Choosing Wisely

Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia (the medical term for unwanted or "foreign" material entering your lungs), functional status, and patient comfort. Food is the preferred nutrient. Tube-feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers (also known as "bed sores").

People with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed.  However, they provide limited and inconsistent benefits while posing risks, including over-sedation, cognitive decline (difficulty with thinking and memory skills), and increased likelihood of falls, strokes, and mortality (death).  Use of these drugs in patients with dementia should be limited to cases where non-pharmacologic measures (i.e., treatment options that don't involve the use of pharmaceuticals) have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary.

There is no evidence that using medications to achieve tight glycemic (blood sugar) control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction (the medical term for a heart attack) and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia (low blood sugar levels) in older adults. Given the long timeframe to achieve theorized micro-vascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 10 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy.

Large scale studies consistently show that the risk of motor vehicle crashes, falls, and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers, and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation, or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies.

Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria (the medical term for having bacteria present in your urine but now showing signs of an "infection," such as a fever). Antimicrobial treatment studies for asymptomatic bacteriuria in older adults show no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated.

Although some randomized control trials suggest that cholinesterase inhibitors may improve cognitive (memory and thinking skills) testing results, it is unclear whether these changes are clinically meaningful.  It is uncertain whether these medicines delay institutionalization, improve quality of life, or lessen caregiver burden. No studies have investigated benefits beyond a year nor clarified the risks and benefits of long-term therapy. Clinicians, patients, and their caregivers should discuss treatment goals of practical value that can be easily assessed and the nature and likelihood of adverse effects before beginning a trial of cholinesterase inhibitors. If the desired effects (including stabilization of cognition) are not perceived within 12 weeks or so, cholinesterase inhibitors should be discontinued.

Cancer screening is associated with short-term risks, including complications from testing, overdiagnosis (the medical term for diagnosing a medical condition unlikely to have caused any symptoms or problems during a person's normal life expectancy), and treatment of tumors that would not have led to symptoms. For prostate cancer, 1,055 men would need to be screened and 37 would need to be treated to avoid one death in 11 years. For breast and colorectal cancer, 1,000 patients would need to be screened to prevent one death in 10 years. For lung cancer, much of the evidence for benefit from low dose computed tomography (CT) screening for smokers is from healthier, younger patients under age 65.  Further, although screening 1,000 persons would avoid 4 lung cancer deaths in 6 years, 273 persons would have an abnormal result, requiring 36 to get an invasive procedure with 8 persons suffering complications.

Instead of using prescription appetite stimulants or high-calorie supplements for treatment of anorexia (a lack or loss of appetite for food) or cachexia (weakness and wasting of the body due to severe chronic illness) in older adults, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations.

Unintentional weight loss is a common problem for medically ill or frail older adults. Although high-calorie supplements increase weight in older people, there is no evidence that they affect other important clinical outcomes, such as quality of life, mood, functional status, or survival. Use of megestrol acetate results in minimal improvements in appetite and weight gain, no improvement in quality of life or survival, and increased risk of thrombotic events (the formation of a clot which can be carried by the blood stream to other blood vessels, causing them to be "plugged"), fluid retention, and death. In patients who take megestrol acetate, 1 in 12 will have an increase in weight and 1 in 23 will have an adverse event leading to death.

The 2012 AGS Beers Criteria (a resource identifying "potentially inapproproate" medications for older people) lists megestrol acetate and cyproheptadine as medications to avoid in older adults. Systematic reviews of cannabinoids, dietary polyunsaturated fatty acids (DHA and EPA), thalidomide, and anabolic steroids have not identified adequate evidence for the efficacy and safety of these agents for weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat depression, but there is little evidence to support its use to promote appetite and weight gain in the absence of depression.

Older patients disproportionately use more prescription and non-prescription medications than other populations, increasing the risk for side effects and inappropriate prescribing.

Polypharmacy (the medical term for using multiple medications at once) may lead to diminished adherence (taking your medications as prescribed), adverse drug reactions, and increased risk of cognitive impairment (difficulty with thinking or memory skills), falls, and functional decline. A medication review identifies high-risk medications and drug interactions, as well as medications continued beyond their indication (the medical term for why a certain medication should be prescribed). Additionally, medication review detects unnecessary medications and underuse of medications, and may reduce medication burden. An annual review of medications is an indicator for quality prescribing in vulnerable older people.

Persons with delirium may display behaviors that risk injury or interference with treatment. There is little evidence to support the effectiveness of physical restraints in these situations. Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Effective alternatives include strategies to prevent and treat delirium, identification and management of conditions causing patient discomfort, environmental modifications to promote orientation and effective sleep-wake cycles, frequent family contact, and supportive interaction with staff.

Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraint-free approach to patients with delirium. This approach includes continuous observation; trying re-orientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions (the medical term for prescription medications) are occasionally used after evaluation by a medical provider at the bedside, if a patient presents harm to him or herself or others. If physical restraints are used, they should only be used as a last resort, in the least restrictive manner, and for the shortest possible time.