Choosing Wisely Campaign: Revised List of Topics to Talk About with Older Adults

By Sondra Forsyth

On April 23rd 2015, the American Geriatrics Society (AGS) released updates to several of its recommendations for the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely® campaign, which raises professional and public awareness about treatments and tests to question and discuss because they may lack efficacy or cause potential harm. The AGS’s updates reflect an expert review of new research on several important conditions impacting older adults, including agitation, certain types of cancer, delirium, dementia, diabetes, insomnia, unintended weight loss, and certain other health concerns that may warrant deeper discussion based on new insights and information on appropriate healthcare choices.

A release from GS quotes Wayne C. McCormick, MD, MPH, AGSF, President of the AGS, as saying,“Providing high-quality care to older adults means recognizing and responding to the specific, evolving challenges and opportunities that we all face as we age. Since 2012, the AGS and the ABIM Foundation have worked together through Choosing Wisely to synthesize pressing updates from the geriatrics field in a format that is easy to understand—and apply—in everyday practice.”

In this most recent update, the AGS expanded earlier guidance on seven specific tests, treatments, or procedures to reflect emerging expert opinion and the latest research insights guiding sound decision making to support elder care:

• The AGS expanded its rationale for recommending against the use of cholinesterase inhibitors (CIs), a class of pharmaceuticals sometimes used to manage dementia, without periodic evaluations to determine mental health benefits and gastrointestinal problems associated with treatment. Although some clinical trials suggest that CIs may improve cognitive testing results, it is now unclear whether these changes are “clinically meaningful” based on available data. Since no studies have investigated the benefits of CIs beyond a year or the risks/benefits of long-term therapy, the AGS expert panel advised that clinicians, patients, and their caregivers discuss treatment goals and the likelihood of adverse effects before beginning treatment, and that they adjust therapy if the desired effects are not achieved within 12 weeks.
• The Society also added lung cancer screenings to a list of oncological screenings (which already includes breast, colorectal, and prostate cancer screenings) that should not be recommended for older adults without first considering life expectancy and the risks associated with testing, over-diagnosis, and over-treatment. Cancer screenings are important, but short-term risks may outweigh benefits for some older patients. New evidence from a screening of 1,000 people for lung cancer, for example, found that the screenings would reduce the death toll by four over a six-year period, but also would yield abnormal results for 273 individuals, 36 of whom would undergo invasive procedures and nearly 10 of whom would suffer unnecessary complications as a result.
• In recommending “moderate” (as opposed to “tight”) blood-glucose control for older patients with diabetes, the AGS also noted that medications other than metformin should be avoided. Setting reasonable glycemic targets based on patient goals, health status, and life expectancy may mean shifting away from glucose-lowering medications that are more likely to harm (rather than help) patients. Evidence continues to mount that metformin improves patient outcomes, while the harms associated with its use appear to be far less common than originally believed.
• The AGS continues to recommend avoiding antipsychotics as the first-choice treatment for behavioral and psychological symptoms associated with dementia, and its rationale for this guidance has been expanded with new data on nonpharmacologic management of the condition. Specifically, the expert AGS panel determined that antipsychotics provide “limited and inconsistent benefits,” while also posing risks for over-sedation, a worsening of memory problems, and an increased likelihood of falls, strokes, and even mortality.
• Making recommendations for older patients with anorexia or cachexia (the medical term for weight loss, fatigue, or diminished appetite in someone not actively trying to lose weight), the AGS expanded its guidance to avoid prescription appetite stimulants and high-calorie nutritional supplements. The Society now also endorses discontinuing medications that may interfere with eating and also providing appealing food and feeding assistance, measures for optimizing social supports, and means to clarify patient goals and expectations. Unintentional weight loss remains a common problem for ill or frail older adults, but it may best be addressed by interventions that present less risk for adverse effects than prescriptions, according to available data.
• The AGS also strengthened its recommendation not to use physical restraints to manage the behavioral symptoms of hospitalized older adults who are delirious. Persons with delirium (a serious medical condition characterized by an abrupt change in mental function that can cause an older person to behave differently than he or she normally would) often display behaviors that result in injury or interfere with treatment. But there is little evidence that physically restraining these older adults offers an effective solution. As such, the new rationale for AGS guidance notes that physical restraints should only be employed “as a last resort, in the least-restrictive manner, and for the shortest possible time.”
• Although guidance for choosing alternatives to benzodiazepines and other “sedative-hypnotics” as initial treatment options for insomnia, agitation, or delirium in older adults remains unchanged, this recommendation is now supported by even more—and more recent—scholarship. Large-scale studies reviewed by AGS experts continue to point to significantly elevated risks for motor vehicle accidents, falls/fractures resulting in hospitalization, and even death for older adults taking “psychoactive” medicines like benzodiazepines. These medications may be better utilized for alcohol withdrawal or severe generalized anxiety unresponsive to other therapies.

These updates add to several other long-standing recommendations available on GeriatricsCareOnline.org and still unchanged following expert review. Additional guidance includes:

• Pursuing oral assisted feeding for patients with advanced dementia instead of a “percutaneous” feeding tube threaded through the skin into the stomach;
• Not using antibiotics to treat patients who have bacteria in their urine (a condition known as bacteriuria) unless certain urinary tract symptoms are present; and
• Conducting a treatment regimen review before prescribing medication.

“As the older adult population in the U.S. continues to grow, it’s so important that geriatrics care principles reflect the latest science, evidence, and advice supporting quality health and care,” said Paul Mulhausen, MD, MHS, FACP, AGSF, who chaired the AGS Choosing Wisely Workgroup responsible for the list. “We are grateful to the ABIM Foundation for this opportunity to share timely recommendations that will help patients avoid unnecessary tests and procedures and support overall well-being.”

Since the inception of the Choosing Wisely initiative in 2012, more than 70 specialty societies like the AGS have contributed recommendations on tests and procedures to question and discuss. The resulting lists have helped patients and health professionals make decisions that are evidence-based, non-duplicative, free from harm, and truly necessary.

About the American Geriatrics Society
Founded in 1942, the American Geriatrics Society (AGS) is a nationwide, not-for-profit society of geriatrics healthcare professionals dedicated to improving the health, independence, and quality of life of older people. Its more than 6,200 members include geriatricians, geriatric nurses, social workers, family practitioners, physician assistants, pharmacists, and internists. The Society provides leadership to healthcare professionals, policymakers, and the public by implementing and advocating for programs in patient care, research, professional and public education, and public policy.