Five Rules of Thumb for Fostering Safe and Appropriate Treatment in Long-Term Care

Overtreatment and inappropriate treatment are significant problems across care settings but may be particularly problematic in long-term care (LTC). The prevalence of multimorbidity and polypharmacy among LTC residents are relatively high,^1-4 and both can increase the risk of overtreatment. A study of nearly 700,000 Medicare enrollees living in US nursing homes found that nearly 30% of the medications administered were “excessive,” and one-third of those treated “lacked appropriate indications for use.”² The American Geriatrics Society (AGS) has long been at the forefront of efforts to prevent inappropriate treatment and overtreatment among older patients. In February, the society joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely^®campaign to further these efforts. 

The ABIM Foundation in collaboration with Consumer Reports launched the groundbreaking Choosing Wisely campaign in 2011. The campaign invites leading medical societies to identify five tests or treatments for which there is insufficient evidence of safety or appropriateness, and then posts these tests and treatments to its Website at www.choosingwisely.org. Just as important, the campaign also encourages laypeople to check the Website to determine whether any tests or treatments they have been prescribed are listed on the site. If so, it advises these persons to broach and discuss the subject with their healthcare providers. The first group of medical societies to join the campaign published their lists of “five things” last year. A second group, including the AGS and 16 other medical societies, posted their lists to the Website in late February. The society also published an article about the development of its list in the Journal of the American Geriatrics Society online and has posted its list of “five things” at www.americangeriatrics.org, along with accompanying professional and public education materials. 

Each of the AGS’s “five things” is a treatment that is relatively common in LTC. What follows is a brief overview of each of the five treatments and evidence-based rationales supporting why they should be used infrequently and with caution, if at all. For more detailed rationales and related studies, be sure to view the entire list on the AGS Website.

1. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, 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. 

2. Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. People with dementia often exhibit aggression, resistance to care, and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke and premature death. Use of these drugs should be limited to cases where nonpharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary. 

3. Avoid using medications to achieve hemoglobin A_1c <7.5% in most adults aged 65 years and older; moderate control is generally better. There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among nonolder adults, except for long-term reductions in myocardial infarction 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 in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0% to 7.5% in healthy older adults with long life expectancy, 7.5% to 8.0% in those with moderate comorbidity and a life expectancy <10 years, and 8.0% to 9.0% in those with multiple morbidities and shorter life expectancy. 

4. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium. Large-scale studies consistently show that the risk of motor vehicle accidents and of falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Patients, their caregivers, and their healthcare 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 that is unresponsive to other therapies.

5. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate 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. 

To identify these “five things,” the AGS convened a Choosing Wisely work group, headed by the vice chair of the society’s Clinical Practice and Models of Care Committee, Paul Mulhausen, MD. The work group first conducted preliminary research and surveyed AGS members, asking which five tests or treatments should be included. The group then expanded its survey to other academics and researchers. From more than 300 individual responses, it identified the tests and treatments most recommended for inclusion in the list, then narrowed the number to 10, and, finally, consulted with AGS members with expertise in these areas to identify the final five.

We at the AGS encourage you to acquaint your staff, your residents, and their family caregivers, as appropriate, to the Choosing Wisely campaign, the society’s list, and other relevant lists on the campaign’s Website. We also encourage you to underscore the importance of discussing the potential benefits and drawbacks of any recommended treatment and to help foster such discussions.

References

1. Williams CM. Using medications appropriately in older adults. Am Fam Physician. 2002;66(10):1917-1925.

2. Nursing Home Licensure and Certification Section; North Carolina Department of Health and Human Services. §483.25(1) Unnecessary drugs. www.ncdhhs.gov/dhsr/nhlcs/pdf/phar_appendix.pdf. Published September 2006. Accessed March 6, 2013. 

3. American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society. J Am Geriatr Soc. 2012;60(10):1957-1968.

4. Bronskill SE, Gill SS, Paterson JM, Bell CM, Anderson GM, Rochon PA. Exploring variation in rates of polypharmacy across long term care homes. J Am Med Dir Assoc. 2012;13(3):309.e15-e21.