Did you know that it’s important to think about “Choosing Wisely,” when it comes to healthcare?
It’s true! Choosing Wisely is a health education campaign meant to help patients and their doctors more easily spot common tests and treatments that are often overused. To do this, many medical societies are creating lists of “Five Things Physicians and Patients Should Question.” Consumer Reports is also a partner in this project.
If you’re a caregiver for an aging person, you probably should know about the Choosing Wisely items identified by the American Geriatrics Society (AGS). These are treatments or tests that are:
- Commonly given to older adults,
- Often unlikely to help aging adults live better, or longer,
- Riskier than many patients and caregivers realize.
In other words, these are treatments that older adults often don’t receive, when geriatricians are involved.
Of course, most older adults aren’t under the care of a geriatrician. If this is your family’s situation, learning about the Choosing Wisely items can be a good way to make sure your older relative avoids healthcare that is unnecessary, or even harmful.
In this post, I’ll review the “Five Things to Question” that were identified by the AGS in their intial Choosing Wisely list. (The AGS recently published a second list; I’ll review those items in a follow-up post.) I’ll also share some tips for caregivers, related to each item.
Five Things to Question for Healthcare in Aging Adults
In February 2013, the American Geriatrics Society (AGS) published their first list of “Five Things Physicians and Patients Should Question.” Here’s what healthcare providers are supposed to keep in mind when it comes to better healthcare for aging adults. If you’re worried about a parent or other other relative, these are healthcare treatments you should question.
1. “Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.” In other words, be careful about placing a feeding tube once a person’s Alzheimers or other dementia has gotten so bad that he or she can no longer swallow.
Why: Studies have found that tube feeding generally doesn’t help people with advanced dementia live longer, or better. Although feeding tubes are sometimes placed in order to avoid “aspiration” pneumonia (which can be caused by unsafe swallowing), many people with feeding tubes still get pneumonias.
Tips for caregivers: Losing the ability to swallow is a sign of very advanced dementia that is likely entering the terminal stage. Consider reviewing goals of care and planning for end-of-life. Research has shown that many families don’t really know what to expect in the last stages of dementia.
I do like the Consumer Reports Tip Sheet about feeding tubes in dementia, you can find it here.
2. “Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.” In other words, if Alzheimers or another dementia is causing difficult behaviors, don’t start by trying an antipsychotic medication. Many difficult behaviors can be reduced or managed by using non-drug approaches. This is safer and often more effective, so these approaches should always be tried first.
Why: Even though drugs aren’t FDA-approved for this purpose, many doctors respond to a caregiver’s complaints by prescribing antipsychotics such as rispderal, olanzapine, and quetiapine (brand names Risperdal, Zyprexa, and Seroquel). But research studies have found that in most cases, using these medications doesn’t improve behaviors or outcomes very much. Furthermore, these medications increase fall risk and have been linked to a small increase in the risk of death.
Tip for caregivers: Difficult behaviors in dementia can often be improved by reducing stress & discomfort (including constipation), implementing routines, and using other non-drug approaches for behavior management. Sedatives and antipsychotics should be used as a last resort, after these other approaches have been tried. If you’re considering these medications, make sure the doctor has a plan to evaluate the effects. It’s vital to stop the medication if it’s not helping.
To find excellent tips on managing dementia behaviors and coping with your own stress, I recommend “Surviving Alzheimer’s: Practical tips and soul-saving wisdom for caregivers.” (Read my comments on this book here.) You can also find great tips in one of the many online communities for dementia caregivers.
3. “Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better.” This item is about diabetes control, especially for Type 2 diabetes. It suggests that older adults not aim for tight blood sugar control. Hemoglobin A1C (A1C) is a blood test that reflects blood sugar control over the past few months; the higher one’s blood sugar on average, the higher the hemoglobin A1c. (Normal people have an A1C below 5.7%.)
Why: A study of 48,000 diabetics aged 50 or older found that outcomes were best with an A1c of 7.5%. Now, historically many patients and doctors have aimed for an A1C less than 7%, believing that the closer we keep blood sugar to normal levels, the better. However, it usually takes 10-20 years for moderately high blood sugar to cause serious health problems. Whereas in the short term, aiming for a low A1C often causes hypoglycemia (episodes of low blood sugar), which can cause falls or emergency room visits. Hypoglycemia has also been linked to a higher risk of cognitive decline, and of cardiovascular events. For these reasons, most expert groups now recommend a target A1C of 7-7.5% for older adults, or 7.5%-8% for frail older adults likely to live 5 years or less.
Tips for caregivers: Take episodes of low blood sugar very seriously! They are often a sign that a person needs a different medication strategy, or perhaps more help managing diabetes medications. (Mistakes are common, especially in people whose memories may be slipping.) You should also make sure you know what your loved one’s A1C is. If it’s less than 7% and the person is taking any diabetes drug other than metformin, you should ask the doctor to re-evaluate the medications.
4. “Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.” As with many issues when it comes to healthcare in the elderly, don’t turn to drugs first! There are usually safer and more effective ways to proceed. Medications should be used carefully, at low doses, and as a last resort.
Why: These drugs are commonly prescribed to older adults, but like virtually all drugs for sleep or tranquilizing, these drugs worsen balance and thinking. They increase fall risk and can worsen dementia or delirium; benzodiazepines have been linked to developing dementia. Commonly prescribed sedatives include lorazepam and zolpidem (brand names Ativan and Ambien, respectively). For a more complete list of medications to be careful about, check this Consumer Reports resource.
Tips for caregivers: Make sure you get a thorough evaluation for delirium, agitation, or insomnia. There may be an underlying problem, such as pain or a medical condition, that needs to be treated. For anxiety, agitation, or insomnia, non-drug approaches such as exercise, stress reduction, or cognitive therapy can be very effective and should be part of the approach before drugs are tried.
For insomnia that’s not due to an underlying medical problem, I have often recommended this Insomnia Workbook.
5. “Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.” In other words, don’t treat a positive urine culture with antibiotics unless there are other symptoms suggesting a clinically significant infection. Symptoms can be related to the bladder, such as discomfort with urination or belly pain. However in older adults it’s also common for a urinary tract infection (UTI) to cause very vague symptoms, such as fatigue, weakness, or delirium (new or worsened confusion).
Why: Although urine is generally sterile, as people age, it becomes common to have “asymptomatic bacturiuria,” which means bacteria in the bladder without causing inflammation or infection. (In women aged 80 or older, up to 20% may have this condition.) In older adults who have developed this condition, the bacteriuria tends to come back after antibiotic treatment. Studies have found that unless there are symptoms, treating bacteriuria doesn’t improve long-term outcomes. But it does increase antibiotic resistance, and exposes the older person to the risk of side-effects.
Tips for caregivers: Two problems often come up for caregivers. The main one is that many doctors are not familiar with the facts and recommendations regarding asymptomatic bacteriuria, so they often treat a positive urine culture without really asking about symptoms. Remind them to Choose Wisely! The other problem is that in frail older adults, especially those with Alzheimer’s, it can be very very hard to figure out whether or not the older person is having symptoms. (Was that fall weakness from a UTI? or just tripping?) If in doubt, it’s reasonable to treat, but if the problem keeps happening, you may need to rethink your approach with the doctors.
For more information, here’s a blog post I wrote last winter on this very topic: “Not all urine bacteria need antibiotics.”
Questions or comments about these Choosing Wisely recommendations? I’d love to hear from you in the comments below.
I also have a follow-up post on this topic here: “5 More Treatments You Should Question in Older Adults.”
VM Jones says
I was prescribed Atavan in 1996 for sleep after my husband died suddenly. I had always had difficulty sleeping and the 1mg Ativan at night gave me significant relief in sleeping. The prescription continued to be filled with no discussion or concern by doctors for the effects of long term use. I have never increased from the 1mg dose and have taken 1 per night for sleep. I am now 72 years old. I do not feel that it has lost the effectiveness for me. I also feel that I have also benefited from anxiety reduction. I recently changed to a new doctor who has insisted that I withdraw (at times withholding my prescription until the last pill would have been used, then causing delays in the pharmacy filling the prescription in time – so I’ve missed doses). Other than saying not to go “cold turkey” there was no other support offered. I have had Nominal Aphasia my entire life, which is becoming increasingly more problematic. It was my feeling that this was a result of normal aging, but I am now wondering if the Nominal Aphasia could be a side-effect of Ativan. Although memory for words/names in one article was not considered to be a side-effect of Ativan, it still makes me wonder. I have not had any side-effects that I am aware of, but have developed Tinnitus which is becoming problematic. I noticed one other person referred to this. Is there any indication that Tinnitus could be a side effect of Ativan?
Leslie Kernisan, MD MPH says
I’m not aware of tinnitus being a known side-effect of benzodiazepines. Benzos do slow down brain function, and so they might make normal age-related cognitive slowing worse. They will also make cognitive function worse if an older person’s brain is actually becoming damaged due to progressive diseases.
So I can understand why your health providers want you to stop the medication. That said, it’s really unfortunate if they aren’t offering you more support in exploring this. Also, one might argue that they should be willing to consider letting you continue, provided they’ve reviewed the risks and you still want to continue.
We have more on how to safely discontinue Ativan here: How You Can Help Someone Stop Ativan. I would recommend downloading Dr. Tannenbaum’s brochure and discussing a very slow reduction with your health providers. good luck!
Gladys spizzirri says
Hi my 84 year old mom is taking Ativan from 1 to 2 mg day for 10 yrs We tried rehab to help to stop taking them and they switched her to take cloneazepan .25 two x day and .5 at bedtime it did not work she is suffering from severe noise in her head saw your tapering off schedule do you do this for all 3 doses ? No drs seem to be able to help her she suffers from withdrawals so much that she would rather die? Please help us We live in Toronto and no dr seems to care?
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s situation, it does sound quite difficult. That is unfortunate if you’ve been unable to find a doctor to work closely with your mother. I cannot advise you as to exactly how would be best to reduce her dose but as a general rule, if the withdrawal symptoms are severe, then consider tapering the dose even more slowly. I don’t have much personal experience tapering people taking multiple doses per day, so not sure what would be best. You might find the Ashton manual helpful, and in some cases switching to a longer-acting benzodiazepine (diazepam is usually longer-acting than clonazepam) can make the withdrawal symptoms more manageable.
If your mother is being made truly miserable by this tapering, then she and your family might benefit by reviewing the priorities for her medical care and her life. It sounds like it’s going to be very difficult and burdensome to reduce her benzos, so it’s important that the benefits be worth it to her. Good luck!
Melodye R Whitaker says
She’s 84. Why would you worry about an addiction to this, since she obviously really needs the medication, as evidenced by her withdrawals? Anxiety is a terrible affliction and I can personally attest to that. There are other medications for anxiety, but this medication also provides muscle relaxation which a lot of people need – especially arthiritis patients.
Nicole Didyk, MD says
I agree that anxiety can be disabling and some people do need lorazepam as part of their management plan. However, in older adults, the risks of benzodiazepines like lorazepam include not only addiction but also falls and cognitive impairment.
In my experience, the taper needs to be exceedingly slow, even over months. I find that it’s easier to withdraw the benzodiaepine when we’re also adding other interventions to help with anxiety and sleep, like exercise, sometimes adding an anxiety-reducing antidepressant, and cognitive behavioural therapy.
Becca Wilson says
Please clarify this statement about older adults and lowering HgA1C, that appears under there heading “Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better.”
The following statement sounds ambiguous to me:
"most expert groups now recommend a target A1C of 7-7.5% for older adults, or 7.5%-8% for frail older adults likely to live 5 years or less."
Does this mean "a target A1C of 7-1.5%" for ALL older adults — or only older adults WITH DIABETES?
Leslie Kernisan, MD MPH says
The recommendation and related statement applies to older adults WITH diabetes.
Adults who do not have diabetes usually have a hemoglobin A1C less than 6.0%. In fact, documenting a hemoglobin A1C of 6.5% or greater is one way that doctors can diagnose diabetes.
For more information about hemoglobin A1C, including what’s considered normal vs prediabetes vs diabetes, see here: A1C Test.
Carmela DiBartolomeo says
I am a 83 year old and I have learned a lot about my health and what to ask my doctor thank you
Leslie Kernisan, MD MPH says
I’m so glad to know you’ve found this helpful.
Jennifer Roa says
So helpful! Especially that you are saying WHY. You have helped me personally, and the people I care for will be receiving this information.
Leslie Kernisan, MD MPH says
Thank you for your comment, I’m glad you found this helpful.
FYI in April 2015 the American Geriatrics Society released an update to its Choosing Wisely lists, in which they clarified their rationale for several of the items and added lung cancer screening to their prior list of cancer screenings to be careful about. More details are available here.