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IPA Bulletin

Geriatric Psychiatry To Be Part of RCT Database

Thomas E. Oxman, MD

Imagine that you are asked to recommend and justify a psychopharmacologic treatment plan for managing an agitated and aggressive patient with dementia. The nursing home facility where the patient resides wants to protect other patients. The family of the patient thinks medications only cause side effects. Other than doing your own literature review, is there any source to which you can turn to answer the concerns of both the facility and the family? Probably not. However, the Cochrane Collaboration is hoping to make such evidence-based challenges much easier for physicians throughout the world to address.

The collaboration is a nonprofit organization named after Archie Cochrane, a British physician who in 1972 drew attention to the need for ready access to evidence from randomized controlled trials to encourage more rational use of resources. The Cochrane Collaboration is an international organization established to conduct systematic reviews (metaanalyses) of randomized controlled trials (RCTs) in all areas of health care so that medical information can be used more effectively. Contributors in many countries and specialties prepare and maintain systematic reviews of RCTs, or other reliable evidence when RCTs are not available. The goal of this international endeavor is to ensure that all areas of health care which have been evaluated using RCTs will be reviewed. The reviews will be disseminated through electronic media as well as through traditional journals.

It is unreasonable to expect people such as the nursing facility administrator or physician who wants reliable information about treatment effectiveness to find all the relevant evidence from original research reports.

Most physicians thus rely on reviews of primary research. Unfortunately, many reviews are not done systematically and do not consider biases or random errors. Systematic reviews of RCTs must also be kept up to date to include new evidence and treatments. Updated analyses are usually published in traditional media, such as journals. Electronic media, however, offer an appropriate and rapid means of modifying and disseminating systematic reviews of RCTs as new evidence is collected.

To achieve the goal of disseminating improved knowledge of RCTs, the Cochrane Collaboration is organized into collaborative review groups, fields, and centers. Collaborative review groups are problem-based, covering such areas as pregnancy and childbirth difficulties, stroke, schizophrenia, and acute respiratory infections. Each group is responsible for preparing systematic reviews relevant to the health problem that is its focus. The review group draws on the expertise of interested and knowledgeable people who act as reviewers. In most cases, reviewers are drawn from a wide cross section of disciplines, including psychiatry. This cross section of participants is essential for ensuring that different perspectives are included in the preparation of reviews. Reviews may start with Medline, but may miss as many as 50% of RCTs. Only since 1992 has the randomized controlled trial been introduced as a publication grouping. Thus, hand searching of relevant journals and other sources is necessary. Each collaborative review group is coordinated by an editorial team, which assembles an edited module of the reviews for dissemination through the Cochrane Database of Systematic Reviews.

Some areas of interest are broader

than a specific health problem. The task of summarizing all the research relevant to older people is so large that it would be impractical for geriatricians to try to establish enough review groups to conduct systematic reviews of all health problems. The Cochrane Collaboration addresses these broader dimensions through field coordination. Field is the term used by the collaboration to describe areas of interest that extend across a number of collaborative review group areas. A group is being established to focus on care of the elderly as a field and to interact with existing collaborative review groups. It is important that the many collaborative review groups studying health problems relevant to older people work with the care of the elderly group to identify treatment effects in the older population. For example, when the stroke collaborative review group conducts a systematic review on acute stroke, it will consult with members of the care of the elderly group to ensure that the information it gathers will also be useful in guiding the treatment of elderly persons. Similarly, it would be difficult for psychiatrists to conduct all necessary reviews of treatment trials relevant to the elderly. Therefore, psychiatrists with an interest and expertise in geriatrics are being recruited to participate in field activities to make sure that information on mental health treatment is covered.

The work of collaborative review groups and field coordination is facilitated by the Cochrane centers. Currently there are nine centers, the Australasia, Baltimore (USA), Canadian, Dutch, Italian, Nordic, San Antonio (USA), San Francisco (USA), and UK Cochrane centers. The support and training role of these centers helps both potential reviewers and those using systematic reviews to gain the necessary skill and expertise to fulfill their tasks. Responsibilities of the centers include establishing collaborative review groups through international collaboration, maintaining a register of contributors and systematic reviews, preparing and developing protocols and software, setting standards of reliability, and organizing colloquia.

The second Cochrane colloquium was held in Hamilton, ON, Canada, in October 1994. There, geriatricians and other interested healthcare professionals met to develop an initial strategic plan for the care of the elderly field. The goal of having the field is to improve the care of elderly people by making the results of existing trials easily accessible and by improving the quality of future trials. The core activities of the care of the elderly field will be to 1) coordinate the search of all journals related to the care of older people, to identify randomized controlled trials; 2) establish a registry of published and unpublished randomized controlled trials conducted with older people; 3) compile a database of Cochrane systematic reviews relevant to older people; 4) promote the representation of older persons in relevant collaborative review groups; and 5) establish and maintain a liaison among healthcare professionals who specialize in some aspect of geriatric medicine. The field has geographic representation from North America, the United Kingdom, Europe, the Middle East, Asia, Australia, and New Zealand. In addition to geriatric medicine, functional representation will include geriatric psychiatry, nursing, occupational therapy, physical therapy, and social work.

Becoming involved with the care of the elderly field represents a commitment to work with those doing systematic reviews to be sure that the focus of elderly people is represented in a particular topic. When relevant topics are identified that are not covered by a collaborative review group, members of the care of the elderly field will conduct a systematic review and keep that review current. Most people involved with the collaboration have not previously undertaken systematic reviews. That is why the collaboration has developed training and support materials, including computer software, to make the task easier.

The third Cochrane colloquium will be held in Oslo, Norway, October 4-8, 1995. To participate in the Cochrane Collaboration Care of the Elderly Field, contact Dr. Paula Rochon, Baycrest Centre for Geriatric Care, 3560 Bathurst Street, Toronto, ON, M6A 2E1 Canada, 416.785.2500, ext. 2516; Internet rochon@utcc.utoronto.ca.

Thomas E. Oxman, MD
Associate Professor of
Psychiatry
Director of Geriatric Psychiatry
Department of Psychiatry
Dartmouth Medical School
Lebanon, NH
USA

This article appeared in IPA Bulletin, Volume 12, Number 1