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Choosing Wisely®: Five Things Physicians and Patients Should Question
An Initiative of the ABIM Foundation (2014—Part 2)

The AGS is pleased to be partnering for a second time with the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely® Campaign to help physicians, patients, and other healthcare stakeholders think about and discuss the overuse of healthcare resources in the U.S. The national campaign aims to help patients take a more involved role in their health care by learning to choose medical tests and treatments that are supported by scientific evidence, are not duplicative of past tests or procedures, and are truly necessary for diagnosis or treatment.

More information on drug-specific recommendations can be found in the AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

Additional supporting professional and public education resources can be found at GeriatricsCareOnline.org (professional) and HealthinAging.org (public).

Five Things Physicians and Patients Should Question
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Choosing Wisely: Part 2

Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
In randomized controlled trials, some patients with mild-to-moderate and moderate-to-severe Alzheimer’s disease achieve modest benefits in delaying cognitive and functional decline and decreasing neuropsychiatric symptoms. The impact of cholinesterase inhibitors on institutionalization, quality of life, and caregiver burden are less well established. 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. If goals of treatment are not attained after a reasonable trial (e.g., 12 weeks), then consider discontinuing the medication. Benefits beyond a year have not been investigated and the risks and benefits of long-term therapy have not been well-established.

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 prostate cancer, 1055 men would need to be screened and 37 would need to be treated to avoid 1 death in 11 years. For breast and colorectal cancer, 1000 patients would need to be screened to prevent 1 death in 10 years. 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. Use of megestrol acetate results in minimal improvements in appetite and weight gain, no improvement in quality of life or survival, and increased risk of thrombotic events, fluid retention, and death. In patients who take megestrol acetate, one in 12 will have an increase in weight and one in 23 will die. The 2012 AGS Beers criteria lists megestrol acetate and cyproheptadine as medications to avoid in older adults. Systematic reviews of cannabinoids, dietary polyunsaturated fatty acids (DHA and EPA), thalidomide, and anabolic steroids, have not identified adequate evidence for the efficacy and safety of these agents for weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat depression , but there is little evidence to support its use to promote appetite and weight gain in the absence of depression.

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. Additionally, medication review elucidates unnecessary medications, underuse of medications, and may reduce medication burden. Annual review of medications is an indicator for quality prescribing in vulnerable elderly.

Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.
Persons 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. Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraint-free approach to patients with delirium. This approach includes continuous observation; trying re-orientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions are occasionally utilized after evaluation by a medical provider at the bedside, if patient presents harm to him or herself or others. Physical restraints should only be used as a very last resort and should be discontinued at the earliest possible time.

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