[Show abstract][Hide abstract] ABSTRACT: In making treatment decisions, doctors and patients must take into account relevant randomised controlled trials (RCTs) and systematic reviews. Relevance depends on external validity (or generalisability)--ie, whether the results can be reasonably applied to a definable group of patients in a particular clinical setting in routine practice. There is concern among clinicians that external validity is often poor, particularly for some pharmaceutical industry trials, a perception that has led to underuse of treatments that are effective. Yet researchers, funding agencies, ethics committees, the pharmaceutical industry, medical journals, and governmental regulators alike all neglect external validity, leaving clinicians to make judgments. However, reporting of the determinants of external validity in trial publications and systematic reviews is usually inadequate. This review discusses those determinants, presents a checklist for clinicians, and makes recommendations for greater consideration of external validity in the design and reporting of RCTs.
The Lancet 01/2007; 365(9453):82-93. DOI:10.1016/S0140-6736(04)17670-8 · 45.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: People aged more than 65 years take more medicines than any other group, with over 90% taking at least one prescription medicine, and nearly half using five or more drugs (polypharmacy).
Medicines in older patients have the potential to provide great gains as well as significant harms.
To provide an ethically sound, evidence based discussion of the benefits and harms of medications commonly used in primary care among older patients.
Appropriate prescribing and deprescribing (drug withdrawal) for older patients requires a thorough understanding of the individual, their therapeutic goals, the benefits and risks of all of their medicines, and medical ethics. There is very limited evidence on the safety and efficacy of medicines in older adults, particularly in the frail, who often have multiple comorbidities and functional impairments. In robust older patients, therapy usually aims to delay or cure disease and to minimise functional impairment. In frail older patients, symptom control, maintaining function and addressing end-of-life issues become the main priorities. Optimising medicines is a time-consuming, multidisciplinary process that requires extensive communication, frequent monitoring and review, and has a major clinical impact.
Australian family physician 12/2012; 41(12):924-8. · 0.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE Behavioral and psychological symptoms are common in dementia, and they are especially stressful for family caregivers. Nonpharmacological (or psychosocial) interventions have been shown to be effective in managing behavioral and psychological symptoms, but mainly in institutional settings. The authors reviewed the effectiveness of community-based nonpharmacological interventions delivered through family caregivers. METHOD Of 1,665 articles identified in a literature search, 23 included unique randomized or pseudorandomized nonpharmacological interventions with family caregivers and outcomes related to the frequency or severity of behavioral and psychological symptoms of dementia, caregiver reactions to these symptoms, or caregiver distress attributed to these symptoms. Studies were rated according to an evidence hierarchy for intervention research. RESULTS Nonpharmacological interventions were effective in reducing behavioral and psychological symptoms, with an overall effect size of 0.34 (95% CI=0.20-0.48; z=4.87; p<0.01), as well as in ameliorating caregiver reactions to these behaviors, with an overall effect size of 0.15 (95% CI=0.04-0.26; z=2.76; p=0.006). CONCLUSIONS Nonpharmacological interventions delivered by family caregivers have the potential to reduce the frequency and severity of behavioral and psychological symptoms of dementia, with effect sizes at least equaling those of pharmacotherapy, as well as to reduce caregivers' adverse reactions. The successful interventions identified included approximately nine to 12 sessions tailored to the needs of the person with dementia and the caregiver and were delivered individually in the home using multiple components over 3-6 months with periodic follow-up.
American Journal of Psychiatry 09/2012; 169(9):946-53. DOI:10.1176/appi.ajp.2012.11101529 · 13.56 Impact Factor
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