GERIATRICS-CHOOSE WISELY

The American Geriatrics Society (AGS) has released a second list of 5 tests or treatments that physicians and older adult patients or caregivers should question before proceeding with them. Release of the evidence-based recommendations is a continuation of the AGS's participation in the Choosing Wisely initiative, launched in 2012 by the American Board of Internal Medicine Foundation.

"We are grateful to have had the opportunity to identify these five additional things," Paul Mulhausen, MD, from Iowa City, Iowa, chair of AGS' Choosing Wisely Workgroup, said in a news release. "Because older patients tend to take more medications, and undergo more medical tests and procedures than younger adults, this information is invaluable."

The new list, released online February 27, adds 5 tests or treatments to a previous Choosing Wisely list by AGS that waspublished in the Journal of the American Geriatric Society in June 2013.

The new recommendations are:

• "Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects." If a patient is started on cholinesterase inhibitors and treatment goals are not achieved after a reasonable time such as 12 weeks, medication discontinuation should be considered.
• "Don't recommend screening for breast or colorectal cancer, nor prostate cancer (with the [prostate-specific antigen] test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment." Screening for these 3 cancers exposes patients with life expectancies lower than 10 years to potential harms with little benefit potential.
• "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." No evidence exists that these stimulants and supplements improve quality of life, mood, functional status, or survival
• "Don't prescribe a medication without conducting a drug regimen review." A review may reduce medication burdens by exposing unnecessary prescriptions
• "Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium." Use physical restraints only as a last resort and discontinue as early as possible

The previous recommendations were:

• "Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding."
• "Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia."
• "Avoid using medications to achieve hemoglobin A1c <7 .5="" 65="" adults="" age="" and="" better.="" control="" generally="" in="" is="" moderate="" most="" older="" p="">
• "Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium."
• "Don't use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present."

A national campaign, Choosing Wisely involves more than 50 medical specialty societies identifying common medical tests and treatments that may not be necessary or of benefit to patients.

"Five Things Physicians and Patients Should Question." AGS. Full text