Big problems in search of small gains

From The Cochrane Library

We have known for some time that hormone therapy provides no protection against heart disease overall, but the latest Cochrane review update suggests there may be some benefit in the subgroup of recently postmenopausal women (aged between 50 and 59 years). However, only a small number of these women are likely to benefit, and potential harms include an increased risk of deep vein thrombosis. Despite data from more than 40 000 women drawn from 19 studies, hormone therapy remains a complex issue where the same treatment offers benefits in some women but harms in others (doi: 10.1002/14651858.CD002229.pub4).

Helping people with long-term conditions manage their own health is another complex area where small gains are often the best we can hope for. In personalised care planning, the patient and clinician jointly agree on goals and actions for managing the patient's health problems. A new review of 19 studies, involving more than 10 000 participants, shows personalised care planning has some merit, probably leading to small improvements in some indicators of physical health, such as better blood glucose levels and lower blood pressure (doi: 10.1002/14651858.CD010523.pub2). Unsurprisingly, the process worked best when the support was intensive and when it was integrated into routine care.

With rates of dementia increasing, the search is on to improve how we identify and assess people who have problems with cognitive functioning. Three recent reviews assess the usefulness of various function tests for measuring and predicting cognitive decline in patients at risk of dementia.

The review of the Mini-Mental State Examination included 11 studies and over 1500 people with mild cognitive impairment but failed to find evidence to support its use as a stand-alone single-administration test (doi: 10.1002/14651858.CD010783.pub2).

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a diagnostic tool used in hospital settings. The evidence from 13 studies of more than 2700 participants strikes a more positive note, suggesting IQCODE is useful for ruling out possible dementia in the general hospital setting, but is less useful in specialist memory clinics and psychiatry wards (doi: 10.1002/14651858.CD010772.pub2).

In the Mini-Cog screening test, an older person's ability to recall three words and draw a clock is assessed to help identify those who may benefit from further evaluation to determine whether dementia is present. The three studies included in the review call into question the accuracy of the test and lead the authors to call for further research before the Mini-Cog can be recommended for routine use (doi: 10.1002/14651858.CD010860.pub2).

For more on these and other reviews, check out www.cochranelibrary.com.