Old age, frailty, and atrial fibrillation: the challenge of heterogeneity

Is age just a number? When it comes to managing older patients, it is and it isn’t. Clinical guidelines and treatment algorithms might use age cut-offs, or they might be age agnostic but still applied to older people. Neither of these situations considers the heterogeneity of ageing.

In their state of the art review of atrial fibrillation management in older adults, Sachin Shah and colleagues argue that “clinicians should assess an individual’s level of function and frailty” to inform decision making (doi:10.1136/bmj-2023-076246).1 Evidence based tools for shared decision making, if available, should be used to discuss treatment goals.

The purpose is to tailor management, but extrapolating from guidelines is difficult because trials that underlie the recommendations may not have included people from that age group, and people with multimorbidity and frailty are under-represented. While the benefit of treatment in older adults is not clear—indeed, it may even be greater—another factor is potential variation in people’s health goals.

What do these evidence gaps mean for clinical practice? One approach to achieving tailored care, say the authors, is to use a clinical frailty scale. Here, older adults who are fit and functional receive disease based care that follows atrial fibrillation guidelines; people who are multimorbid or frail are offered individualised care, balancing benefits and harms; and those at the end of life with end stage disease are given symptom and palliative care.

None of this, of course, is a substitute for more representative recruitment to clinical trials. In particular, information on new drugs continues to be unfit for purpose. Courtney Davis and colleagues explore the difficulties in making informed treatment decisions based on drugs with recent regulatory approval (doi:10.1136/bmj-2024-081720).2 The landscape is fragmented and doesn’t provide the complete, current, and non-promotional information that patients need. Information sources tend to communicate about drug harms, which is important but doesn’t provide sufficient context for evidence based decision making.

New biological drugs for patients with immune mediated inflammatory disease come with questions about drug monitoring. Our Rapid Recommendation clinical practice guideline examines this question and finds that the strength of the evidence for monitoring regimens is dependent on the drug and whether it’s being used for induction or maintenance (doi:10.1136/bmj-2024-079830).3 Either way, the evidence base needs strengthening.

Women are another neglected group in clinical studies, but two new papers present important additional evidence. A cohort study following more than 110 000 US women with endometriosis or uterine fibroids finds an increased risk of premature death in women with laparoscopically confirmed endometriosis (doi:10.1136/bmj-2024-078797).4 Prathiba De Silva and others propose the restructuring of endometriosis care, casting it as a chronic disease with better collaboration between primary and secondary care, and delivery of care that “women with endometriosis desperately need and deserve” (doi:10.1136/bmj.q2416).5

In better news, a trial of fezolinetant, a non-hormonal neurokinin 3 receptor antagonist, suggests a reduction in moderate to severe vasomotor symptoms associated with menopause in women considered unsuitable for hormone therapy (doi:10.1136/bmj-2024-079525, doi:10.1136/bmj.q2486).67 But, as ever, better news supported by better data (doi:10.1136/bmj.q2494)8 tends to be lacking. Perhaps if we put what our patients need and deserve at the top of the agenda—be it a 10 year NHS plan (doi:10.1136/bmj.q2551)9 or an integrated neighbourhood team (doi:10.1136/bmj.q2556)10—we’d end up with better clinical algorithms generated by humans and by artificial intelligence (doi:10.1136/bmj.q2393)11 to respond to the heterogeneity inherent in clinical encounters.