients. The report serves to remind us that any potential side effects of a therapy observed in the general population are probably even more likely to occur in elderly and other frail individuals. What do you think? Is it appropriate to exclude people from clinical trials based on their age alone?