Choosing Wisely
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Fifteen Things Physicians and Patients Should Question in Post-Acute and Long-Term Care:
1. Don’t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings.
Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Contrary to what many people think, tube feeding does not ensure the patient’s comfort or reduce suffering; it may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems.
2. Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home.
SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s physiologic insulin needs nor is it efficient in the long-term care (LTC) setting in medically stable individuals. Use of SSI is associated with more frequent glucose checks and insulin injections, leads to greater patient discomfort and increased nursing time and resources. With SSI regimens, patients may be at risk from wide glucose fluctuations or hypoglycemia when insulin is given when food intake is erratic.
3. Don’t obtain urine tests until clinical criteria are met.
Asymptomatic bacteriuria (ASB) and/or pyuria is common in residents in PALTC and is the major driver for overuse of antibiotics for Urinary Tract Infections (UTI), leading to an increased risk of adverse drug events, resistant organisms, and infection due to Clostridioides difficile. Due to the high rate of bacterial colonization of urine in older adults, it is important to avoid obtaining a urinalysis or urine culture unless the resident has signs or symptoms suggestive of UTI such as dysuria, and one or more of the following: frequency, urgency, suprapubic pain or gross hematuria. An additional concern is that the finding of bacteriuria/pyuria without urinary symptoms (ASB) may lead to an erroneous assumption that a UTI is the cause of an acute change of status, hence failing to detect or delaying the timely detection of an alternative source of infection.
4. Don’t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia unless management of potential underlying causes fails to respond to best treatment practices. Only use for symptoms that severely impact quality of life or safety from self and/or others, in lowest dose possible and with frequent re-assessment for necessity and efficacy.
Careful differentiation of cause of the symptoms (physical or neurological versus psychiatric, psychological) may help better define appropriate treatment options. The therapeutic goal of the use of antipsychotic medications is to treat patients who present an imminent threat of harm to self or others, or are in extreme distress – not to treat nonspecific agitation or other forms of lesser distress. Treatment of BPSD in association with the likelihood of imminent harm to self or others includes assessing for and identifying and treating underlying causes (including pain; constipation; and environmental factors such as noise, being too cold or warm, etc.), ensuring safety, reducing distress and supporting the patient’s functioning. If treatment of other potential causes of the BPSD is unsuccessful, antipsychotic medications can be considered, taking into account their significant risks compared to potential benefits. When an antipsychotic is used for BPSD, it is advisable to obtain informed consent.
Refer to F-758: Free from Unnecessary Psychotropic Medications/PRN Use. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
5. Don’t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.
Hypercholesterolemia is an important risk factor for all-cause mortality, coronary heart disease mortality, hospitalization for myocardial infarction or unstable angina in persons with known CAD (i.e., secondary prevention) and among those up to age 75 years without prior CV events (i.e., primary prevention), for whom statins may have additional benefits. The strength of association between cholesterol and events is weaker in those with advanced age, and competing risks play a greater role particularly among those with frailty, comorbidity, physical or cognitive decline, or limited life expectancy. Both primary and secondary prevention should aim to achieve a net-benefit, balancing potential harm(s) of polypharmacy and side effects, and in some cases discontinuation may be reasonable. However, discontinuation of secondary prevention statin therapy should only be done after careful discussion of risk/benefit. Among high risk patients (i.e. with diabetes or multiple CV risk factors), without functional decline in whom there is a benefit to continuation of therapy but who develop side effects, consideration could be given to dose reduction.
6. Don’t place an indwelling urinary catheter to manage urinary incontinence.
Bacteremia are most commonly caused by UTIs in the post-acute and long-term care (PALTC) setting, the majority of which are catheter-related. The federal Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends minimizing urinary catheter use and duration of use in all patients. Specifically, HICPAC recommends not using a catheter to manage urinary incontinence in the PALTC setting. Appropriate indications for indwelling urinary catheter placement include acute retention or outlet obstruction, to assist in healing of deep sacral or perineal wounds in patients with urinary incontinence, and to provide comfort at the end of life if needed.
7. Don’t recommend screening for breast, colorectal or prostate cancer if life expectancy is estimated to be less than 10 years.
Many patients residing in the LTC setting are elderly and frail, with multimorbidity and limited life expectancy. Use of screening tests in patients with the shortest life expectancies is common even though they are the least likely to survive long enough to benefit from the intervention and the most likely to suffer complications of the intervention. Preventive cancer screenings have both immediate and longer term risks (e.g., procedural and psychological risks, false positives, identification of cancer that may be clinically insignificant, treatment-related morbidity and mortality). Benefits of cancer screening occur only after a lag time of 10 years (colorectal or breast cancer) or more (prostate cancer). Discussing the lag time (“When will it help?”) with patients is at least as important as discussing the magnitude of any benefit (“How much will it help?”), and it is critical to elicit whether the patient’s values and goals include pursuing a treatment if an abnormality is found. Prostate cancer screening by prostate-specific antigen testing is not recommended for asymptomatic patients because of a lack of life-expectancy benefit. One-time screening for colorectal cancer in older adults who have never been screened may be cost-effective; however, it should not be considered after age 85 and for most LTC patients older than 75 the burdens of screening likely outweigh any benefits.
8. Don’t obtain a C. difficile toxin test to confirm “cure” if symptoms have resolved.
Patients residing in PALTC are particularly at risk for CDI due to advanced age, frequent hospitalizations and frequent antibiotic exposure. Only symptomatic patients with diarrhea should be tested for C. difficile. Furthermore, C. difficile tests may remain positive for as long as 30 days after symptoms have resolved. False positive “test-of-cure” specimens may complicate clinical care and result in additional courses of inappropriate anti-C. difficile therapy as well as prolonged isolation. To limit the spread of C. difficile, care providers in the PALTC setting should concentrate on early detection of symptomatic patients and the consistent use of proper infection control practices including the use of gloves, hand hygiene (with an alcohol-based hand rub or soap and water), contact precautions, and environmental cleaning with a sporicidal agent.
9. Don’t recommend aggressive or hospital-level care for frail individuals without a clear understanding of the individual’s goals of care and the possible benefits and burdens.
Hospital-level care has known risks, including delirium, infections, side effects of medications and treatments, disturbance of sleep, and loss of mobility and function. Multiple studies have shown an increase in cognitive decline following hospitalization, especially admissions involving intensive care and those in which delirium was identified. These risks are often more significant for patients in the PALTC setting, who are more likely to be frail, have multimorbidity, functional limitations, and dementia. Therefore, for some frail older adults, the balance of benefits and harms of hospital-level care may be unfavorable. To avoid unnecessary hospitalizations, care providers should engage in advance care planning by defining goals of care for the patient and discussing the risks and benefits of various interventions, including hospitalization, in the context of prognosis, preferences and indications. Patients who opt for less-aggressive treatment options are less likely to be subjected to unnecessary, unpleasant and invasive interventions and the risks of hospitalization. Advance directives such as the Physician Orders for Life Sustaining Treatment (POLST) paradigm form and Do Not Hospitalize (DNH) orders communicate a patient’s preferences about end-of-life care.
10. Don’t initiate aggressive antihypertensive treatment in frail individuals ≥60 years of age. For frail individuals with hypertension, multiple medical comorbidities, and limited life expectancy, use clinical judgment, incorporate patient/family preferences, and evaluate risk/benefit in deciding on medication(s) and the intensity of control.
There is strong evidence for the treatment of hypertension in older adults. Achieving a goal SBP of 150mm Hg reduces stroke incidence, all-cause mortality and heart failure, and data supports treating more aggressively to a goal SBP of <140mm Hg in community-dwelling individuals ≥75 years of age with elevated cardiovascular risk. However, more data is needed to guide treatment of hypertension in frail older adults in the post-acute and long-term care setting. Target SBP and DBP levels should be based on shared decision-making with the patient, with particular consideration of physiologic age and the presence of underlying coronary artery disease. Antihypertensive therapy may not be appropriate to initiate in some patients with severe frailty or geriatric syndromes, as moderate or high-intensity treatment of hypertension has been associated with an increased risk of serious falls and injury in frail older adults, and low BP targets have added risk for syncope in the context of dehydration, especially during periods of high ambient heat, diminished thirst sensitivity, as well as polypharmacy with other medications (Parkinson’s, etc). Using a reliable, representative method of taking blood pressures with special attention to orthostatic hypotension is important, as orthostatic hypotension has been associated with increased mortality and cardiovascular events. Careful initiation of a single agent with subsequent monitoring and evaluation for side effects can decrease the risk of adverse outcomes.
11. Don’t continue hospital-prescribed stress ulcer prophylaxis with Proton-Pump Inhibitor (PPI) therapy in the absence of an appropriate diagnosis in the post-acute and long-term care (PALTC) population.
In the absence of an appropriate diagnosis for the use of PPI’s long-term in PALTC populations, stop hospital prescribed medications for stress prophylaxis, as literature does not support PPI use for stress ulcer prophylaxis outside the Intensive Care Unit setting. It is important to determine the indication for use and balance potential harm versus benefit recognizing potential adverse events with long-term PPI use, including pneumonia, fracture, chronic kidney disease and bacterial infections such as Clostridioides difficile.
12. Don’t order routine follow up chest imaging for post-acute and long-term care residents with community acquired pneumonia whose symptoms have resolved within 5–7 days.
Radiographic findings tend to lag behind clinical response. Obtaining routine follow up chest radiograph in patients with CAP who have responded to prescribed therapy is therefore not indicated and does not improve care outcomes. This approach is similar to that outlined by the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA), both of whom recommend not obtaining a follow-up chest radiograph in patients whose symptoms have resolved within five to seven days.
13. Don’t routinely prescribe or continue sedative hypnotics such as Restoril or Ambien, diphenhydramine (Benadryl), benzodiazepines, or Serotonin Modulators (Trazadone) for long-term treatment of sleep disorders in geriatric populations. Consider the use of nonpharmacological interventions (e.g., physical activity, a regular schedule or cognitive behavioral therapy.)
Use of diphenhydramine (or other first generation antihistamines), benzodiazepines or sedative hypnotics with anticholinergic side effects should be avoided as the data suggests these drugs may cause confusion and delirium in the short term, and some have been associated with an increased risk of dementia with long-term use. These drugs are associated with a five-fold increase in adverse cognitive events, an increase in adverse psychomotor events and are associated with an increased risk of falls. The 2019 updated Beers criteria for potentially inappropriate medications for use in older adults recognized these medications as problematic.
14. Don’t routinely prescribe or continue acetyl cholinesterase inhibitors or N-Methyl-D-Aspartate antagonists in patients with advanced dementia.
Use of acetyl cholinesterase inhibitors in mild to moderate dementia or NMDA antagonists in moderate to severe dementia may help with Behavioral and Psychological Symptoms of Dementia (BPSD) but have not been shown to prolong life. Once an individual is institutionalized, review of the risks and benefits of the medications should be reviewed periodically and de-prescribed when no longer demonstrating benefit to the patient. Acetyl cholinesterase inhibitors can worsen anorexia and NMDA receptor agonists are not indicated with severe renal insufficiency, both of which could be present in the older population.
15. Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.
Post-acute and long-term care practitioners should prescribe opioids based on thoughtful inter-professional assessment indicating a clear indication for opioid use. Periodic review to evaluate risk factors for potential harms of long-term opioid therapy should be incorporated into the individualized plan of care. For residents on long term opioid therapy for chronic pain (not for cancer, palliative care, or end-of-life), tapering plans should be individualized and should minimize symptoms of opioid withdrawal while maximizing pain treatment. Clinicians should offer alternative behavioral therapies, non-opioid analgesics and other non-pharmacologic treatments whenever available and appropriate.
Resources for Patients & Families
AMDA has partnered with Choosing Wisely to produce free resources for patients and families related to AMDA's Choosing Wisely recommendations .