The American Geriatrics Society (AGS), as part of the Choosing Wisely initiative, has released another list of five tests and treatments that those caring for older adults should question and discuss:
- Cholinesterase inhibitors for dementia. These medications should not be prescribed without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects, according to the AGS. Clinicians, caregivers and patients/residents should discuss cognitive, functional and behavioral goals of treatment before a trial of cholinesterase inhibitors begins. Advance care planning, patient/resident and caregiver education about dementia, diet and exercise, and non-pharmacologic approaches to behavioral issues are integral to the care of those with dementia and should be included in the treatment plan in addition to any consideration of a trial of cholinesterase inhibitors.
- Screening for breast, colorectal cancer or prostate cancer (with the prostate-specific antigen, or PSA, test). Such screening should not be recommended without considering life expectancy and the risks of testing, overdiagnosis and overtreatment, according to the AGS. Cancer screening is associated with short-term risks, including complications from testing, overdiagnosis and treatment of tumors that would not have led to symptoms. For patients/residents with a life expectancy of less than 10 years, screening for these three cancers exposes them to immediate harms with little chance of benefit.
- Prescription appetite stimulants or high-calorie supplements to treat anorexia or cachexia in older adults. Such stimulants or supplements should not be used, according to the AGS. Instead, optimize social supports, provide feeding assistance and clarify patient/resident goals and expectations. Unintentional weight loss is a common problem for medically ill or frail elderly. Although high-calorie supplements increase weight in older people, no evidence exists that they affect other important clinical outcomes, such as quality of life, mood, functional status or survival.
- Prescription medication. Don’t prescribe a medication without conducting a drug regimen review, according to the AGS. Older patients/residents disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Polypharmacy may lead to diminished adherence, adverse drug reactions and increased risk of cognitive impairment, falls and functional decline. Medication review identifies high-risk medications, drug interactions and those continued beyond their indication.
- Physical restraints. Physical restraints should not be used to manage behavioral symptoms of hospitalized older adults with delirium. People with delirium may display behaviors that risk injury or interference with treatment. Little evidence exists 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.
"We are grateful to have had the opportunity to identify these five additional things," says Paul Mulhausen, MD, who chaired AGS’ Choosing Wisely Workgroup for the current and initial AGS recommendations. "Because older patients tend to take more medications and undergo more medical tests and procedures than younger adults, this information is invaluable."
The AGS is a partner in the ABIM Foundation’s Choosing Wiselyinitiative, which encourages healthcare providers and those for whom they care to discuss the benefits and drawbacks of certain tests, medications and procedures as a way to advance safe, high-quality care. The AGS’ new list was published (PDF) in the online early edition of the Journal of the American Geriatrics Society. The society released its first list in February 2013.
Also as part of the initiative, AMDA released a list of tests to avoid in long-term care settings, and the American Psychiatric Association released guidelines on the use of antipsychotic medications, in September.