- The Washington Times - Tuesday, August 9, 2005

Using current clinical practice guidelines to treat elderly patients with several illnesses may have undesirable effects, as most CPGs address single disorders, not multiple diseases that are common in this age population, a new study has found.

“For the present, widely used CPGs offer little guidance to clinicians caring for older patients with several chronic diseases,” according to the report published in today’s issue of the Journal of the American Medical Association.

“Difficulties escalate with the number of diseases the patient has,” wrote lead investigator Dr. Cynthia M. Boyd of Johns Hopkins University’s Center on Aging and Health.

The report by Dr. Boyd and colleagues at Johns Hopkins points out that in 1999, 48 percent of Medicare recipients 65 or older had at least three chronic health disorders, such as high blood pressure, chronic heart failure, diabetes and osteoporosis. That year, approximately 21 percent of Medicare beneficiaries had five or more chronic medical conditions.

Health care costs for those with at least three chronic conditions accounted for 89 percent of Medicare’s annual budget in 1999, the researchers said. They also said having more than one chronic disease is “associated with poor quality of life, physical disability, high health care use, multiple medications, and increased risk for adverse drug events and mortality.”

“Optimizing care for this population is a high priority,” given the aging of the population and the “increasing prevalence of chronic diseases,” the authors say, adding that the CPGs “are based on clinical evidence and expert consensus to help decision-making about treating specific diseases.”

“CPGs help to determine standards of care and focus efforts to improve quality. Most CPGs address single diseases in accordance with modern medicine’s focus” on individual diseases, according to the report.

But in a telephone interview yesterday, Dr. Boyd said it may be time to change the focus of CPGs used to care for older patients.

“We may be at a time when we should be thinking less about individual diseases and more about individual people who are living longer with multiple diseases,” he said.

As things stand, the investigators said, physicians caring for older adults with several serious disorders “must strike a balance between following CPGs and adjusting recommendations for individual patients’ circumstances.” A doctor’s difficulties increase in proportion to the number of diseases an elderly patient has, they said.

In reviewing national CPGs for nine chronic disorders common in the elderly, the researchers found that most did not modify or discuss the applicability of their recommendations for older patients with multiple ailments.

The researchers examined a hypothetical 79-year-old female patient with five chronic disorders, including obstructive pulmonary disease and Type 2 diabetes. If the relevant CPGs were followed, they say, she would be prescribed 12 medications costing $406 a month and a “complicated nonpharmacological regimen.”

Adverse interactions between drugs and diseases could result, the investigators said.

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