geriatrics issues: choosing wisely

The Am Geriatrics Soc released a second set of "five things physicians and patients should question" (see http://www.americangeriatrics.org/files/documents/5things_list_PART.pdf, or choosing wisely geriatrics 2014 in dropbox). the items:

1. don't prescribe cholinesterase inhibitors for dementia without periodic assessment of cognitive benefits and adverse GI effects. benefits overall are modest, impact on quality of life unclear. so give 12 weeks and stop if no significant improvement. continue with nondrug management (pt/caregiver education, diet, exercise, direct nonpharm behavioral approach depending on the specific issues).

2. not do routine screening for breast, colon, prostate cancer without considering life expectancy and risks (testing, overdiagnosis, overtreatment). esp if life expectancy less than 10 years. basically for these tests (per their numbers) need to screen 1000 patients to prevent 1 death in 10 years for each of these three tests)

3. avoid prescription appetite stimulants or high-calorie supplements for treating anorexia/cachexia in older adults. best to optimize social supports, provide feeding assistance, and clarify patient goals and expectations. supplements do increase weight, but no evidence of change in quality of life. megestrol assoc with thrombotic events, fluid retention, death and no clear improvement in quality of life. mirtazapine leads to wt gain in setting of depression, little evidence of utility in absence of depression [though i have had limited positive experience, with very low-dose: 7.5mg/d]. cyproheptadine (and megestrol) to be avoided per Beers criteria. [that being said, the only one i have used several times is low dose cyproheptadine (4mg once a day) and anecdotally --> no adverse effects, but increased appetite/weight and improved quality of life of my patients -- they have been clearly happier.]

4. don't prescribe new medicine without conducting drug regimen review. lots of polypharmacy in older adults, lots of drug-drug interactions, and increased risk of problems in elderly (cognitive impairment, falls, functional decline)

5. avoid physical restraints to manage behavioral symptoms of hospitalized elderly with delirium.

The 2013 list (see http://www.americangeriatrics.org/files/documents/Five_Things_Physicians_and_Patients_Should_Question.pdf or choosing wisely geriatrics 2013 in dropbox):

1. not use percutaneous feeding tubes in pts with advanced dementia. offer oral assisted feeding. no clear diff in outcomes, and tube-feedings assoc with agitation, more use of restraints, more bedsores.

2. not use antipsychotics as first chose to treat behavioral/psych symptoms of dementia. increased risk of stroke, death. use if nonpharm measures fail and pts pose threat to themselves/others.

3. avoid meds to achieve A1c<7.5% in most adults > 65yo. harms outweigh risks. they suggest: 7-7.5% goal in healthy older adults with longer life expectancy, 7.5-8% if moderate comorbidity and life expectancy <10years, 8-9% if multiple comorbidities and shorter life expectancy [seems reasonable to me, though not based on actual data, just mathematical modeling. as per previous blogs, important to treat the patient and not the number: some patients cannot be safely brought to A1c of 9 without significant risk of hypoglycemia]

4.don't use benzos or other sedative/hypnotics as first choice for insomnia, agitation or delirium. more adverse events, eg falls.

5. don't use antibiotics for asymptomatic bactiuria in older adults. screening not generally appropriate unless about to get urologic procedure where mucosal bleeding anticipated.