Grey Hairs and Grey Zones: A Comment on the Extrapolation of Clinical Trials and Guidelines to Complex Elderly Patients

1While the development of evidence-based medicine gives clinicians some degree of probabilistic comfort in decisionmaking, there still exist extensive grey zones of knowledge in clinical practice. The management of complex geriatric patients is one such grey zone. It is understood that the elderly are underrepresented in clinical trials. 2 Factors such as multi-morbidity and polypharmacy compound the problem. In complex geriatric cases, it is unclear whether we can justifiably generalize the typical randomized controlled trial (RCT) or clinical practice guideline. We must remember that the management of these patients, as a result, often depends on intuition and individualized clinical judgment rather than on good statistical evidence. Clinical practice guidelines help physicians manage patients, but typically do so one disease at a time. 3 They rarely address the needs of the multi-morbid elderly. 4, 5 In a 2011 review of 14 Canadian chronic disease guidelines, five described some recommendations for patients over 80 years of age. Comorbidities, however, were only considered in specific cases (e.g. dealing with hypertension in the setting of diabetes). 6 Management despite extensive comorbidity and polypharmacy, nonetheless, is a pressing challenge for Canadian clinicians. In 2005, 33% of Canadians aged 65-79 and 42% of those 80 and above had four or more chronic conditions. 7 A 2009 Statistics Canada survey showed 63% of Canadians over 65 years of age to be taking more than five medications. Thir ty percent of Canadians over 85 years were taking more than ten. 8