21-10-2016, 12:15 PM
Quality of dementia clinical guidelines and relevance to the care of older people
with comorbidity: evidence from the literature
1460350598-CIA65046qualityofdementiaclinicalguidelinesandrelevancetothe0820141.pdf (Size: 298.24 KB / Downloads: 9)
Purpose: The aim of this paper was to explore the applicability of dementia clinical guidelines
(CGs) to older patients, to patients with one or several comorbidities, and to both targets in order
to evaluate if an association between the applicability and quality of the CGs exists.
Materials and methods: A systematic search strategy conducted on electronic databases identified
CGs on diagnosis and treatment of dementia published from 2000 to 2013. In addition, websites
of organizations devoted to the treatment and awareness of dementia were searched. The quality
of evidence was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE)
instrument. Two investigators independently scored the relevance of the CGs by means of a specific
tool. Descriptive and inferential analyses were performed (Mann–Whitney test, 0.05 α-level).
Results: Twenty-two CGs met our inclusion criteria. On average, the quality of the CGs was
higher than 70% in three of six domains measured by the AGREE tool. The domains with lower
mean scores (less than 50%) were “Applicability” and “Editorial independence”. Considering
applicability to older patients, 20 CGs (91%) addressed issues of treatment for older patients,
five of them (23%) classified older patients by age, and 13 CGs (60%) addressed issues of
comorbidity. Only seven (32%) discussed the quality of evidence for patients with multiple
comorbid conditions. Thirteen CGs (60%) reported recommendations for patients with at least
one comorbid condition, while seven of them (32%) reported on several comorbid conditions.
No statistically significant association between CG quality and relevance to care of older people
with or without comorbidity was found (P0.05).
Conclusion: This study showed that dementia CGs poorly address treatment for older patients
with comorbidities, regardless of their quality. Therefore, they scarcely satisfy the need of
modern clinical practice
Background
Dementia is a widespread clinical syndrome characterized by chronic, global,
irreversible deterioration of memory, executive function, and personality severe enough
to interfere with daily, social, and occupational functioning.1 In 2010, it was estimated
that 35.6 million people were living with dementia worldwide. The number of people
with dementia will continue to grow, doubling every 20 years, particularly among the
elderly and in countries in demographic transition.2
These days, Western Europe is the region with the highest number of people with
dementia (7.0 million), with a prevalence of 7.2% in people over 60 years of age,
closely followed by East Asia with 5.5 million, South Asia with 4.5 million, and North
America with 4.4 million, where the prevalence of dementia in adults over 60 years
old is 6.9%.
It is widely known that caring for people with dementia
requires a holistic approach, including the management of
cognitive, behavioral, and psychological symptoms and the
provision of social care.4 Furthermore, due to the higher prevalence
of dementia among the elderly, the co-occurrence of
other chronic conditions is frequent. Schubert et al found that
patients with dementia attending primary care have on average
2.4 chronic conditions and receive 5.1 medications.5
Comorbid conditions can interact at various levels and
overlap with each other during the management of treatment.
Patients and caregivers can experience difficulties with the
therapies prescribed for each comorbid condition, reducing
adherence to the treatment plan and consequently diminishing
its efficacy. Overlapping therapies could also increase
the economic burden of disease.6
There is increasing evidence suggesting that clinical
guidelines (CGs) directed at the management of chronic
conditions should be modified for patients with comorbidities.
Few researchers have analyzed CGs in order to evaluate
their applicability to older patients and patients with several
comorbidities, irrespective of the topic of the CGs.7–9 The
literature showed a limited applicability of many current
CGs to patients with comorbid conditions.10,11 With regard
to the elderly, the evidence suggested a low representation of
patients in advanced old age in CGs.9 When CGs discussed
evidence for the elderly population, few of them addressed
issues related to elderly patients with comorbidities.8,12
People with dementia are frequently old and with comorbid
conditions. Although many studies have considered the
complexity of providing medical care for patients with multiple
comorbid conditions and dementia, to our knowledge
there is no evidence about the relevance of dementia CGs to
the care of older people with comorbidities.
Our aim was to explore the applicability of dementia CGs
to elderly patients, to patients with one or several comorbidities,
and to both targets by assessing how CGs addressed the
issue of the treatment of elderly patients, of patients with one
or several comorbidities and both targets and how CGs analyzed
the evidence on this topic. Furthermore, the presence
of specific recommendations for the management of both
targets was evaluated. Finally, the association between the
quality of the CGs and their applicability to elderly patients
and to patients with comorbidity was also evaluated.
Materials and methods
Guideline search and selection
Dementia CGs were identified through searches in the Medline
and Embase databases and via Google searches, using
the following keywords (variously combined): “dementia” “treatment”, “diagnosis”, “clinical guidelines”. In addition,
the National Guideline Clearinghouse and International
Guideline Database were searched.
To be included in this review, a CG had to: 1) be published
from the 2000 to 2013; where CGs published were
by the same organization and on the same topic, the latest
version was included; 2) be published by European and North
American associations; 3) be published in English; and 4)
have as their main focus dementia treatment, considering
together all the etiologies of dementia or dealing exclusively
with the most prevalent etiologies, such as Alzheimer’s
disease or vascular dementia. CGs excluded were those
that focused on low-prevalence types of dementia, such as
frontotemporal dementia or dementia with Lewy bodies, and
those that focused exclusively on prevention and/or early
diagnosis and/or diagnosis of dementia.
In this review, we defined comorbid disease as the simultaneous
occurrence of at least one medical condition in the
same person in addition to dementia.13 Considering the complex
relationship between dementia and depression in terms
of definitions, epidemiology, related concepts, treatment, and
emerging biomarkers,14 we chose to consider depression as
a comorbidity only when in the CGs there was an explicit
reference to diagnosed depression and not if the impact of
depressive symptoms was considered alone.15,16
Quality assessment and data abstraction
Two reviewers assessed the quality of the CGs independently
by using the Appraisal of Guidelines for Research and
Evaluation (AGREE) II. This instrument has been validated
and tested in several countries, and it is considered the best
current tool for assessing the quality of a CG.17–21 AGREE
II includes 23 items categorized in six domains, each capturing
a separate dimension of CG quality. The first domain,
“Scope and purpose” (three items) is concerned with the overall
aim of a CG, specific clinical questions and/or problems,
and the target patient population. The domain “Stakeholder
involvement” (four items) focuses on the extent to which
the CG reflects the views of its intended users and affected
patients. “Rigor of development” (seven items) relates to
the process used to gather and synthesize the evidence, as
well as the methods used to develop, review, and update
recommendations. “Clarity and presentation” (four items)
deals with comprehensibility of the language applied in the
CG and general CG format. The domain “Applicability”
(three items) pertains to the likely organizational, behavioral,
and economic implications of applying the CG. Finally,
“Editorial independence” (two items) is concerned with the
independence of the recommendations and acknowledgment of possible conflicts of interest of the CG developers. The
instrument also includes two final overall assessment items
that require the appraiser make overall judgments of the
practice CG and consider how they rated the 23 items.22 The
scores, independently assessed by two reviewers involved
in the revision process, were summed and standardized.
The domain scores were calculated as the percentage of the
maximum possible score.
To evaluate the applicability of the selected CGs to the
care of older people, and/or of people with comorbidities,
a specific instrument (developed by Boyd et al and then
modified by Vitry and Zhang) was used.7,8 This instrument
was composed of 14 items assessing whether or not CGs
address treatment for older people and for people with several
comorbid conditions, as well as patient-centered aspects, like
patient preferences, for example.
To answer the research questions, the following items of
the instrument were used:
• Guideline addressed treatment for patients with multiple
comorbid conditions
• Guideline addressed treatment for older patients with
multiple comorbid conditions
• Quality of evidence discussed for older patients
• Quality of evidence discussed for patients with multiple
comorbid conditions
• Quality of evidence discussed for older patients with
comorbid conditions
• Specific recommendations for patients with one comorbid
condition
• Specific recommendations for patients with several
comorbid conditions.
Two investigators extracted data independently, and
agreement between the two reviewers was measured with
Cohen’s κ-statistic. Any disagreement was then resolved
through discussion with a third reviewer. Data were summarized
and tabulated, and descriptive statistics were
calculated.
Finally, for the assessment of the association between
CG quality and the relevance to care of older people with
and without comorbidity, four of the 14 items of the checklist
were considered (Guideline addressed treatments for
older patients divided in different classes of age; Guideline
addressed treatments for older patients with multiple
comorbid conditions; Quality of evidence discussed for older
patients; Quality of evidence discussed for older patients with
multiple comorbid conditions). The mean AGREE domain
score for CGs that resulted in having a positive score or not
on each of the selected items was compared by means of the
Mann–Whitney U test at the 0.05 significance level.
Results
A total of 22 CGs23–44 met our inclusion criteria, as shown
in Figure 1. More than half of them were published in the
US (12 of 22), with six and four in Canada and Europe,
respectively. In five CGs, the intended user was explicitly
general practitioners (GPs); eleven CGs were ascribed to
specialists, caregivers, nurses, and others; and six did not
mention GPs among the intended users. Diagnosis was discussed
in 14 CGs, 17 CGs addressed both pharmacological
and nonpharmacological treatment, four CGs were primarily
concerned with pharmacological treatment, and only one was
about nonpharmacological treatment (Table 1).
The individual standardized AGREE domain score for
the 22 CGs selected and the mean score for every AGREE
domain are shown in Table 2. The highest mean score was
for “Scope and purpose” (75%, standard deviation [SD] 14)
followed by “Clarity of presentation” (75%, SD 15), while
the lowest was “Applicability” (45%, SD 21), followed by
“Editorial independence” (49%, SD 34).
Table 3 summarizes the findings from the review about
the relevance of dementia CGs for the treatment of older
patients with comorbid conditions. Interrater agreement was
generally from “moderate” (weighted κ from 0.41 to 0.60)
to “substantial” (weighted κ from 0.61 to 0.80), according
to the Landis and Koch scale,45 for almost all the domains.
Nevertheless, some degree of variability remained within the
“Burden of treatment” domain, where the κ-statistic scores
varied from “fair” (weighted k=0.30) to “almost perfect”
(weighted k=0.84).
Of the 22 CGs, 20 (91%) addressed issues of treatment for
older patients, five of which divided older patients into different
classes of age (Table 3), and 13 (60%) CGs addressed issues
of comorbidity. The quality of evidence for older patients was discussed in 18 (82%) CGs, while the quality of evidence for
patients with multiple comorbid conditions was considered in
seven (32%) of the 22 CGs analyzed by the review. Thirteen
(60%) CGs and seven (32%) CGs, respectively, provided
specific treatment recommendations for patients with at least
one or more comorbid condition (Table 3).
More than half of the dementia CGs analyzed discussed
the burden of treatment in the context of time from treatment
to benefit, for patients and their caregivers, while less than
50% discussed the financial burden of treatment. Sixteen
(73%) CGs considered the preferences of patients, and eleven
(50%) especially considered end-of-life treatment.
The study of the association between CGs quality and
the relevance to care of older people with and without
comorbidities showed no statistically significant quality
differences in the mean AGREE score for each domain,
comparing CGs addressing older patients and comorbidity
with those CGs who did not address older patients and
comorbidities (P0.05 for each item and each AGREE
domain).