Five Treatments to Avoid in Long-Term Care Residents

In another important step toward safer, more appropriate healthcare for older adults, the American Geriatrics Society (AGS) in partnership with the American Board of Internal Medicine Foundation (ABIM) has identified five additional recommendations regarding tests, treatments, or procedures that healthcare providers should question because the best available evidence shows that they may be unnecessary or may even cause harm.

“The AGS’ second list of ‘five things’ for the ABIM’s Choosing Wisely^® campaign continues a general theme to highlight the potential harm of medical interventions often used in the care of older adults,” says Paul Mulhausen, MD, Chair of the AGS Clinical Practice and Models of Care Committee and leader of the AGS Choosing Wisely work group. “All five of the Choosing Wisely ‘choices’ are relevant to the care of geriatric patients residing in long-term care settings and are frequently encountered in these settings.”

The AGS’ effort is part of the ABIM Foundation’s ongoing national Choosing Wisely campaign, which asks medical societies and related organizations to review research in their purview, and identify five common medical interventions that are unnecessary or potentially harmful. Having identified its “five things,” each participating organization then participates in the Choosing Wisely campaign in various ways, including publishing its findings in its journal, “translating” its recommendations into laypersons’ language, and disseminating its findings to its members, other healthcare professionals, and the media. The ABIM Foundation’s Choosing Wisely website (www.choosingwisely.org) currently includes about 130 recommendations developed by over 60 participating medical societies. It also includes numerous public-education materials developed in collaboration with Consumer Reports, so professionals and laypeople alike can learn more about the recommendations. The campaign is intended to encourage conversations between healthcare providers and their patients and caregivers, so they can work together in making sound healthcare decisions.

The ABIM Foundation asked the AGS to join its campaign in 2012 and the society completed its first list of “five things” in 2013. The AGS again partnered with the ABIM Foundation to develop a second list that was released in February 2014. Given the particularly heterogeneous nature of older adults in long-term care—who often have multiple health problems and take an average of seven medications daily—many of the AGS Choosing Wisely recommendations are particularly important for older adults residing in these settings. An article about the AGS’ second list was released in the February early online edition of the Journal of the American Geriatrics Society (JAGS). The article explains the process used to develop AGS’ second list, with detailed rationales and references for each recommendation. JAGS articles and copies of both AGS Choosing Wisely lists are available at GeriatricsCareOnline.org.

Just as important as these professional resources are the easily understandable “ask the experts” and “tip sheets” that the AGS’ Health in Aging Foundation has developed for older adults and their caregivers. These, and related public education materials developed by Consumer Reports, are all available at the foundation’s public education website, HealthinAging.org. These materials clearly and succinctly explain the research that led the AGS to conclude why the medical interventions in its lists should be questioned and discussed, because they are likely to be inappropriate, or even harmful, for those aged 65 years and older.

We with the AGS hope you’ll make the most of these resources and share them with your patients and their caregivers. As we know, doing so can spark informed conversations and lead to improved decisions and better care and quality of life for our patients. Here is the AGS’ second group of “five things”:

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 nonpharmacologic 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 PSA test) without considering life expectancy and the risks of testing, over-diagnosis, 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 less than 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 nonprescription 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 medications 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.

“To-Do” List From Paul Mulhausen, MD: Based on the AGS’ New “Five Things”

• Monitor for the adverse effects of the acetylcholinesterase inhibitors and discuss their discontinuation if the benefits are unclear.

• Counsel patients, caregivers, and loved ones about the impact of overall prognosis on the benefits of cancer screening.

• When caregivers and loved ones are asking about the benefits of appetite stimulants and nutrition supplements, make sure that the potential adverse effects of these interventions are a part of the conversation. Highlight the benefits of feeding assistance and help patients and families clarify their goals and expectations.

• Conduct a drug regimen review before prescribing a medication.

• Continue efforts to avoid the use of physical restraints and work with the interdisciplinary team to offer alternative strategies for care.

“Successful discussions around these five choices will help patients living in long-term care settings, their caregivers, and their loved ones make more effective healthcare choices, informed with the full picture of benefit and risk,” says Dr. Mulhausen.