Blog | Monday, March 3, 2014

QD: News Every Day--Geriatrics society cites 5 more things older patients should question

The American Geriatrics Society (AGS) released a new list of 5 more tests and treatments that older adults and their health care providers should question and discuss:

1) Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
Clinicians, caregivers and patients should discuss cognitive, functional and behavioral goals of treatment prior to beginning a trial of cholinesterase inhibitors. Advance care planning, patient and caregiver education about dementia, diet and exercise, and non-pharmacologic approaches to behavioral issues are integral to the care of patients with dementia, and should be included in the treatment plan in addition to any consideration of a trial of cholinesterase inhibitors.

2) Don’t recommend screening for breast or colorectal cancer, nor prostate cancer with the prostate-specific-antigen test, without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.
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 with a life expectancy under 10 years, screening for these three cancers exposes them to immediate harms with little chance of benefit.

3) Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance and clarify patient 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, there is no evidence that they affect other important clinical outcomes, such as quality of life, mood, functional status or survival.

4) Don’t prescribe a medication without conducting a drug regimen review.
Older patients 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.

5) Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.
People 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.

The latest list of “five things” was published online Feb. 27 in the Journal of the American Geriatrics Society. The society’s first list appeared in February 2013.

Paul Mulhausen, MD, FACP, who chaired AGS’ Choosing Wisely Workgroup for the current and initial AGS recommendations, said in a press release, “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 Wisely® initiative, which encourages healthcare providers and their patients to discuss the benefits and drawbacks of certain tests, medications and procedures as a way to advance safe, high-quality care.