Journal of General Internal Medicine

, Volume 26, Issue 7, pp 783–790

Examining the Evidence: A Systematic Review of the Inclusion and Analysis of Older Adults in Randomized Controlled Trials

  • Donna M. Zulman
  • Jeremy B. Sussman
  • Xisui Chen
  • Christine T. Cigolle
  • Caroline S. Blaum
  • Rodney A. Hayward
Reviews

ABSTRACT

BACKGROUND

Due to a shortage of studies focusing on older adults, clinicians and policy makers frequently rely on clinical trials of the general population to provide supportive evidence for treating complex, older patients.

OBJECTIVES

To examine the inclusion and analysis of complex, older adults in randomized controlled trials.

REVIEW METHODS

A PubMed search identified phase III or IV randomized controlled trials published in 2007 in JAMA, NEJM, Lancet, Circulation, and BMJ. Therapeutic interventions that assessed major morbidity or mortality in adults were included. For each study, age eligibility, average age of study population, primary and secondary outcomes, exclusion criteria, and the frequency, characteristics, and methodology of age-specific subgroup analyses were reviewed.

RESULTS

Of the 109 clinical trials reviewed in full, 22 (20.2%) excluded patients above a specified age. Almost half (45.6%) of the remaining trials excluded individuals using criteria that could disproportionately impact older adults. Only one in four trials (26.6%) examined outcomes that are considered highly relevant to older adults, such as health status or quality of life. Of the 42 (38.5%) trials that performed an age-specific subgroup analysis, fewer than half examined potential confounders of differential treatment effects by age, such as comorbidities or risk of primary outcome. Trials with age-specific subgroup analyses were more likely than those without to be multicenter trials (97.6% vs. 79.1%, p < 0.01) and funded by industry (83.3% vs. 62.7%, p < 0.05). Differential benefit by age was found in seven trials (16.7%).

CONCLUSION

Clinical trial evidence guiding treatment of complex, older adults could be improved by eliminating upper age limits for study inclusion, by reducing the use of eligibility criteria that disproportionately affect multimorbid older patients, by evaluating outcomes that are highly relevant to older individuals, and by encouraging adherence to recommended analytic methods for evaluating differential treatment effects by age.

KEY WORDS

clinical trial methodology exclusion criteria subgroup analysis comorbidities 

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Donna M. Zulman
    • 1
    • 2
    • 3
  • Jeremy B. Sussman
    • 1
    • 2
    • 3
  • Xisui Chen
    • 4
  • Christine T. Cigolle
    • 2
    • 5
    • 6
  • Caroline S. Blaum
    • 2
    • 6
  • Rodney A. Hayward
    • 1
    • 2
    • 3
  1. 1.The Robert Wood Johnson Foundation Clinical Scholars ProgramUniversity of MichiganAnn ArborUSA
  2. 2.Department of Internal MedicineUniversity of MichiganAnn ArborUSA
  3. 3.Department of Veterans Affairs, Health Services Research and Development Center of ExcellenceAnn ArborUSA
  4. 4.College of Literature, Science, and the ArtsUniversity of MichiganAnn ArborUSA
  5. 5.Department of Family MedicineUniversity of MichiganAnn ArborUSA
  6. 6.VA Ann Arbor Healthcare SystemGeriatric Research Education and Clinical Center (GRECC)Ann ArborUSA

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