Things to Question When It Comes to Treating the Elderly

American Geriatrics Society suggests which therapies to avoid or use sparingly in older people

(RxWiki News) The elderly often won’t benefit from many of the procedures or tests recommended for younger folks. That's why the American Geriatrics Society has released a list of 10 therapies to carefully consider before using in the older population.

This list includes recommendations to not treat diabetes as aggressively as in younger people and to avoid certain medications in the elderly because these older patients may not respond to therapies in the same way as those who are younger.

These recommendations are part of the Choosing Wisely campaign, which was established to promote conversations between patients, their families and doctors about effective, evidence-based healthcare practices.

The authors of the recommendations noted that their aim is to control spiraling healthcare costs and discourage unnecessary therapies.

"Ask your doctor about which tests are necessary."

The American Geriatrics Society (AGS) compiled this list to improve the health, independence and quality of life of all older people, the authors wrote.

Feeding tubes are the first thing the AGS recommends avoiding in those with advanced dementia (loss of brain function that effects memory and thinking). They suggested that feeding someone by hand is as good as tube-feeding, and that there are complications associated with tube feeding, such as increased agitation and more pressure ulcers.

The AGS also cautions against using antipsychotic medications in the elderly. While these medications are often used to handle aggression or resistance to care, they provide limited help and can even lead to stroke or premature death. AGS suggested that identifying and addressing reasons for the patient's behavior may make medicating them unnecessary.

While controlling diabetes is important in younger people, there is less emphasis on control in the older person. People older than 65 who have type 2 diabetes (non-insulin dependent) may not need diabetes medications. Even if an elderly person has a high AC blood test (measure of blood sugar levels over the course of three months), most physicians do not aggressively treat an older diabetes patient. Too many older diabetes patients have their blood sugars plummet when they are aggressively treated.

Most doctors encourage diabetes patients to keep their A1C level below 7.5 percent. AGS recommended that more reasonable blood sugar targets, which could be as high as an an A1C of 9 percent for some people, should be used.

Benzodiazepines and other sedative-hypnotics are often used to treat insomnia or agitation in the elderly, but their use has been linked to a greater risk for falls, car accidents and death, AGS cautioned. AGS suggested that use of these medications should be limited to alcoholics trying to quit or to people with generalized anxiety disorder who can’t be helped with other therapies.

According to AGS, antimicrobials, which are used to treat urinary tract infections, shouldn’t be used if an older person has an infection but is not showing symptoms. These patients don’t usually benefit from medications to treat infection and can even be harmed by them, AGS cautioned.

Cholinesterase inhibitors for dementia stop the breakdown of acetylcholine in the brain (the enzyme that breaks down the chemical that is useful for memory). Modest benefit has been noticed in delaying decline in mental activity in these patients. However, whether their use really helps with things like quality of life are not known, the authors cautioned. The caregiver, patient and doctor should consider lifestyle changes that may help the patient before adding these medications, and if started, there should be talk of discontinuing the medication if the desirable changes are not seen after 12 weeks of therapy, they suggested. Risks and benefits beyond a year are not well-known, they wrote.

For patients whose life expectancy is less than 10 years, screening for breast, colon or prostate cancer testing is not likely to be helpful and may lead to complications from testing, overdiagnosis and treatment of tumors that likely would have never caused symptoms, according to AGS.

AGS also cautioned against prescription medications to improve appetite and high-calorie supplements. Although these may add some weight to a frail older person, there is no evidence that quality of life, mood, functioning or even survival is better, AGS wrote. Furthermore, they suggested that medications to stimulate appetite come with their own risks, including fluid retention and death.

Older people use more medications than other age groups, so the AGS cautioned against adding medications without reviewing what the older person is already taking. Too many medications (prescription and over-the-counter) raise the risk for adverse events, falls and functional decline, AGS explained. Doing a review of the medications a patient is already taking may identify high-risk medications, medication interactions or those continued longer than they should be, the authors wrote.

People who are delirious may have problems with their treatment or possibly hurt themselves, and applying physical restraints may seem like a good idea, but they are not advisable in most situations, according to AGS. Physical restraints can cause injury or death, or worsen the patient's agitation. Alternative therapies, such as frequent family contact or reorientating the patient to where they are and reminding them of the people who are around, may help, AGS suggested. Physical restraints are a last resort and then should be used for the shortest time possible, they cautioned.

Almost 100 healthcare groups, including the American Academy of Pediatrics, the American College of Cardiology and the American College of Surgeons, have compiled Choosing Wisely lists.

Review Date: 
March 16, 2014