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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.

In 2014, AGS released a second list. Click here to learn more

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.

Professional Education Resources

Older Adults with Advanced Dementia Who Can No Longer Feed Themselves Should Be Fed By Hand, Not Fitted With Feeding Tubes, American Geriatrics Society Confirms

AGS Position Statement - Feeding Tubes in Advanced Dementia

Public Education Resources

Ask the Expert - Tube Feeding, and Alternatives, for Older Adults With Advanced Dementia

Healthinaging.org: End of Life Care

Consumer Reports publishes "Feeding tubes for people with Alzheimer’s disease"

Consumer Reports publishes "Feeding tubes for people with Alzheimer’s disease” (Spanish Translation)

Resources from Other Organizations
Education on Tube Feeding from INTERACT


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.

Professional Education Resources Public Education Resources

A Guide to Dementia Diagnosis and Treatment

Guide to the Management of Psychotic Disorders and Neuropsychiatric Symptoms of Dementia in Older Adults

iGeriatrics

Ask the Expert - Alternatives, for Older Adults with Behavioral Problems Due to Dementia

Healthinaging.org: Dementia 


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.

Professional Education Resources Public Education Resources

AGS Education & Clinical Resources on Diabetes

Updated Diabetes Guideline

Diabetes in Older Adults: A Consensus Report

Ask the Expert - Glycemic Control

Healthinaging.org: Diabetes

 

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.

Professional Education Resources Public Education Resources

AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

iGeriatrics

Ask the Expert - Ask the Geriatrician: Sedative-Hypnotic Drugs and Related Medications 

Healthinaging.org: Sleep Problems

Consumer Reports Publishes "Insomnia and anxiety in older people"

Insomnia and Anxiety in Older People (Spanish Translation)

 

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. 

Professional Education Resources Public Education Resources

Ask the Expert - Urinary Tract Infections and Asymptomatic Bacteruria

Antibiotics for Urinary Tract Infections in Older People

 

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