Date Published: January 13, 2017
Publisher: Public Library of Science
Author(s): Jesse Jansen, Shannon McKinn, Carissa Bonner, Les Irwig, Jenny Doust, Paul Glasziou, Katy Bell, Vasi Naganathan, Kirsten McCaffery, Maciej Buchowski.
Primary cardiovascular disease (CVD) prevention in older people is challenging as they are a diverse group with varying needs, frequent presence of comorbidities, and are more susceptible to treatment harms. Moreover the potential benefits and harms of preventive medication for older people are uncertain. We explored GPs’ decision making about primary CVD prevention in patients aged 75 years and older.
25 GPs participated in semi-structured interviews in New South Wales, Australia. Transcribed audio-recordings were thematically coded and Framework Analysis was used.
Analysis identified factors that are likely to contribute to variation in the management of CVD risk in older people. Some GPs based CVD prevention on guidelines regardless of patient age. Others tailored management based on factors such as perceptions of prevention in older age, knowledge of limited evidence, comorbidities, polypharmacy, frailty, and life expectancy. GPs were more confident about: 1) medication and lifestyle change for fit/healthy older patients, and 2) stopping or avoiding medication for frail/nursing home patients. Decision making for older patients outside of these categories was less clear.
Older patients receive different care depending on their GP’s perceptions of ageing and CVD prevention, and their knowledge of available evidence. GPs consider CVD prevention for older patients challenging and would welcome more guidance in this area.
Decision making for older adults is complex, especially for those who have multimorbidity. Scientific evidence for treatments and tests in the older population is often limited as this group has traditionally been excluded from clinical trials, and when included they are generally more fit and healthy than older people in the community . Multimorbidity often leads to polypharmacy, which increases the risk of drug-related problems (e.g. adverse drug reactions) . As a result, it is difficult to predict the effect of each individual drug and to compare the overall benefits and harms [3, 4]. In addition, the older population is heterogeneous. Older people vary widely in their health and function, and in their treatment and health outcome preferences [5–7]. General practitioners (GPs) are at the frontline of providing care for older people, and not surprisingly studies have identified numerous challenges [8, 9].
Most GPs felt uncertain about CVD risk management in older people, however they varied in: 1) their awareness of (the lack of) evidence for primary CVD prevention in older people, 2) their perceptions of treatment complexity and feasibility in the older patient context, and 3) their ability and confidence to adapt management accordingly. In the following section, we will explain overall patterns relating to GPs decision making about primary prevention of cardiovascular disease in older adults. Table 2 provides a summary of these themes, with illustrative quotes from the data. For evidence relating to GPs’ decision making approaches, please see S1 Table.
This study identified factors that are likely to contribute to variation in how GPs manage CVD risk in older people (defined as ≥75 years). This includes: differences in GP knowledge of available evidence for CVD prevention, applicability of the guidelines for older people, attitudes towards ageing, awareness of older patient context, and perceived importance of CVD prevention and risk reduction in the older population. Some GPs suggested treating older patients the same as younger patients, assuming the guidelines apply equally to patients of all ages; other GPs considered older people’s management required careful adjustment according to their specific context and circumstances. These latter GPs often mentioned the importance of reducing the burden of treatment and prioritising care (often with prevention perceived as less important than symptom management and improving/maintaining quality of life). It is not surprising that there is substantial variation in GP practice. Two recent reviews independently showed that clinical practice guidelines are highly disease specific and tend to ignore patient context , often recommending the initiation of preventive medication therapy without consideration of multimorbidity, advanced illness, or limited life expectancy .
Depending on their perceptions of ageing and CVD prevention, and their knowledge of available evidence, GPs vary in how they make decisions about primary CVD prevention in older people. More support for SDM with older patients in GP practice (e.g. training, decision aids) is needed. In addition, guidelines should adopt an approach that is more suited to the increasing population of older people with multimorbidity. These guidelines should provide guidance on the challenges faced by GPs, including limited available evidence, and balancing the harms and benefits of CVD prevention in older people of varying life expectancy and levels of frailty.