Aging & Health A to Z
Basic Facts & Information
The American Board of International Medicine (ABIM) Foundation and Consumer Reports launched the Choosing Wisely campaign to encourage people to learn more about the tests and treatments their healthcare providers recommend, and to question and discuss these with their healthcare professionals under certain circumstances. Numerous medical societies have gone through an in-depth review process to identify five tests or treatments for which there may not be enough medical research that shows safety or effectiveness. In some cases, the research may even show unwanted effects. At the same time, the ABIM Foundation and Consumer Reports have been encouraging people to check the lists to see if tests or treatments their healthcare providers have recommended are on them. If so, the campaign urges people to bring this up with their healthcare professionals and discuss it.
The American Geriatrics Society published their list in February 2013, which includes five treatments that may pose more risks than benefits in older people. This is particularly important for older adults. Why? Treatments that may be helpful for younger adults may not be safe or reliable in older people, because of physical changes that take place as we get older. Check to see if any medications or other treatments you’ve been prescribed are listed. Don’t worry if a test or treatment your healthcare provider has recommended is on one of the Choosing Wisely lists, and don’t stop a treatment if it’s on the list. Talk to your healthcare provider and sort it out. The Choosing Wisely campaign’s goal is to spark conversations about potentially unnecessary tests or treatments and to empower the public to ask questions of their healthcare providers.
Just because a test or treatment is listed doesn’t mean it’s unreliable or ineffective for you. Different people respond differently, and there is no “one-size-fits-all” when it comes to medical care.
Choosing Wisely: Five Things Physicians and Patients Should Question
Item 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.
Item 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 non-pharmacologic 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.
Item 3: Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 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 non-older 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 micro vascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0 – 7.5% in healthy older adults with long life expectancy, 7.5 – 8.0% in those with moderate comorbidity and a life expectancy < 1 0 years, and 8.0 – 9.0% in those with multiple morbidities and shorter life expectancy.
Item 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, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers and their 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 unresponsive to other therapies.
Item 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.