10 ways to 'Choose Wisely' for elderly patients

AGS releases second list as part of the overuse campaign


From the Reading Room
Are you "Choosing Wisely," too?

The American Geriatrics Society (AGS) recently published its second list of unnecessary procedures for physicians treating geriatric patients as part of the Choosing Wisely campaign.

Choosing Wisely was launched in April 2012 with 45 recommendations from nine leading medical groups. Since then, the effort has expanded to include more than 50 groups, each with its own list of five tests or procedures that often are unnecessarily performed. The guidelines include recommendations against performing CT scans for routine evaluations of abdominal pain in children and against ordering annual electrocardiograms for low-risk patients with no symptoms.

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Last year, AGS contributed five items to the Choosing Wisely lists, and this month the group added another five. Altogether, the 10 recommendations urge physicians to refrain from:

  • Using feeding tubes in patients with advanced dementia;
  • Prescribing a medication without first reviewing the existing drug regimen;
  • Using physical restraints to manage patients with delirium;
  • Using antipsychotic drugs as a first line of care in treating symptoms of dementia;
  • Prescribing medications to achieve certain hemoglobin levels;
  • Using sedatives as a first choice to treat insomnia, agitation, and delirium;
  • Using antimicrobials to treat bacteriuria, unless patients are suffering from urinary tract infections;
  • Prescribing cholinesterase inhibitors for patients with dementia without first assessing for adverse gastrointestinal effects and perceived cognitive benefits;
  • Screening for breast, colorectal, prostate cancer without first considering risks and life expectancy; and
  • Prescribing appetite stimulants to treat anorexia without first using social supports, feeding assistance, and clarifying patient expectations.

List author discusses details

One of the list's authors, University of California-San Francisco geriatrician Sei Lee, spoke with the New York Times' Paula Span about some of the list's specific recommendations, like refraining from using appetite stimulants.

"Sometimes, families think patients are dying because they're losing weight… I tell them, they're losing weight because they're dying of something else," Lee says, adding that there is no evidence that adding calories—which does not improve muscle mass—will help them with their diseases. Moreover, the drugs have side effects that can increase the risk of blood clots, for instance.

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The list also encourages physicians to review a patient's entire drug regimen before prescribing new medications, since so many drugs may interact in harmful ways.

"In a busy practice, it's hard to look at everything someone is on, every time you prescribe a new drug," Lee says, adding that physicians should review patients' medications at least once a year (Span, "The New Old Age," New York Times, 3/7).

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