Choosing Wisely®: Five Things Physicians and Patients Should Question
An Initiative of the ABIM Foundation

The AGS is pleased to be partnering 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.  

Five Things Physicians and Patients Should Question
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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 ac hieve theorized microvascular 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 th at, when associated with bacteriuria, define urinary tract infec tion. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated. 

Acknowledgements

• Members of the Panel
• Disclosures

Related Resources

• ABIM Foundation’s Choosing Wisely Initiative
• ABIM Foundation’s Media Gallery
• 2013 JAGS Article
• Tip Sheet on How to Communicate with Your Healthcare Provider
• 2013 Q1 Newsletter Article on Choosing Wisely
• 2013 Q1 Newsletter Letter from the President
• 2012 Q3 Newsletter Article on Choosing Wisely
• New Year, New Guidelines: Resolving to Optimize Geriatric Care in 2013 With the AGS Updated Beers Criteria
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• AGS Collaborates With Leading Organizations to Revise Quality Measures
  Annals of Long-Term Care: Clinical Care and Aging. 2012;20(8):10-11
• 2012 Beers Criteria Update
  Annals of Long-Term Care: Clinical Care and Aging. 2012;20(3):9-10
• Making Use of the 2012 AGS Beers Criteria
  Clinical Geriatrics. 2012;20(3):16-17