Updated AGS Choosing Wisely® Helps Drive Long-Term Care Discussions for Older Adults

In its fourth year as a partner in the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely®  initiative, the American Geriatrics Society (AGS) recently unveiled a revised list of tests and treatments that older adults and their healthcare providers should discuss when planning care. The list reflects a broader, interdisciplinary effort to empower patients facing important healthcare decisions, including older adults assisted here through the long-term care expertise of the AGS. “Providing   high-quality   care   for older people means recognizing and responding to their unique health needs and expectations,” said AGS President Wayne  C.  McCormick,  MD,  MPH, AGSF. “Since the latter part of 2011, the AGS and the ABIM Foundation have worked together through Choosing Wisely  to  get  tools  and  tips  for healthy aging into common practice. It’s  one  of  several  ways  we  advance quality care for a growing population of older adults.”

Among other insights, the 2015 AGS list continues to recommend avoiding antipsychotics as the first-choice treatment for behavioral and psychological symptoms associated with dementia, an important consideration in long-term care settings and one now supported with new data on nonpharmacologic management. In a variety of care contexts but especially in nursing homes and supportive living environments, people with dementia can become aggressive, disruptive, and resistant to care in potentially harmful ways. Yet antipsychotic medications sometimes prescribed to manage these symptoms offer “limited” or “inconsistent” benefits, according to the expert work group convened by the recommendations. Several  pharmaceutical treatments, in fact, may even pose additional risks for over-sedation, a worsening of cognitive decline, and an increased likelihood for falls, strokes, and mortality.

“We’ve learned that nonpharmacologic interventions are a better fit for patients with dementia who still may respond to these types of measures and who do not yet pose an imminent threat to themselves or others,” said Paul Mulhausen, MD, MHS, FACP, AGSF, chair of the AGS Choosing Wisely work group. “AGS’s ability to get the word out about this important care consideration through the Choosing Wisely initiative is but one example of how our efforts are making geriatrics care principles relevant, accessible, and actionable for those who need quality health care in old age.”

In addition to guidance on treatments for the symptoms of dementia, the AGS Choosing Wisely update also highlights other insights for care conversations. These include recommendations to avoid the following:

Percutaneous feeding tubes in patients with advanced dementia. Offering oral-assisted feeding may be preferred.

Diabetes medications other than metformin to achieve hemoglobin A1c levels greater than 7.5%. Moderate control generally works better.

Benzodiazepines or other sedative-hypnotics for older adults as a first choice for insomnia, agitation, or delirium. Large-scale studies of these treatment options show risks for falls, fractures, and death.

Antimicrobials for the treatment of bacteriuria in older adults without symptoms. There is little evidence of benefit for asymptomatic patients.

Cholinesterase inhibitors for dementia without periodic assessments for perceived cognitive benefits and adverse gastrointestinal effects. It remains unclear whether improvements in cognitive testing remain clinically meaningful.

Screenings for breast, colorectal, prostate, and lung cancer. Consideration to life expectancy and risks associated with testing, overdiagnosis, and overtreatment may be particularly important for frail older adults.

Prescription appetite stimulants or high-calorie supplements for anorexia or cachexia in older adults. Optimizing social supports, discontinuing medications that interfere with eating, providing appealing food and feeding assistance, and clarifying patient goals and expectations may do more to manage weight loss.

Prescribing medication without first conducting a treatment regimen review. Older adults disproportionately take more prescription and non-prescription medicines, increasing the risk for side effects and inappropriate prescribing.

Physical restraints to manage behavioral symptoms among hospitalized older adults with delirium. There is little evidence to support the effectiveness of physical restraints in situations where delirious individuals display behaviors that risk injury or treatment interference.

The revised AGS Choosing Wisely recommendations are available online at GeriatricsCareOnline.org.