EBMGERIATRIC

Dr.SufiDesriniM.Sc
INTRODUCTION
Thedemographictrendinbothdevelopedand
developingcountriesismovingtowardsa
societywithanincreasingpercentageof
peopleabove65yearsofage
Thenumberofpeople90yearsandolderwill
increasefrom8.1to37.7millioninthe
developedcountriesandfrom12.9to123.5
millioninthedevelopingcountriesrepresenting
anincreaseof463%and954%,respectively
2010 2020 2030 2040 2050
Developedcountries
Totalpopulation
Population65y
%oftotalpopulation

1.365.899
204.140
14,9

1.397.353
248.215
17.8

1.411.479
298.215
23.2

1.412.224
327.122
23.2

1.402.753
343.396
24.5
DevelopingCountries
Totalpopulation
Population65y
%oftotalpopulation

5.539.491
323.716
5.8

6.267.938
467.255
7.5

6.903.864
671.557
9.7

7.408.412
919.185
12.4

7.785.105
1.122.963
14.4
INTRODUCTION
INTRODUCTION
THEIMPACTOFTHEDEMOGRAPHIC
CHANGE
Thisshiftindemographiccompositionis
expectedtoraisethecostsoflong-term
careservicesintheUSAfrom195bio
USDin2000to540bioUSDin2040[Eskildsen
andPrice,2009].
Evidence-basedMedicine(EBM)
Evidence-basedmedicineisthe
integrationofbestresearchevidence
withclinicalexpertiseandpatient
values.
(DavidSackett)
Evidence-BasedMedicines
EBMisacoinedin1992byagroup
ofclinicalepidemiologistbasedat
McMasterUniversityinHamilton,
Ontario
Howtousetheliteratureinthecare
ofanindividualpatient
Emphasized3basicconsept
WhatisthePracticeofEBM?

Wherethereisevidenceofbenefit
andvalue,doit
Wherethereisevidenceofno
benefit,harm,orpoorvalue,dontdo
it.
Whenthereisinsufficientevidenceto
knowforsure,beconservative.

WhyisEBMNeeded?

Decayofclinicianknowledgeovertime
Humancognitivebiases
Inefficienttransferofknowledgetopractice
Organizationalneedtodecidebetweeneffective
andineffectivetherapies
KnowledgeDecayUnanswered
Questions
Primarycarephysicianshave3to7questions
perevery10patients
Theyusuallydontlookfortheanswers
Whentheydothesourcesmaynotbe
evidence-based(Ely:BMJ,319(7206):358-361)
KnowledgeDecayInformation
Explosion
>30,000newcitationsaddedtoMedline
everymonth
Volumeofmedicalinformationdoubles
every19years
TheInevitableConsequence:
KnowledgeDecay
Onaverage,theclinically-important
knowledgeofphysiciansdeteriorates
rapidlyaftercompletionoftraining.
Evidence-basedPractice(EBP)
EBMisfocusedonindividualpractice
EBPisanorganizationalissuerequiring:
Organizations
Abletogenerateevidence
Flexibilitytoincorporateevidence
Individualsandteams
Abletofindandappraiseevidence
Opentoapplyevidencetopatientcare
Whatdoesevidence-basedmean?
Acomprehensive,systematic,open-mindedreview
ofalltheevidence
Evidencedeterminestheconclusion(notvice-
versa)
Notthecitationofpaperssupportingapreformed
conclusion(andrejectionofthosethatdont)
Nottheuseofevidencewhenitispositiveand
judgmentwhenitisnegative
Whatisgoodevidence?
Resultsfrommostappropriatestudydesign
Hierarchyofevidence
Exclusionofbias
Directlyorindirectlydemonstratestreatmenteffecton
healthoutcomes
Clinicallymeaningfulresults(NNT)
Notlabvaluesorotherintermediateoutcomes
Isapplicabletothepatientorpopulation
Inthiscase,olderadults
Hierarchyofevidence
Thefirst
conceptisthat
allevidence
isnotcreated
equal
Depending
onthetype
ofclinical
question
Example:Hormone&Estrogen
ReplacementRCTStudy
(HERS):HormoneandEstrogen
Replacementtherapy(HRT)
givenas0,625mgconjugated
equineestrogensand2,5mg
medroxyprogesteroneacetate
didnotimprovesurvivalor
decreaseCADeventinwomen
withexistingCAD,eventhough
severalprospectivecohorttrials
suggesteditwould
2other
RCTsto
supportthis
finding
InObservational
trials
characteristicof
womenwho
offeredandchose
totakeHRT
differed
Hierarchyofevidence
Mostclinicalquestionintoof7
categories:clinicalfindings,dd/,
etiology,diagnostictet,prognosis,
therapyorprevention.
Hierarchyofevidence
1. RCT
2. Systematicreviewsofrandomized
trials
3. Systematicreviewofobservational
studie
4. Physiologicstudies
5. Unsystematicobservation
Hierarchyofevidence
http://www.ncbi.nlm.nih.gov/pubmed/
clinical/

Clinicalstudycategories

Clinicallymeaningfulresults
The2conceptisaclinical,notstatistical
Manyoutcomesarestatisticallysignificantarenotclinicallyimportant
Example:
beforedefinitivestudiesusingpatient-orientedoutcomessupressionof
ventricularprematurecontraction(VPB)wasconsideredbeneficialwas
increasingBMD
YetwhenthestudiesweredoneitwasfoundthatsuppressingVPBwith
certainagentsincreasesptmortalityandincreasingBMDwithfluoride
increasesfractures
Clinicallymeaningfulresults
Clinicallysignificancesalsomeansthatthemagnitudeof
theeffectisworththecostsofintervention,includingthe
incovenience,AEs,andphyshologicoremotionaland
costs
RRR
ARR
Thesizeofthetreatment
benefit(NNT)
APPLICABILITY
Thethirdconcept
Iseasywhentheptsittinginfrontofyoumeetsthe
studyinclusionandexclusionriteria
Butitisfarmoredifficultwhentheptgeriatric:
old,frail,withmultiplemedicalconditionsandtaking
medication
LimitationsofGuidelinesinelderlypeople
Thedecisiontoprescribeadrugisoftenbasedondisease-
orientedapproachthatstemsfromguidelinerecommendations
foreachsinglesymptom,disease,orclinicalproblem
Thisparadigmacanbeimplementedeasilyinyoungeradults,
buthasmanylimitationsinolderpatientswhy?
Becauseitfailstotakeintoaccountage-relatedchangesinPK
andPD,comorbidit,useofmultipledrugs,riskofinteraction
(drug-drugordrug-disease),cognitivestatusanddisability.
APPLICABILITY
TheprimarychallengetopracticingEBMingeriatricsisthelackof
high-qualitystudiesthatincludeolderadults
Evidenceontreating/diagnosinginelderly<
Ex:howshouldptwithCHFbetreated?
TherangeofmeanagesofptsystolicCHF:58-65years
Onerecentpopulation-basedstudyfoundthatalmost50%ofnewonsetCHF:>=
80yandhadsystolicCHF
Will80-yearoldsbeabletotoleratetherecenttandartsforsystolicCHFth/,which
includetheadditionof3-5newmedications(aspirin,B-blocker,HMG-CoA
reductaseinhibitor,ACEinhibitor)
Howshouldthe40-50%pt>70ywhoseCHFisdiastolicbetreated:
Theanswer:unknown
LimitationsofGuidelinesinelderlypeople
Example:ifclinicianappliestherelevant
guidelinestoawomanaged79ywith
hypertension,type2DM,COPD,OAand
Osteoporosis,theptshouldbetaking19
dailydosesof12differentdrugsat5
differenttimesoftheday,withahighrisk
notonlyofpooradherencebutalsoAEs
fromdrug-drug-diseaseinteraction
LimitationsofGuidelinesinelderlypeople
Thedosagesandeffectsof
medications,beneficialoradverse,
aredefinitelydifferentintheelderly
thanyougerpatients
LimitationsofGuidelinesinelderlypeople
Theevidencewhichareoftenbiasedbythe
exclusionorunder-representationofelderly
peopleespecialythoseaffectedby
multimorbidityandreceivingpolypharmacy
LimitationsofGuidelinesinelderlypeople
Enrollomentinclinicaltrialsforcancer
drugsfoundonly20%and9%,respectively,
ofpatientsolderthan70yand75y
Anotherstudy:>40%ofclinicaltrials(heart
failure)hadoneormorepoorlyjustifiable
exclusioncriteriathatlimitedtheinclusion
ofelderlypatients
LimitationsofGuidelinesinelderlypeople
InRCTsamplesize,durationand
co-prescribeddrugtherapiesare
oftentailoredtothetargetdisease
andgeriatricsproblems(disability,
cognitiveimpairment,multimorbidity,
lifeexpectancyandsosioeconomic
difficultiesareseldomconsidered
LimitationsofGuidelinesinelderlypeople
Thatlimitationsmakeitdifficultto
extrapolatetheresultsofclinicaltrial
andtheresultingguideline
recommendationtoolderpeople
Howcanwetacklethenewchallengesofan
agingpopulation
Usemultidimensionalevaluation
toolsthatbroadlyexploreclinical,
nutritional,functional,cognitive,
psychologycal,andsocioeconomic
domainsaglobalassessmentof
theneedsoftheelderly
Question
Inanelderlywomanwithhypochromic,
microcyticanaemia,canalowferritin
diagnoseirondeficiencyanaemia?You
orderaferritinandheadforthelibrary(10
dayslateritcomesbackat40g/l)

SearchusingtheMeSH
ferritinandsensitivityand
specificity
findanarticleondiagnosingiron
deficiencyanaemiaintheelderly
publishedinajournalthatyourlibrary
doestake
(AmJMed1990;88:205-9)

Readthearticleanddecide

1.Aretheresultsofthisdiagnosticarticle
valid?
2.Arethevalidresultsofthisdiagnostic
studyimportant?
3.Canyouapplythisvalid,important
evidenceaboutadiagnostictestincaring
foryourpatient?

Thank You