New horizons in clinical practice guidelines for use with older people

Abstract

Globally, more people are living into advanced old age, with age-associated frailty, disability and multimorbidity. Achieving equity for all ages necessitates adapting healthcare systems. Clinical practice guidelines (CPGs) have an important place in adapting evidence-based medicine and clinical care to reflect these changing needs. CPGs can facilitate better and more systematic care for older people. But they can also present a challenge to patient-centred care and shared decision-making when clinical and/or socioeconomic heterogeneity or personal priorities are not reflected in recommendations or in their application. Indeed, evidence is often lacking to enable this variability to be reflected in guidance. Evidence is more likely to be lacking about some sections of the population. Many older adults are at the intersection of many factors associated with exclusion from traditional clinical evidence sources with higher incidence of multimorbidity and disability compounded by poorer healthcare access and ultimately worse outcomes. We describe these challenges and illustrate how they can adversely affect CPG scope, the evidence available and its summation, the content of CPG recommendations and their patient-centred implementation. In all of this, we take older adults as our focus, but much of what we say will be applicable to other marginalised groups. Then, using the established process of formulating a CPG as a framework, we consider how these challenges can be mitigated, with particular attention to applicability and implementation. We consider why CPG recommendations on the same clinical areas may be inconsistent and describe approaches to ensuring that CPGs remain up to date.

Keywords: applicability; evidence-based; guidelines; methodology; older people; patient-centred.

Figure 1

Process of creating a clinical practice guideline. Note the iterative nature of the process. Suggested for further reading: https://academic.oup.com/intqhc/article/28/1/122/2363781.

Figure 2

Considerations in formulating a guideline recommendation. Factors that influence the quality of evidence and the strength of recommendation are distinct but complementary and combine to give a standard text. Further reading: https://www.gradeworkinggroup.org/.

Figure 3

Advantages and disadvantages of clinical practice guidelines for older people. Note the fine balance between benefits and harms, additional factors such as conflict of interest or multiplicity of guidelines could tip the balance unfavourably. Note that some of negative factors (dark shaded) can be overcome, others not so. Further reading: https://www.sciencedirect.com/science/article/pii/S0020138322000778.