5 recommendations for deciding treatment for older adults with chronic diseases
More than half of all adults 65 and older have three or more chronic diseases and meet the criteria for multimorbidity. The Oxford Journal defines multimorbidity as the co-existence of two or more long-term conditions in an individual. These “complicated” patients are usually excluded from research causing patients with complex health issues to be under-represented and making diagnoses and treatment difficult. The result is that patients are often treated for each individual disorder. According to the American Geriatrics Society, a 2005 study following the guidelines for treating a hypothetical 71-year old woman with chronic obstructive pulmonary disease, type 2 diabetes, mellitus, osteoporosis, hypertension and osteoarthritis “would result in her taking a list of medications that would put her at significant risk of multiple drug side effects and drug-drug interactions.” In addition to the overuse of medications, a 2012 study found an overuse of surgery and unwanted intensive care at the end of life.
One approach that American Geriatrics Society (AGS) has taken was to update and improve the Beers Criteria for Potentially Inappropriate Medication use (that list can be found here). As we covered in an April article of this year, at least 5 percent of seniors were prescribed one or more medications from that list. Another was to create a series of articles for lay people based on the new criteria. Those articles are published as a series of brief, easy to understand tip sheets covering avoidance of drug interactions, questions to ask your healthcare provider and a medication diary to make it easier to keep track of medications. Those sheets can be found at www.healthinaging.org.
Choosing Wisely is a program designed by the American Board of Internal Medicine Foundation (ABIM Foundation) to lead families, patients and medical personnel in discussions about the safety and appropriateness of medical tests and procedures with the aim to reduce inappropriate or overuse of tests and procedures in patients making health care decisions. The goal of the program is to improve the quality of patient care and reduce what the Congressional Budget Office estimates is an overuse of healthcare spending by as much as 30 percent. The ABIM Foundation partnered with over 60 other leading medical specialist societies, as well as consumer and advocacy groups to identify lists the physicians and patients should question as they relate to older adults. One of those groups was the AGS whose list includes five commonly prescribed medications and treatments that older adults, caregivers, and healthcare providers should question and discuss.
ABIM asked each participating organization to keep in mind the following criteria when they submitted their lists: the five items must be within the purview of the society submitting the lists, the tests and procedures must be used frequently or were costly, recommendations must be based on sufficient evidence and the process must be documented and available to the public if requested. (The “uncut” version of this list can be found at www.choosingwisely.org.)
Here are the five recommendations in brief:
- Rather than recommending percutaneous feeding tubes in patients with advanced dementia, suggest oral assisted feeding. Hand feeding offers comfort as well as functional status that is as good as if not better than tube feeding and runs a lower risk of aspiration pneumonia and mortality. Tube feeding often results in agitation that is then handled by the use of physical and chemical restraints and worsening pressure ulcers.
- Avoid using antipsychotics for treatment of behavioral and psychological symptoms of dementia. Findings show that the medications are generally ineffective and can increase the risks of serious harm, including stroke and premature death and should only be used when other measures have failed and patients pose a threat to themselves or others.
- Avoid using medications to achieve tight glycemic control in older adults with type 2 diabetes. Trials are generally focused on middle-aged adults and as a result there is sparse evidence of effectiveness in using targets of less than 7 percent as they risk greater harm. Benefits are less likely to be achieved than among younger adults primarily because it takes so long (10 to 19 years) for the benefits to be seen and because older adults are less likely to be newly diagnosed and established levels are less likely to respond to treatment.
- Don’t use benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia, agitation or delirium. Extensive evidence exists that benzodiazepines and other sedative-hypnotic medications more than double the risk of falls and hip fractures and lead to hospitalization and death in older adults.
- Avoid antimicrobials for treating bacteriuria in older adults unless specific urinary tract symptoms are present. Studies have shown that older adults not treated with antimicrobials have no adverse outcomes while those who are treated with antimicrobials run the risk of adverse drug reactions, and re-infection with more resistant organisms.
Eighty percent of adults 65 and older have at least one chronic health condition and half have three or more. The evidence for treating or conducting many common tests on these older adults is inadequate and due to the complexity of their conditions, that evidence is likely a long ways off. It’s important for the individual, family caregivers and healthcare providers to follow the suggestions outlined by the ABIM to allow them to research the benefits and risks before making a choice about their healthcare.