Australian clinical guideline for deprescribing in older people

Clinical practice guidelines aim to assist medical practitioners in making efficient evidence-based decisions in daily practice. However, international studies have shown that the majority of recommendations in American and European guidelines are not based on strong evidence. To review Australian clinical practice guidelines across a broad range of high-impact conditions and determine how evidence-based they are. Australian guidelines published from January 2010 to May 2018 relating to the top 10 causes of death in Australia were identified from the National Health and Medical Research Council (NHMRC) clinical practice guideline database and other relevant sources. The graded recommendations in these guidelines were extracted for analysis and the systems used for grading the recommendations were recorded. Ten relevant Australian guidelines were identified, containing a total of 748 graded recommendations. All 10 guidelines used either the Grading of Recommendations Assessment, Development and Evaluation (GRADE) or NHMRC systems to assess recommendations. However, only 18% (n = 136) of these recommendations were based on Level I (or equivalent) evidence; 25% (n = 185) were based on Level II evidence, 29% (n = 218) on Level III, and 9% (n = 66) on Level IV. Consensus-based recommendations accounted for 19% (n = 143) of all recommendations. Despite the enthusiasm of the evidence-based medicine movement and its documented successes, contemporary medicine appears to remain largely evidence-poor, not evidence-based. Future research should aim to provide reliable descriptions of what constitutes valid clinical reasoning in evidence-poor situations.

To identify the number of Australian clinical practice guidelines, and their key characteristics. Clinical practice guidelines that were produced or reviewed between 2003 and 2007 for use in Australia at a national or state level were identified by approaching health-related organisations and searching websites. Their characteristics were abstracted from the published guidelines and publicly accessible accompanying material. Number of clinical practice guidelines, key health areas, documentation of evidence search and appraisal processes, numbers and types of guideline producers and funders, presence of competing interest statements. 313 clinical practice guidelines were identified, of which 91 (29%) were evidence-documented, either in the guideline itself or in an accessible accompanying document. Over 80 guideline producers were identified. Federal or state government agencies produced or contributed funding to 53% of the guidelines (167/313); 28% of the guidelines supported by government agencies (46/167) were categorised as evidence-documented. A review date was specified in 52% of evidence-documented guidelines (47/91), but a third of these had passed the review date at the time of our study and no updated guidelines were found. Areas with a large burden of disease did not necessarily receive government support for guideline development. Most guidelines (246/313; 79%) made no mention of possible competing interests of members of the guideline development group. A more coordinated approach to identifying national priorities for developing and updating clinical practice guidelines may produce better returns on investment in Australian guidelines. In addition, more transparency in documenting the guideline development process, including details on competing interests, is needed.

Review question/Objective What is the effectiveness of nutritional interventions for optimizing healthy body composition in older adults living in the community, and what are these people’s qualitative perceptions and experiences? The objectives of this umbrella review are to measure and compare the overall effectiveness of nutritional interventions for optimizing healthy body composition in older adults living in the community and to better understand how they perceive and experience the nutritional interventions. Inclusion criteria Types of participants 1.This umbrella review will include systematic reviews involving:Older adults 60 years of age or older (sometimes referred to as “elderly”). More specifically, it is proposed that at least 50% of the people included in the review should be 60 years or older, OR that the mean age of people in the study should be at least 60 years. If one of these criteria is fulfilled but the other is not, the study will be included. 2 Living in the community. More specifically, it is proposed that at least 50% of the people included in the review should be: a) People living in their own homes or in retirement living. b) Those recently discharged from hospital and / or attending outpatient clinics. Those studies with a population meeting the above criteria exhibiting co-morbidities (e.g. included but not limited to diabetes, hypertension and asthma) will be included in the study. Where possible, results will be reported separately for different co-morbidities. Types of interventions/phenomena of interest This umbrella review will include systematic reviews that evaluate nutritional interventions, as previously defined. The seven types of nutritional interventions, which are included in this review are listed below. If other nutritional interventions are identified during the review, they will be assessed for inclusion using the above definition. Dietary programs High protein / low carbohydrate diet Mediterranean diet/lifestyle (including exercise, social engagement) Okinawa diet Caloric restriction Palaeolithic diet Nutritional supplements Oral nutritional supplements (ONS) including non-pharmacological dietary supplements (e.g. Sustagen) Powders, capsules Vitamins, minerals Meal replacements e.g. replacing a meal with a drink Food groups e.g. dairy, meat, fish, fruit Food delivery TRUNCATED AT 350 WORDS

To assess the quality of Australian clinical guidelines for chronic diseases and their relevance to older people with multiple comorbid conditions. Selection and assessment of national clinical guidelines for chronic conditions listed as National Health Priority Areas: cardiovascular health, diabetes mellitus, mental health, asthma, arthritis and musculoskeletal conditions, and cancer. Standardised mean scores obtained with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument (criteria grouped into six domains: scope and purpose; stakeholder involvement; rigour of development; clarity and presentation; applicability; and editorial independence). Relevance of guidelines for older people with multiple comorbid conditions. 17 guidelines were included in the study. Guidelines approved by the National Health and Medical Research Council (NHMRC) scored significantly better than those not approved by the NHMRC in all domains except for editorial independence and clarity and presentation. The mean quality of guidelines not approved by the NHMRC was below 50% in all domains except clarity and presentation. Half of the guidelines addressed treatment for older patients or for patients with one comorbid condition, but only one addressed treatment for older patients with multiple comorbid conditions. Professional societies and charities should be encouraged and supported to develop clinical guidelines in compliance with NHMRC requirements. Future guidelines should place more emphasis on the management of older people with multiple comorbid conditions.

Older people (aged 65 years +) are under-represented in clinical research across many disease areas. Such exclusions limit the generalisability of trial results and can lead to a gap in critical knowledge regarding the efficacy and safety of interventions in older age groups. International bodies and regulators have addressed this issue to varying degrees. The USA's Food and Drug Administration (FDA) has produced regular non-binding guidance about the inclusion of older trial participants, while the National Institutes of Health's (NIH) binding regulations mean that those seeking research funding must include participants of all ages unless there are scientific or ethical reasons to exclude them. European regulations governing clinical trials of new medications require that participants represent the population groups that are likely to use the product being tested, while Britain highlights the need to improve trial participation of under-served groups, which include older people. Australian clinical trial guidelines point to the potential problem of excluding some groups from research but do not specifically address older participants. While current international approaches may provide some improvements in trial representation, additional strategies are required to promote clinical research that better reflects populations seen in clinical practice. Australia could benefit from clinical trial guidance that highlights the specific issue of the under-representation of older participants and outlines strategies to facilitate greater inclusion. This article provides an overview and critique of the current approaches to the inclusion of older people in clinical research and highlights policy gaps and limitations of current strategies.

The papers by Radcliffe et al.1 and Yap et al.2 provide a broad picture of COVID in people living in aged care facilities before and after the advent of vaccination. Radcliffe et al. reviewed their prospective experience of in-reach services at 45 residential aged care facilities (RACFs) in metropolitan Melbourne for 6 months during Victoria's first and second waves, prior to the availability of vaccination. Yap et al. examined the impact of vaccination in a cohort of residents in nine aged care facilities affected by outbreaks a year later, after vaccines had become available, in the era of the Delta variant. The striking finding from both studies was the high mortality of COVID-19. For unvaccinated people living in these aged care facilities, the overall mortality was 23% in Radcliffe's study and 39% in Yap's study (noting small numbers). In Yap's study, mortality was still 15% amongst those who were fully vaccinated. This reflects the major impact of COVID-19 in Australian nursing homes. In Australia in 2020, 7% of the cases and 75% of the deaths from COVID-19 occurred in residents of aged care facilities.3 A study of 86 RACFs in Queensland during the Omicron outbreak from December 2021 to January 2022 reported infections in 12% of residents and mortality in 12% of those infected, with the odds of mortality 13.0 (6.2–27.0) times greater in those who were unvaccinated than in those who had received three or more vaccine doses.4 By 3 February 2023, 5067 COVID-19 deaths and 127 992 cases had been reported nationally across 2803 RACFs, even with over 75% of residents having received a fourth dose of vaccine.5 While people living in aged care facilities have a limited life expectancy, COVID-19 is a traumatic and significant event. The impact of COVID-19 outbreaks, over and above the direct consequences of the illness due to SARS-CoV-2, includes facility lockdowns, staff shortages, visitor restrictions and mass transfers to hospital for infection control reasons, with consequent compromised care, isolation and distress. This was most dramatically illustrated by the stories from St Basils and Newmarch House. It has had a major impact on people living and working in most aged care facilities and on their families.6 Grim mortality statistics are only part of the story. The papers by Radcliffe et al.1 and Yap et al.2 hint at the diversity of presentations in this population, including delirium, falls, physical and cognitive decline and other non-respiratory (e.g. gastrointestinal) presentations. With the change from ancestral and Delta variants to Omicron and its subvariants, and the advent of widespread infection and immunisation against COVID-19, older people now comprise the majority of hospitalisations with COVID-19. We are now seeing far fewer respiratory presentations and a more diverse clinical phenotype with variable attribution to COVID-19. Older people often present with non-specific, multifactorial geriatric syndromes, and infections are one of the commonest reversible causes of these. When older patients present with delirium, falls or functional decline and are found to have SARS-CoV-2 infection, COVID-19 is likely to be a contributing cause of the presenting syndrome. Clinical services must reflect this diversity. Staff in aged care facilities, outreach teams and hospital teams need to work together with clinicians skilled in infection control, respiratory management, delirium management, comprehensive geriatric assessment, palliative care and rehabilitation. At this time of elevated risk, there needs to be a focus on prevention and management of delirium, falls and unstable comorbidities. The COVID-19 pandemic has highlighted the importance of clarifying and documenting individual goals of medical treatment through advance care directives in all patients, preferably prior to illness. Challenges in access to treatment – considering drug interactions with nirmatrelvir/ritonavir, pill burden with molnupiravir, and delivery of intravenous remdesivir – need to be addressed at an individual, facility and health system level. The increase in survival of aged care residents after COVID-19 raises the importance of access to allied health for rehabilitation, as well as recognition and management of the sequelae of COVID-19 (including long COVID) in this population. In Australia, management of COVID-19 has been guided by the National Clinical Evidence Taskforce COVID-19 Guidelines.7 The ‘Care of Older People and Palliative Care Panel’ specifically considers the application of the evidence to frail older people, including those living in residential aged care, and a flowchart has been published on ‘Management of people with COVID-19 who are older and living with frailty and/or cognitive impairment’. However, guidance frequently relies on general principles due to uncertainty of the applicability of the available evidence. The disproportionate impact of the COVID-19 pandemic on frail older people has highlighted the importance of evaluating vaccines and treatments in populations relevant to the population that will use them, with outcomes relevant to those people.8, 9 Older people with frailty have been largely excluded from clinical trials,10 including the large UK PANORAMIC trial of molnupiravir11 conducted after the emergence of Omicron and after immunisation programmes had been implemented. The protocol specifically included recruitment of ‘care home residents’, including those who lacked capacity to consent through a legal representative. However, there is no subgroup analysis presented on this population, and only 2% of trial participants overall were over 80 years old. This evidence gap was captured by the Australian guidelines, which advise that non-routine use of molnupiravir may be considered in highest-risk patients if all other treatments for mild, early COVID-19 are contraindicated or inappropriate.7 This is often the case for residents of aged care facilities due to interactions with or lack of access to alternative agents. In all major trials of vaccines and therapeutics, the main outcomes considered have been mortality, hospitalisation and/or severe respiratory COVID-19. However, in frail older people, analyses of effects on mortality and hospitalisation are confounded by competing causes. Hospitalisation may be from another disease or reasons other than medical illness (e.g. infection control) or may not be clinically appropriate despite severe COVID-19 due to comorbidities/prognosis. While early in the pandemic prevention of death and hospitalisation were priority outcomes, it is now time to also consider the clinical relevance of other outcomes. The impact of other manifestations of COVID-19, such as a respiratory illness classified as ‘mild’, diarrhoea or delirium, on physical and cognitive function and quality of life needs to be measured and considered. It is biologically plausible that reduced symptom intensity and duration and potentially an earlier release from isolation (or reduced infectivity shortening outbreaks and infection control requirements) may well reduce cognitive and physical decline in people living in aged care settings. However, this hypothesis remains untested and cannot be inferred from studies of other populations. A clinical trial of treatments demonstrated to be effective in younger, healthier populations is now unlikely to be feasible in frail older people, due to a lack of equipoise in this group at highest risk of death. In such situations, epidemiologists can consider observational data in a ‘target trial’ framework, in terms of the trial that would ideally have been performed to answer this question. Such a trial would have allocated patients to receive or not receive antivirals within 5 days of symptom onset. Differences between those who received antivirals and those who did not, usually accounted for by randomisation, would include age, frailty and measures of comorbidity. Outcome measures would include the full range of clinical, functional and cognitive issues potentially related to COVID-19, whether hospitalised or not. Other outcome measures, including secondary attack rate and impact on staff and residents in the facility, could also be assessed, with the appropriate adjustment for facility-level clustering. We have learned much since COVID-19 swept through aged care facilities in 2020, leaving horrific stories of heartbreak and suffering in its wake. Infection control measures are still a significant burden. Testing of visitors and staff remains routine, and some residents may not have seen a maskless face in years. However, there is now a much better balance between infection control requirements and the needs of residents in seeing visitors and receiving care. Vaccination has significantly reduced mortality and almost eliminated severe respiratory infection. COVID-19 is now a somewhat different disease to that experienced in the pre-Omicron, pre-vaccination era. The extrapolation of evidence to the population and the management of non-respiratory symptoms and of long COVID remain challenges for RACFs and the health services that support them, which include the aged care outreach services described in the papers by Radcliffe et al.1 and Yap et al.2 Older people are different. They are a heterogenous group with a spectrum of risks, frailty, needs and goals of care. Consideration of whether a person lives in residential care or how frail they are gives an indication of their risk on a population level but is not sufficient for clinical decision-making on an individual level.12 Advance care directives are one important clinical tool in crystallising what is important to individuals in the context of medical treatment. We also need to consider the outcomes of public health, preventive measures and treatments through the lens of patient-centred outcomes, and design interventions and trials accordingly, to inform reliably the care of those who need it most.

To assess the composition by gender of Australian clinical practice guideline development panels; to explore guideline development-related factors that influence the composition of panels. Survey of clinical guidelines published in Australia during 2010-2020 that observed the 2016 NHMRC Standards for Guidelines, identified (June 2021) in the NHMRC Clinical Practice Guideline Portal or by searching the Guideline International Network guidelines library, the Trip medical database, and PubMed. The gender of contributors to guideline development was inferred from gendered titles (guideline documents) or pronouns (online biographies). The overall proportion of guideline panel members - the guideline contributors who formally considered evidence and formulated recommendations (ie, guideline panel chairs and members) - who were women. Of 406 eligible guidelines, 335 listed the names of people who contributed to their development (82%). Of 7472 named contributors (including 511 guideline panel chairs [6.8%] and 5039 guideline panel members [67.4%]), 3514 were men (47.0%), 3345 were women (44.8%), and gender could not be determined for 612 (8.2%). A total of 215 guideline panel chairs were women (42.1%), 280 were men (54.8%); 2566 guideline panel members were men (50.9%), 2071 were women (41.1%). The proportion of female guideline panel members was smaller than 40% for 179 guidelines (53%) and larger than 60% for 71 guidelines (21%). The median guideline proportion of female panel members was smaller than 50% for all but two years (2017, 2018). The representation of women in health leadership roles in Australia does not reflect their level of participation in the health care workforce. In particular, clinical guideline development bodies should develop transparent policies for increasing the participation of women in guideline development panels.

This study assessed Australian clinical practice guidelines for life-limiting index conditions for the extent to which they acknowledged comorbidities and framed management recommendations within the context of older age and reduced life expectancy. A comprehensive search identified current, evidence-based Australian guidelines for chronic life-limiting conditions directed at general practitioners. Guideline content was analysed qualitatively before comorbidity acknowledgements were quantified using a 17-item checklist. Full guidelines were quality appraised using AGREE-II. Ten documents covering chronic obstructive pulmonary disease, heart failure, cancer pain, dementia and palliative care in aged care were identified. Most guidelines addressed one 'comorbid' condition and prompted clinicians to consider patient quality of life and personal preferences. Fewer addressed burden of treatment and half suggested modifying treatments to account for limited life expectancy, age or time horizon to benefit. Half warned of potential adverse drug interactions. Guidelines were of moderate to very high quality. Guidelines naturally prioritised their index condition, directing attention to only the most common comorbidities. However, there may be scope to include more condition-agnostic guidance on multimorbidity management. This might be modelled on the 'guiding principles' approach now emerging internationally from organisations such as the American Geriatrics Society in response to increasing multimorbidity prevalence and evidence limitations.

This study assessed Australian clinical practice guidelines for life-limiting index conditions for the extent to which they acknowledged comorbidities and framed management recommendations within the context of older age and reduced life expectancy. A comprehensive search identified current, evidence-based Australian guidelines for chronic life-limiting conditions directed at general practitioners. Guideline content was analysed qualitatively before comorbidity acknowledgements were quantified using a 17-item checklist. Full guidelines were quality appraised using AGREE-II. Ten documents covering chronic obstructive pulmonary disease, heart failure, cancer pain, dementia and palliative care in aged care were identified. Most guidelines addressed one 'comorbid' condition and prompted clinicians to consider patient quality of life and personal preferences. Fewer addressed burden of treatment and half suggested modifying treatments to account for limited life expectancy, age or time horizon to benefit. Half warned of potential adverse drug interactions. Guidelines were of moderate to very high quality. Guidelines naturally prioritised their index condition, directing attention to only the most common comorbidities. However, there may be scope to include more condition-agnostic guidance on multimorbidity management. This might be modelled on the 'guiding principles' approach now emerging internationally from organisations such as the American Geriatrics Society in response to increasing multimorbidity prevalence and evidence limitations.

the study aimed to examine the prevalence of comorbidity, the prescribing of potentially inappropriate medications and treatment conflicts in a large sample of older people who have been dispensed an antidepressant medicine. a cross-sectional study of administrative claims data from the Department of Veterans' Affairs, Australia, 1 April-31 July 2007, of veterans aged > or =65 years was conducted. Comorbidities determined using the pharmaceutical-based comorbidity index, Rx-Risk-V. Concomitant medicines that may be potentially inappropriate for patients with depression and areas of treatment conflicts were determined from Australian clinical guidelines or reference compendia. a total of 39,695 subjects were included, with a median of 5 comorbid conditions (inter-quartile range 3-6). Ninety percent of medicine use was attributed to the treatment of comorbid conditions. Eighty-seven percent of the study cohort was identified as having at least one comorbid condition that may cause a potential treatment conflict when an antidepressant is used. Those conditions of most concern included cardiovascular diseases, anxiety disorders, arthritis or pain management and osteoporosis. we observed a high level of potentially inappropriate prescribing and treatment conflicts that may arise when caring for older patients dispensed an antidepressant with comorbidity. These have the potential to place a large number of older people with depression at increased risk for adverse events.

Primiparity at Very Advanced Maternal Age (≥45 years)

Multimorbidity is common in older patients with heart failure (HF), complicating therapeutic management and increasing the risk of harm. This study sought to examine the prevalence of medicines for the treatment of comorbid conditions potentially associated with harm in older people, before and after HF hospitalization. A retrospective cohort study of older people hospitalized with a primary diagnosis of HF over a 12-month period was conducted using administrative health claims data from the Department of Veterans' Affairs (DVA) Australia. We examined the prevalence of medicines that may exacerbate or worsen HF as defined by the American Heart Association (AHA) and Australian HF clinical guidelines, in the 30days prior and 120days before and after discharge for HF. A total of 4069 older adults were hospitalized for HF during the study period; almost 60% (n = 2435) received at least one medicine associated with an increased risk of harm before hospitalization, with the majority (66.7%, n = 1623) dispensed in the 30days prior. A small but significant reduction after hospitalization was observed, but 56% (n = 1638) received at least one of these medicines after hospitalization (p = 0.001). Over one-quarter received two or more medicines before hospitalization, and this only reduced to 22% post-hospitalization (p < 0.0001). Little change in the prescribing of potentially harmful medicines for HF was observed; 56% of older adults received at least one following hospitalization for HF, highlighting the therapeutic complexity of multimorbidity in HF. Use of the AHA list to facilitate identification of potentially harmful medicines, followed by prioritization of treatment goals and appropriate risk mitigation are needed to facilitate reduction in hospitalization for patients with HF with multimorbidity.

SummaryThis narrative review describes efforts to improve the care and prevention of fragility fractures in New Zealand from 2012 to 2022. This includes development of clinical standards and registries to benchmark provision of care, and public awareness campaigns to promote a life-course approach to bone health.PurposeThis review describes the development and implementation of a systematic approach to care and prevention for New Zealanders with fragility fractures, and those at high risk of first fracture. Progression of existing initiatives and introduction of new initiatives are proposed for the period 2022 to 2030.MethodsIn 2012, Osteoporosis New Zealand developed and published a strategy with objectives relating to people who sustain hip and other fragility fractures, those at high risk of first fragility fracture or falls and all older people. The strategy also advocated formation of a national fragility fracture alliance to expedite change.ResultsIn 2017, a previously informal national alliance was formalised under the Live Stronger for Longer programme, which includes stakeholder organisations from relevant sectors, including government, healthcare professionals, charities and the health system. Outputs of this alliance include development of Australian and New Zealand clinical guidelines, clinical standards and quality indicators and a bi-national registry that underpins efforts to improve hip fracture care. All 22 hospitals in New Zealand that operate on hip fracture patients currently submit data to the registry. An analogous approach is ongoing to improve secondary fracture prevention for people who sustain fragility fractures at other sites through nationwide access to Fracture Liaison Services.ConclusionWidespread participation in national registries is enabling benchmarking against clinical standards as a means to improve the care of hip and other fragility fractures in New Zealand. An ongoing quality improvement programme is focused on eliminating unwarranted variation in delivery of secondary fracture prevention.

Detection and management of mood disorders in the maternity setting: the Australian Clinical Practice Guidelines.

Clinical Practice Guidelines (CPGs) are key instruments in providing the most appropriate decision in the treatment of any disease. CPG was developed to improve health care by increasing the incorporation of evidence-based treatments to reduce the use of unnecessary, ineffective or harmful interventions. This study assessed 5 Malaysian CPGs using Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument which could help the stakeholders to decide if further improvement or modification is needed. AGREE-II is an international instrument that aids in CPG development. It comprises of 23-items under 6 different domains. The κ statistics was used to look for agreement between 3 appraisers across these domains. The relevance of the Malaysian CPG to the care of older people in this study was also assessed using an instrument that have been developed by a previous study (Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions). This instrument evaluated if the guidelines addressed the treatment for older people, the burdens to the patients and caregivers as well as patient-centered aspects such as patients’ preferences and their quality of life. This study showed that all 5 Malaysian CPGs are of good quality and acceptable to clinical settings according to the AGREE instrument. However, it was found that none of the CPG considered patients’ preferences in developing CPGs. In terms of the CPGs’ relevance to the care of older people, our results showed that there is poor relevance on the patients’ burden of treatment. Only two CPGs (Management of Type 2 Diabetes Mellitus and Management of Hypertension) had a higher agreement between the appraisers compared to other CPGs in relation to management of medical conditions in older patients. As a conclusion it was found all 5 Malaysian CPGs evaluated were in good quality but need improvement in terms of involving stakeholder in the development of CPGs at par with other developed countries.