The Geriatrics For Caregivers Blog

Last week, I wrote about the first Choosing Wisely list of 5 treatments that older adults and their doctors should question.

In this post, I’ll cover the 2014 Choosing Wisely list for healthcare in aging adults, which was released by the American Geriatrics Society (AGS) this past February. This 2014 edition of things to question include:

• The most popular class of medications prescribed for Alzheimer’s and other dementias,
• Breast, colon, and prostate cancer screening,
• A common approach to weight loss and poor appetite,
• The prescribing of additional medications,
• A common — but risky — approach to handling confusion during hospitalization.

As I explained in my last post, 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. 

For the Choosing Wisely items selected by AGS (my specialty society), I’d say the real problem is that these are healthcare interventions that are usually used before safer alternatives have been tried.

Many older adults and their caregivers are never told that a safer alternative exists. People often also have an overly optimistic understanding of the likely benefits, but haven’t been properly informed of the risks.

Aren’t doctors supposed to offer the safest alternatives first? Of course they are. However, many doctors haven’t been trained in modifying healthcare to better fit the needs of aging adults. And it’s often hard for a busy clinician to keep up with the latest recommendations from experts in geriatrics.

By learning about the Choosing Wisely recommendations, you can prepare yourself to be a “smarter” patient or caregiver, and you can be more proactive about making sure the healthcare you get is a good fit for your family’s needs. That’s why Choosing Wisely is supported by Consumer Reports, which makes the recommendations available on their website.

In this post, I’ll review the 2014 list of five Choosing Wisely items that older adults — and their families — should question. I’ll also share some tips for caregivers, related to each item.

Five (More) Things to Question for Healthcare in Aging Adults

1. Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects. In other words, after starting a dementia medication such as donepezil (brand name Aricept), don’t forget to follow-up! You’ll want to make sure that the drug is making thinking or behavior better, and that the side-effects are tolerable. Other cholinesterase inhibitors include rivastigmine and galantamine (brand names Exelon and Razadyne, respectively).

Why: Although these drugs are often prescribed in Alzheimer’s, clinical studies suggest that the likely benefits are smaller than many people realize. Also, although these drugs may improve cognitive symptoms for a minority of patients, they are not “disease-modifying” and don’t truly slow the progression of Alzheimer’s. (Want to avoid acceleration of Alzheimer’s? See this post.)

A comprehensive review in 2008 described the benefits of these medications as “clinically marginal,” especially since it’s been hard to prove that these drugs improve quality of life or overall life function. Another review calculated that 12 people have to be treated with these drugs, in order for one person to experience marginal improvement or better; the same review noted that about 1 in 12 people will experience a significant side-effect (usually diarrhea or stomach-related).

Because some clinical trials suggest that the drugs work better for some people than others, many experts now recommend a time-limited trial of these medications: if a patient or family notice an improvement, the drugs should be continued. If not, the care team should consider stopping them.

Tips for caregivers: The main thing to realize is that it’s not at all guaranteed that these medications will help in Alzheimer’s. In fact, it’s fairly common for these drugs to seem to have no effect at all, and sometimes they do cause uncomfortable diarrhea or stomach upset. If you don’t see much improvement, know that it’s reasonable to consider stopping these medications, especially if you want to reduce costs or pill burden.

That said, I find that these drugs tend to cause fewer side-effects and risks than many of the other drugs older adults often take; generally the greatest harm from Aricept is to the wallet. Although all medications should come with a plan to assess effectiveness and side-effects regularly, these types of medications are usually lower on my priority list. They likely aren’t helping as much as people think they are, but at least they aren’t very risky. (Whereas antipsychotics and benzodiazepines — commonly used for difficult Alzheimer’s patients — are risky; they are on the original Choosing Wisely list.)

2. 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. This means that doctors shouldn’t automatically refer older adults for cancer screening. Instead, doctors and patients should consider life expectancy and the risks of screening, before deciding whether to proceed.

Why: Cancer screening is an important part of preventive health. But most people do reach a point at which their age, or their chronic illnesses, make it unlikely that cancer screening will be beneficial. That’s because research suggests that cancer screening is most likely to help those who are likely to live another 10 years or more. Furthermore, screening for cancer does harm some patients, due to overdiagnosis or complications of procedures such as colonoscopy.

Cancer screening used to be reflexively recommended for most adult patients, no matter what their age or health status. But today, experts recommend that people first weigh the likely benefits and risks. This is called individualized cancer screening.

At this time, US Preventive Services Task Force (USPSTF) recommends against routine colon cancer screening in adults older than 75 years. Breast cancer screening is recommended for women aged 50-74.

Tips for caregivers: If your older loved one is older than 75, or is in declining health, be sure to ask questions if cancer screening is recommended without first having a thoughtful conversation.

Wondering how long your loved one is likely to live? A team of UCSF geriatricians offers access to mortality calculators at ePrognosis.org. I find the life-expectancy graphs here to be especially helpful.

 3. 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. In other words, for older adults who are losing weight or seem to not be eating well, don’t start by requesting medication, or a nutritional drink such as Ensure. Instead, make sure the person gets any help he or she needs with grocery shopping and meal preparation. You’ll also want to talk to the doctor about the health status; if weight loss is due to a medical problem such as depression, or cancer (a cause of cachexia), you’ll need to discuss goals and management options before you turn to stimulants and supplements.

Why: Weight loss and malnourishment are fairly common in older adults, and it’s very important to spot these issues and address them. However, research studies have found that prescription appetite stimulants often don’t provide a lot of benefit, and can cause problematic side-effects.  Nutritional supplements such as Ensure or Boost are safer in that there’s usually little risk of side-effects. But comprehensive reviews of clinical research suggest that the benefits are usually slim.

Tips for caregivers: If you’re worried about appetite or weight loss in an older person, start by asking for help assessing the underlying cause — or causes — of the problem. For instance, some aging adults develop difficulty getting and preparing food, due to physical disabilities (such as crippling arthritis) or memory problems. In other cases, the problem is an underlying medical problems, such as depression, heart failure, lung disease, or cancer. You should also make sure an oral evaluation is done; tooth pain or chewing problems can affect nutrition.

 4. Don’t prescribe a medication without conducting a drug regimen review. This recommendation is pretty straight-forward. Before accepting a new prescription for a medication, always make sure the clinician has an up-to-date medication list, and has reviewed it.

Why: Polypharmacy (the taking of multiple medications) raises the risk of potentially dangerous medication interactions. Older adults also tend to be more vulnerable to side-effects of medications. A 2011 study estimated that seniors experienced over 250,000 emergency room visits per year, due to medications. People aged 80+ were especially likely to need hospitalization.

Tips for caregivers: This is a common-sense recommendation that can still be tricky to implement, because many clinicians are used to handing out prescriptions fairly quickly. You’ll want to be prepared, by making sure you always have an up-to-date medication list handy. And then be ready to be gently persistent: if the doctor doesn’t ask to review all medications, ask that she does so. You may also want to ask if the new drug is on the Beer’s List of medications to be used with caution.

For tips on maintaining an up-to-date medication list, read this post.

For a link to a free online drug interaction checker, see this post.

5. Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium. This means that if your older loved one becomes confused and difficult during a hospitalization, don’t let the staff tie him or her down, unless all other options have failed.

Why: It’s very common for older adults to develop delirium — a state of worse-than-usual confusion — during a hospitalization. While confused, people may pull at IVs, thrash around in bed, or try to get up when they are too weak to do so safely. This understandably looks dangerous, and historically hospital staff have responded by tying patients’ arms down. However, research has found that this approach does not improve outcomes. Feeling tied down can increase an older person’s confusion and panic, and people often still manage to struggle partly out of bed despite restraints. A more effective approach is for hospital staff to use comprehensive approaches that soothe restless patients and minimize stressors.

Tips for caregivers: If an older person becomes restless and confused in the hospital, be sure to bring it to the attention of the doctors. Studies have found that delirium is often missed by busy hospital staff. To prevent — and to help treat — delirium, it often helps to have family at the bedside, to provide reassurance and support.

To learn more about how delirium is treated, including tips on what you can do as a caregiver, see here.

Delirium is especially common in people with Alzheimer’s and other dementias; for more information and resources, see this post.

Questions or comments about these Choosing Wisely recommendations? I’d love to hear from you in the comments below.