Improving clinical practice guidelines for older people: considerations and recommendations for more inclusive and ageing-relevant guidelines
Authors: Kerry Hwang, Kirsten J Moore, Terence W H Chong, Sue Williams, Frances Batchelor
Journal: The Lancet Healthy Longevity (2022)

The global population is rapidly ageing and the UN has marked this decade (2021–30) as the Decade of Healthy Ageing, with an action plan to improve the lives of older people around the world.1WHOUN Decade of Healthy Ageing.https://www.who.int/initiatives/decade-of-healthy-ageingDate: 2020Date accessed: February 3, 2022Google Scholar A key aspect outlined in the global action plan is the need for access to high-quality health services. An important component of access to high quality health services for older people are clinical practice guidelines, which summarise best evidence regarding treatment options to provide a framework for clinicians in treating older people. Major problems highlighted by multiple systematic reviews are the inconsistencies and scarcity of applicability of clinical practice guidelines for older populations, particularly older populations with comorbidities.2Vitry AI Zhang Y Quality of Australian clinical guidelines and relevance to the care of older people with multiple comorbid conditions.Med J Aust. 2008; 189: 360-365Crossref PubMed Scopus (75) Google Scholar, 3Mutasingwa DR Ge H Upshur REG How applicable are clinical practice guidelines to elderly patients with comorbidities?.Can Fam Physician. 2011; 57: e253-e262PubMed Google Scholar, 4Singh S Bajorek B Defining ‘elderly’ in clinical practice guidelines for pharmacotherapy.Pharm Pract (Granada). 2014; 12: 489Crossref PubMed Scopus (107) Google Scholar Such incongruity creates guidance deficits for clinicians working with older people and those with multiple comorbidities. This paucity of guidance can result in clinicians solely relying on clinical judgement in the treatment of older people. Inadequate attention to older people in clinical practice guidelines can lead to inappropriate treatment, as clinicians might extrapolate clinical guidance from younger populations, while risk–benefit profiles might change with age. Other potential harms from a scarcity of clinical guidance might include additional health-care costs and overprescription of medication.5Hughes LD McMurdo MET Guthrie B Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity.Age Ageing. 2013; 42: 62-69Crossref PubMed Scopus (284) Google Scholar To ensure that clinical guidelines are relevant to older people and align with the action areas outlined in the UN Decade of Healthy Ageing action plan, we provide four suggestions based on the literature. First, inclusion of older people and those with multimorbidities in clinical studies should be increased. Unfortunately, older people and people with multiple comorbidities are severely under-represented in clinical trials,6Zulman DM Sussman JB Chen X Cigolle CT Blaum CS Hayward RA Examining the evidence: a systematic review of the inclusion and analysis of older adults in randomized controlled trials.J Gen Intern Med. 2011; 26: 783-790Crossref PubMed Scopus (268) Google Scholar which results in evidence gaps within clinical practice guidelines and an inability to provide evidence-based recommendations for clinicians. Improving inclusion of older people—especially those with multimorbidities—in clinical research will ensure that clinical practice guidelines are relevant, sufficiently evidence-based, and useful for clinicians treating older people.7Watts G Why the exclusion of older people from clinical research must stop.BMJ. 2012; 344e3445Crossref Scopus (59) Google Scholar Second, evidence search strategies and outcomes for distinct cohorts of older people need to be developed and recognised. Older people are not one homogenous group, and clinical guidance should be provided on the basis of overall health profile rather than age. van Munster and colleagues8van Munster BC Portielje JEA Maier AB Arends AJ de Beer JJA Methodology for senior-proof guidelines: a practice example from the Netherlands.J Eval Clin Pract. 2018; 24: 254-257Crossref PubMed Scopus (3) Google Scholar outlined four distinct categories of older people: healthy older people, older people with one comorbidity or chronic condition, older people with multiple chronic morbidities, and frail older people. Their recommendations provide a useful reference source for guideline developers in the context of older people, as they contain explicit search strategies and systematic steps that can be used when improving and developing guidelines for older people. These recommendations will enable clinicians to identify the most relevant evidence for individual older people in their care. Third, cross-referencing and vignettes should be used to aid in clinical decision making for multimorbidities. To emphasise the need for consideration of multimorbidities, cross-referencing to other clinical practice guidelines or guidelines of commonly co-occurring comorbid conditions has been recommended.5Hughes LD McMurdo MET Guthrie B Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity.Age Ageing. 2013; 42: 62-69Crossref PubMed Scopus (284) Google Scholar, 9Guthrie B Payne K Alderson P McMurdo MET Mercer SW Adapting clinical guidelines to take account of multimorbidity.BMJ. 2012; 345e6341Crossref Scopus (314) Google Scholar This cross-referencing of guidelines helps break down the siloed effect of clinical practice guidelines operating in isolation, and helps to emphasise the need for consideration of multimorbidities. In addition, Hughes and colleagues5Hughes LD McMurdo MET Guthrie B Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity.Age Ageing. 2013; 42: 62-69Crossref PubMed Scopus (284) Google Scholar suggest the use of vignettes in clinical guidelines. Vignettes illustrate patient-related case scenarios to aid clinicians in decision making, and can be especially useful in situations where multimorbidity is concerned, particularly for pharmacological guidelines. Fourth, a patient-centred approach with supported decision making should be followed. Including subject-matter experts in the development of guidelines, particularly those who have expertise in the health of older people and common comorbid conditions, will improve the applicability and usefulness of clinical practice guidelines for older people. Guideline development teams should make every attempt to include older people as well as carers, given their crucial role in supporting older people. Subject-matter experts in conditions not as prevalent in older people as in the general population should also form an important part of the development team.8van Munster BC Portielje JEA Maier AB Arends AJ de Beer JJA Methodology for senior-proof guidelines: a practice example from the Netherlands.J Eval Clin Pract. 2018; 24: 254-257Crossref PubMed Scopus (3) Google Scholar Specific consideration also needs to be given to quality of life, as this might be more important than longevity of life. Yet, the development of clinical practice guidelines is often scientifically-driven rather than patient-driven. The inclusion and synergistic use of patient decision-making tools will help to support clinicians and older patients with regard to making decisions.10Heen AF Vandvik PO Brandt L et al.A framework for practical issues was developed to inform shared decision-making tools and clinical guidelines.J Clin Epidemiol. 2021; 129: 104-113Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar Clinical practice guidelines are essential tools for clinicians in providing the best care possible for older people. However, guidelines should be urgently reviewed and updated by considering older people, their carers, and clinicians with relevant specialist expertise. This will ensure they are informative and relevant, particularly for older people who have multiple comorbid conditions. Although not exhaustive, the suggestions outlined here could be useful strategies that might improve clinical practice guidelines and the underlying evidence base for the treatment of older people, and subsequently contribute towards achieving the goals of the UN Decade of Healthy Ageing action plan. KH reports personal fees for conference presentations from Melbourne Ageing Research Collaboration. All other authors declare no competing interests.