NEW YORK– American Geriatrics Society (AGS) today released a new list of five tests and treatments that older adults and their healthcare providers should question and discuss. 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. The AGS’ new list of “five things” was published in the online early edition of the Journal of the American Geriatrics Society today. The society released its first list of “five things” in February 2013.
AGS’ new list recommends that those who care for older adults:
- 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.
- 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, 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.
- 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.
- 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.
- 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.
“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.”
Launched in April 2012, Choosing Wisely® encourages physician and patient conversations aimed at avoiding unnecessary tests and procedures to improve quality of care. Nearly 100 partners have joined the movement thus far. For more information about AGS’ lists and theChoosing Wisely campaign, visit www.americangeriatrics.org/choosingwisely2
To view a PDF of the the 1st and 2nd lists for Choosing Wisely click here.