Authors' objectives:

This report summarizes the results of an extensive systematic literary review aiming to catalog (but not evaluate) the published literature on treatment studies in 18 different areas that are significant to geriatric care care of patients older than 65. The aim has been to provide a basis for SBU to prioritize important evaluation projects in the field of geriatric care.

Authors' recommendations: Some conclusions: 1. Inaccurate inpatient statistics: The 18 problem areas covered in this report were selected by a planning group consisting of three experienced geriatricians with research training, and one geriatric-specialist nurse with research training. However, other equally important areas are not covered in this report. The number of inpatient diagnoses for 1999 differs greatly between the selected problem areas. As expected, stroke diagnoses were frequent (27,859 in all), while there were surprisingly few diagnoses in the areas of urinary incontinence (222), chronic pain (122) and malnutrition (103). According to their respective chapters, these three conditions are very common in geriatric care and in fact constitute public health issues in these age ranges. The explanation for the great divergence in actual prevalence and the statistics is that inpatient diagnoses are based on acute illnesses, while underlying clinical problems (chronic ailments) are less often specified as formal diagnoses in the discharge notes. This indicates that todays inpatient statistics do not give an accurate picture of the total ailment statistics of elderly people. 2. Incomplete indexing: The scientific articles referring to clinical treatment trials of elderly patients in various databases are not consistently indexed, making it hard to gain easy access to all treatment literature in any given area. In addition, some abstracts (summaries) of trial articles do not contain information on the age of the patients, which means that some articles may have been excluded even though they referred to patients with an average age over 65. On the whole, the report shows a very large percentage of the available scientific literature on clinical trials of people over 65, but does not claim to be a complete listing. 3. Great variation between problem areas: The number of published clinical treatment trials and the types of studies vary widely between the selected problem areas. It is also important to point out that even if an area has many RCTs, this does not necessarily mean that a satisfactory treatment method is available. 4. Poorest knowledge base where the need is greatest: Initially our intent was only to cover clinical trials of patients aged 75+. However, we soon realized that only a handful of trials exist where the entire patient population fell into that age range. In addition, the Medline database only has two age categories for patients: over 65 and over 80. This forced us to lower our age minimum to 65. The average age of inpatients at many clinics is around 75, in geriatric care over 80 and in municipal elderly care often above 85. Paradoxically, the patient groups who receive the most inpatient care and the most multiple treatments are the ones for whom we have the poorest basis of scientific material. This lack of knowledge on the effects of treatment on elderly people, plus the fact that elderly people in general are more sensitive to side effects of medications, make careful and regular evaluation of the effects of treatment especially crucial for elderly patients. This is especially true in cases of polypharmacy (concurrent treatment with several drugs). One can question if it is ethically defensible that many elderly patients receive a large number of long-term drug prescriptions with no structured evaluation of whether or not they create the desired effect in relation to the indications. 5. Important to convert science to practice: It is important to create good conditions for converting the results of published scientific trials into solid practice, so that they can benefit the patients in elderly care. To do this, elderly care must be organized to allow structured monitoring of the effects of different types of treatments on individual patients over time. This demands more continuity between the patient and the treating physician, as well as the development of uniform documentation defined by the clinical problem 6. Need for evaluation in elderly care: Only a limited number of problem areas have extensive enough published scientific literature related to the elderly that an evaluation can be done: - Cognitive disorders (dementia) - Drug treatment - Stroke - Infections - Skin ulcers - Geriatric rehabilitation - COPD (chronic obstructive pulmonary disease) - Depression Of these, SBU has previously evaluated stroke and COPD, and extensive reviews of depression and dementia are under way. This leaves four possible areas for scientific evaluation. All of the other areas have so few published trials that they cannot be evaluated. The goal here must be to stimulate further treatment research. 7. Need for clinical treatment research in elderly care: There is a pressing need for clinical treatment research on elderly patients, particularly for those over 75. All of the writers of these chapters have pointed out the lack of knowledge and the need for more clinical trials. In particular, these areas show a significant lack of trials for the elderly: - Palliative care - Confusion/delirium - Chronic pain - Malnutrition - Emergency geriatric care - Parkinsons disease - High blood pressure - Urinary incontinence - Heart failure - Osteoporosis - Coordinated service and care planning Considering that many elderly patients have many concurrent ailments (multimorbidity) and many concurrent treatments (multiple treatments), there is also an urgent need for studies of the effect of several concurrent treatments, both combination treatments within one method (such as multiple drugs) and combinations of different treatment methods (such as drugs, nutrition and training).

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.sbu.se/Published

Year Published: 2003

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Sweden

Organisation Name: Swedish Agency for Health Technology Assessment and Assessment of Social Services

Contact Address: P.O. Box 3657, SE-103 59 Stockholm, Sweden. Tel: +46 8 4123200, Fax: +46 8 4113260

Contact Name: registrator@sbu.se

Contact Email: registrator@sbu.se

Copyright: Swedish Council on Technology Assessment in Health Care (SBU)