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Elderly Patients: Making Wise Choices

Laurie Scudder, DNP, NP, Paul L. Mulhausen, MD, MHS

February 27, 2014

Editor's Note:
The Choosing Wisely initiative of the American Board of Internal Medicine (ABIM) Foundation was launched in 2012
with a goal of reducing overuse of tests and procedures, and helping patients, in consultation with physicians, to
mak e smart and effective care choices. Since then, 30 professional societies have joined the effort, releasing lists of
common practices that should be questioned by both healthcare professionals and patients.
This month, the American Geriatrics Society (AGS) released their second "Top 5" list of low-value practices in the
care of older adults. Medscape spok e with Paul Mulhausen, MD, MHS, Chief Medical Officer at Telligen and Chair of
the AGS Choosing Wisely work group, about the recommendations and k ey tak e-home messages for clinicians.
AGS's Recommendations

Recommendation 1: Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for
perceived cognitive benefits and adverse gastrointestinal effects.
The rationale: Although some patients with mild-to-moderate and moderate-to-severe Alzheimer disease (AD)
achieve modest benefits with use of cholinesterase inhibitors, including delayed cognitive and functional decline and
decreased neuropsychiatric symptoms, the impact of these drugs on institutionalization, quality of life, and caregiver
burden are less well established. Treatment plans must also include advanced care planning, patient and family
education, diet and exercise, and other nonpharmacologic approaches.
Medscape: When is it appropriate to prescribe a trial of cholinesterase inhibitors?
Dr. Mulhausen: I would like to contextualize my response. There has been a general observation that the outcomes
used to measure the effectiveness of an acetylcholinesterase inhibitor are modest in their effect. Equally, the
beneficial effects of using an acetylcholinesterase inhibitor for people with dementia are modest.
More important, there has been general concern among many geriatricians that the measured beneficial effects don't
translate in to a patient-centered, relevant outcome -- such as function, nursing home placement, or longevity.
Acetylcholinesterase inhibitors do not fundamentally improve underlying pathophysiology, but improvements in some
of the symptoms, especially those related to cognitive loss, have been measured.
The US Food and Drug Administration (FDA) has approved the use of acetylcholinesterase inhibitors for people with
mild-to-moderate and moderate-to-severe AD. In those circumstances, a trial of an acetylcholinesterase inhibitor may
be clinically appropriate. The spirit of the Choosing Wisely program would indicate that clinicians should be engaging
their patients with mild-to-moderate AD and the caregivers and loved ones of those with moderate-to-severe AD in a
conversation on the benefits and the risks of using acetylcholinesterase inhibitors, clarifying the modest benefit and
making sure that people understand the risks and have a meaningful impression of the risk/benefit balance.
Medscape: How long is a reasonable period in which to assess for benefits?
Dr. Mulhausen: We don't have randomized controlled trial data that can answer your question. We have clinical
impressions, and we have studies that have used the duration of an individual trial to determine effectiveness.
I think our membership and the experts whom we consulted in formulating this recommendation agree that a 12-week
trial is sufficient time for a patient, or the caregiver and families of a patient, to truly assess whether or not there is a
perceived benefit. The 12-week trial allows the patient and the clinician to optimize the dose. And it gives ample
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opportunity for all of the key stakeholders -- the prescriber, the patient, the people who live with and love the patient -to try to assess whether or not it's been truly effective.
Recommendation 2: Don't recommend screening for breast or colorectal cancer, or prostate cancer (with the
prostate-specific antigen [PSA] test), without considering life expectancy and the risks of testing, overdiagnosis, and
overtreatment.
The rationale: Cancer screening is associated with a number of risks, including the risk for overdiagnosis and
unnecessary treatment. The number needed to screen and treat in order to prevent a single death is over 1000 for
both breast and prostate cancer in elderly adults.
Medscape: This recommendation is not discouraging screening all older adults for breast, colorectal, or
prostate cancer -- but rather, only those with a life expectancy of less than 10 years. Can you speak about
that determination and, importantly, strategies to assist families with understanding the rationale behind
not screening?
Dr. Mulhausen: I do find these conversations difficult. Let me share my own experience.
I once counseled an elderly man in his late 80s, with multiple medical problems, to stop undertaking screening with
the PSA test. His response -- in part serious and in part tongue-in-cheek -- was, "Oh, so you're just going to let me
die of prostate cancer." That is a tough statement to respond to!
As a culture, we have embraced the concept of screening to prevent both mortality and morbidity from cancer. To
counsel people not to take advantage of these technologies in the spirit of doing no harm is difficult, but that is what
we should do. We are obligated as professionals to engage people in meaningful conversations about risks and
benefits.
There are harms associated with these screening modalities. Part of the problem is that we are not as effective at
educating patients about potential harm as we are in teaching about potential benefit. The AGS Choosing Wisely
committee believes that there comes a point in a person's life -- when medical complexity, combined with frailty,
multimorbidity, or limited life expectancy -- that the harms become much more likely than the benefits. As physicians
caring for people who are having those health experiences, we are obligated to clarify the risks and benefits. It's a
difficult choice because in essence, we are highlighting issues surrounding overtreatment and the potential harm
associated with procedures that people generally view as valuable and helpful.
There is a need and an obligation to engage patients in these conversations more effectively. It takes a long time to
learn how to do a difficult procedure, such as colonoscopy. Equally, it takes time, and it is difficult to acquire the skill
needed for these conversations. Both are important in effective patient care, and we have to master both. We have to
master the procedures we do in the spirit of benefit, and we have to master the conversations we undertake with our
patients to clarify risk and harm for true patient-centered, informed consent.
The role of the conversation with the caregiver or family member is not as clear-cut in this particular issue as it is for
something like cholinesterase inhibitors, which typically involve progressive neurologic illness in which dependency
becomes a part of the symptomatology. With screening discussions, there may be family and loved ones as
stakeholders in the conversation as well, but these patients are often independent, functional people who are really
the only person engaged in the conversation with the clinician.
Medscape: This also speaks only to these 3 cancer types. What about other cancer screening -- for
example, chest CT for lung cancer? How is a risk/benefit determination regarding that type of screening
best done?
Dr. Mulhausen: I'm not sure I can answer that question effectively. The US Preventive Services Task Force has
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made a grade B recommendation to perform low-dose CT in heavy smokers between the ages of 55 and 80 years. [1]
They define that as a history of 30 pack-years or more of smoking in a person who currently smokes or has quit
smoking within the previous 15 years. Studies demonstrating the effectiveness of low-dose CT as a screening tool
have included patients up to the age of 77 years.
One of the fundamental understandings about using low-dose CT is that a patient would be able to undergo resection
of a tumor, should one be identified by screening. The common-sense thought I have at this point is that there are
probably many geriatric patients younger than 80 years who are frail and perhaps have a limited life expectancy from
some other comorbidity, who would not be candidates for this kind of surgery.
There is still a lot that we have to sort out with low-dose CT screening technology. We felt much more comfortable
with the knowledge base regarding the risks and benefits of screening, including the impact of longevity on benefit, for
the 3 cancers we discussed: prostate, breast, and colorectal. Although prognosticating tools to assist with the
determination of life expectancy are not perfect, there are tools out there that can help clinicians think more
rigorously about prognosis, such as ePrognosis, and can also be used to help educate patients about their own
risk/benefit calculation.

AGS's Recommendations - Continued

Recommendation 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.
The rationale: Although high-calorie supplements increase weight in older people, there is no evidence that they
affect other important clinical outcomes, such as quality of life, mood, functional status, or survival. Stimulants such
as megestrol acetate and cyproheptadine should be avoided in older adults, as noted in the 2012 AGS Beers criteria.
Studies of cannabinoids, dietary polyunsaturated fatty acids (DHA and EPA), thalidomide, and anabolic steroids have
not demonstrated the efficacy or safety of these agents for weight gain in elderly adults.
Medscape: Many older adults experience a normal decline in appetite, which can be distressing to their
family members, who worry that this is harmful. Can you briefly review the appropriate assessment for an
adult with unintentional weight loss? What are the first steps in appropriate management?
Dr. Mulhausen: I would argue again that there should be a conversation about the risks and benefits of [appetite
stimulants and high-calorie supplements] and in some circumstances -- probably not all -- a strong counseling to
avoid their use. Unintentional weight loss is commonly experienced in old age. It is rarely without impact. It usually
represents something serious going on: either late-age sarcopenia, an underlying illness that is already recognized,
or an underlying new pathology that the clinician is obligated to investigate. There are several potential causes that I
think are worth highlighting.
The first is failing social support. On the basis of my own experience, I would suggest that there needs to be some
proactive inquiry into that possibility as the reason for weight loss. Many people, as they get older, become a little
less independent. Their social structure is declining, and they are vulnerable. They're not dependent, but they're really
not truly independent anymore. Neighbors, friends, and family don't often recognize this change, and they fail to
recognize that the subtle loss of independence is resulting in poor access to nutrition.
The next is alcohol use. In my own clinical experience, I have found value in asking about alcohol consumption. It is
not infrequent for me to discover a patient has an alcohol substance abuse disorder as the root cause of their
unintentional weight loss.
The last thing I want to highlight is to make sure to engage a screening process for unrecognized depression.
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My approach, therefore, is to screen for alcohol use, depression, and declining social support. The reason I highlight
those areas is that many of us as clinicians often forget to think about them.
Approaching unintentional weight loss in a young person or in an old person has to be very individualized. It's one of
those circumstances where a comprehensive history, and inquiring specifically about diet and gastrointestinal
symptoms, can be very helpful. A physical examination is needed. Finally, a laboratory investigation that includes a
basic metabolic evaluation, especially looking for disruptive thyroid function, unrecognized diabetes, hyperglycemia,
and evidence of some other unrecognized occult illness, is appropriate.
Remember, a lot of medical diseases experienced in old age are chronic and associated with weight loss: chronic
obstructive pulmonary disease; heart failure; and the commonly encountered neurodegenerative disorders, such as
Parkinson disease and Alzheimer disease. So I look for something new, and if I don't find something, I am then
comfortable attributing the weight loss to the illness that we already know about and remaining vigilant.
Recommendation 4: Don't prescribe a medication without conducting a drug regimen review.
The rationale: Older patients use more prescription and nonprescription drugs than other populations. This increase
in medication burden -- particularly concerning when high-risk and potentially additive medications are used -- may
lead to diminished adherence; adverse drug reactions; and increased risk for cognitive impairment, falls, and
functional decline. Medication review identifies high-risk medications, drug interactions, and those continued beyond
their indication.
Medscape: This recommendation is really a mouthful! The risks of polypharmacy are well documented, but
clear strategies for deprescribing are lacking. What do you recommend as best practice for both reviewing
medication and possibly discontinuing those that are no longer appropriate?
Dr. Mulhausen: There are several issues here. If you work in the domain of geriatric care or immerse yourself in the
geriatric literature, you become very aware of the unintended adverse consequences of treatment. Older people who
are losing homeostatic reserve become more vulnerable to the adverse effects of medical intervention. We (as
geriatricians, and all of those who treat older adults) think a lot about side effects of medications; we think a lot about
the safety of procedures, because our clientele is predictably more vulnerable to those problems.
All of the Choosing Wisely committee members had an interest in advising people to use less medication. There is
clear evidence of undertreatment or overtreatment, and duplication in treatment, as well as a trend toward an
increased risk for adverse effects from medical interventions.
The committee felt strongly that the standard of care should be that medications and other treatments are reconciled
periodically, and those that are no longer necessary, have no indication, or are duplicated should be reviewed for
discontinuation. How to identify that? The AGS Beers Criteria for potentially inappropriate medications provides a
strategy to make sure that the treatment program is truly necessary and truly effective, and not duplicative.
The other part of that process is to look for undertreated indications. So you were right: This is a complex
recommendation. It's rooted in our belief that treatment regimens can be both helpful and harmful and that we truly
need to proactively manage the medication treatment regimens of the geriatric patient, because the payback for that
proactive management is so much greater.
Medscape: In your experience, are most clinicians familiar with the Beers criteria?
Dr. Mulhausen: I do not think they are universally known, although they are widely used in the geriatric and longterm care communities, as a quality benchmark. Certainly, there are more people in the primary care disciplines who
are probably aware of it, but I don't think it's the majority.

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This is anecdotal, but in a presentation recently, I polled the audience of maybe 100 people to ask about their use of
this document, and approximately 5 raised their hands to say they were familiar with the Beers criteria. I don't think
they're broadly known.
Some clinicians feel that the Beers criteria overstate risk in identifying potentially inappropriate medications. I don't. I
am very comfortable with the list and believe it has been developed and vetted in a rigorous process. I think there is
continued value in promoting the Beers list as a potentially helpful tool.
Recommendation 5: Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with
delirium.
The rationale: Physical restraints can lead to serious injury or death and may worsen agitation and delirium.
Effective alternatives include strategies to prevent and treat delirium, identification and management of conditions
causing patient discomfort, environmental modifications to promote orientation and effective sleep/wake cycles,
frequent family contact, and supportive interaction with staff. Physical restraints should only be used as a very last
resort and should be discontinued at the earliest possible time.
Medscape: The 2013 AGS Choosing Wisely list recommended avoidance of chemical restraints.
Specifically, AGS cautioned clinicians not to use benzodiazepines or other sedative-hypnotics in older
adults as the first choice for insomnia, agitation, or delirium. This year's recommendation with regard to
physical restraints is specific to hospitalized adults. What are some effective strategies for management of
delirium in this setting? Does this recommendation extend to the long-term care environment?
Dr. Mulhausen: The committee members, as clinicians, believe that we continue to see physical restraints used
excessively. We wanted to highlight this concern and reinforce the standard of minimizing physical restraint use
across the spectrum of care.
There are strong disincentives already in place for the use of physical restraints in long-term care settings, although
there are continued opportunities to improve. A great deal of state-to-state variability remains in the rate of physical
restraint use. And within states, we see great variability from long-term care institution to long-term care institution,
suggesting that there is more to it than simply a perception on the part of staff at a facility that their patients need
physical restraints.
If one state seems to have a lower rate and one institution within that state is actually able to be completely restraintfree, perhaps we can make improvement in those settings where there is continued excessive physical restraint. So
we recognize that there is potential for improvement in the long-term care setting, but we also feel that there is a
cultural or a healthcare environment quality approach that disincentivizes their use in long-term care. That disincentive
to use restraints may not be felt as strongly in the hospital. The committee members agreed that in our consultative
roles, physical restraints continue to be used excessively in hospitalized older patients.
We wanted to highlight that we find country-to-country variability, institution-to-institution variability, and you can
actually find variability within institutions from ward to ward. This suggests that the indications for which restraints are
being used in all of these settings are not necessarily appropriate. Those who practice in intensive care units are
often faced with the struggle of trying to prevent confused and delirious patients from interfering with their treatment
program -- pulling out intravenous lines, indwelling catheters, and endotracheal tubes inadvertently. Staff in these
settings continue to feel that physical restraints are necessary and use them to some extent.
The alternatives are very patient-centered, and rooted in a multidisciplinary approach. We offer a variety of potential
strategies to try to address this kind of problematic behavior. We try to discuss at a very high level how physical
environment redesign could be helpful. Particular care issues, such as discomfort, should be addressed.
Environmental modifications should include more bedside support from volunteers. Sharon Inouye, MD, and
colleagues have published a model for delirium prevention and management, [2] which describes a multifaceted,
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comprehensive approach clearly demonstrated to reduce delirium while avoiding the use of physical restraints.
These are complicated issues. They require interprofessional teams. They require thoughtful, deliberative approaches
to care in often very difficult emotional circumstances. And they require a knowledge base on top of that.
So the question is, how should AGS, as a professional organization, approach this issue? We would make the
argument that we need to find ways to make these difficult interventions less difficult for the bedside clinician and
more a part of the systems of care, so that our patients are receiving their treatment in ways that are the least
restrictive. We highlight volunteers in our writing, but really what it's about is bedside support -- which can be from
family members, close personal friends, volunteers, or other people who can be a calming influence on the patient.
What if you redesign that hospital so that it would be easier to do that? What about developing a volunteer program
that recruited people to be a bedside companion?
These are not all simple solutions, but they are solutions that have been tested and demonstrated to work, and that
require a significant rethinking of the way we deliver care.
References

1. US Preventive Services Task Force. Screening for lung cancer. US Preventive Services Task Force
Recommendation Statement. December 31, 2013.
http://www.uspreventiveservicestaskforce.org/uspstf13/lungcan/lungcanfinalrs.htm Accessed February 11,
2014.
2. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in
hospitalized older patients. N Engl J Med. 1999;340:669-676. Abstract
Medscape Internal Medicine 2014 WebMD, LLC

Cite this article: Elderly Patients: Making Wise Choices. Medscape. Feb 27, 2014.

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