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. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. 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.
According to William Smucker, MD, CMD, one of the AMDA members who participated in the Choosing Wisely® workgroup, "People make some logical but incorrect assumptions about the potential benefits of tube feeding. As dementia progresses to the advanced stages, people have trouble eating enough to stay healthy, leading to weight loss. Since weight loss and poor nutrition can lead to problems such as functional decline and pressure ulcers, people think that tube feeding will result in reversal of these conditions. However, this isn't supported by the clinical evidence. In fact, the evidence shows that up to half of Medicare patients with advanced dementia who have feeding tubes inserted die within six months and that this intervention has no positive impact on function or pressure ulcers." He added, "Instead of inserting feeding tubes when people experience weight loss due to progression of dementia, we should be reconsidering goals of care with the family. For example, we should discuss the possibility of hospice and various palliative care interventions that might be appropriate." Dr. Smucker also stresses the benefits of involving family members in hand feeding the resident. "When patients are hand fed, they are getting some social interaction and some level of pleasure from the food," he said, adding, "Even when it's not enough to maintain optimum health, hand feeing is still compassionate. It's the caring thing to do, and it gives families some comfort in knowing that they are contributing to the care of their loved one." He hopes that the inclusion of this issue in the Choosing Wisely® campaign will encourage conversations about end-of-life care and comfort care, as well as put everyone — practitioners, caregivers, and patients alike — on the same page with the evidence.
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 insulin needs nor is it efficient in the long-term care (LTC) setting. Use of SSI leads to greater patient discomfort and increased nursing time because patients' blood glucose levels are usually monitored more frequently than may be necessary and more insulin injections may be given. With SSI regimens, patients may be at risk from prolonged periods of hyperglycemia. In addition, the risk of hypoglycemia is a significant concern because insulin may be administered without regard to meal intake. Basal insulin, or basal plus rapid-acting insulin with one or more meals (often called basal/bolus insulin therapy) most closely mimics normal physiologic insulin production and controls blood glucose more effectively.
"Sliding Scale Insulin [SSI] is overused. It basically treats elevated blood glucose after the fact, rather than preventing it. The clinical evidence shows that this is ill-advised for patients and is associated with very high and low glucose levels. Low glucose levels or frank hypoglycemia can result in problems such as falls, fall-related injuries, and hospitalizations," said Naushira Pandya, MD, CMD, a member of the Choosing Wisely® workgroup. "It also puts an incredible burden on patients, who must get insulin injections and have their fingers stuck several times a day. This can be painful and upsetting, especially for individuals with some level of cognitive impairment," she added. "Moreover, SSI is associated with wide glucose excursions, and could be replaced with small and often fewer doses of scheduled insulin." Dr. Pandya is pleased that this issue is included in the Choosing Wisely® campaign because "it will create a discussion point between practitioners, caregivers, patients, and families. This is important, she said, as "health care decision making increasingly is a team activity." The items in the Choosing Wisely® campaign include brief, concise points that practitioners can use to sit down with families to discuss care planning for their loved one, she noted. Dr. Pandya added that because these issued were identified by leading experts in the field and backed by clinical evidence and national standards, they carry with them a high level of credibility. "They create a level playing field for care, giving everyone the same information and rationale. This truly does enable patients, families, and practitioners to work together to choose treatments, interventions, and care wisely."
3. Don't obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract.
Clinical uncertainty surrounding asymptomatic bacteriuria (ASB) and/or pyuria is the major driver for overtreatment of Urinary Tract Infections (UTI) in PALTC, (Nace). Colonization (a positive bacterial culture without signs or symptoms of a localized UTI) is a common problem in PALTC facilities that contributes to the over-use of antibiotic therapy in this setting, leading to an increased risk of diarrhea or other adverse drug events, resistant organisms, and infection due to Clostridioides difficile. An additional concern is that the finding of asymptomatic bacteriuria 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 5 signs and symptoms likely indicative of uncomplicated cystitis. These include dysuria, and one or more of the following: frequency, urgency, supra-pubic pain or gross hematuria. In the presence of dysuria and one or more sign/symptom, collection of a urine culture is indicated.
4. Don't prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior.
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.
It is important to include this issue in the Choosing Wisely® campaign to stress the need to drill down and determine the root cause(s) of behaviors before prescribing medication, said Susan Levy, MD, CMD, a member of the Choosing Wisely® workgroup. It will also encourage regular review of antipsychotic use and dose reduction or discontinuation of these medications as appropriate. "There is a clear goal for the use of antipsychotics - and that involves addressing behaviors that present an immediate threat to the patient or others or that are causing the patient extreme distress. Clinical evidence does not support long-term use of these medications for BPSD. In fact, it shows that these medications can have a negative impact on patients and cause side effects such as akathisa (inability to sit still), tremor and muscle rigor, or acute dystonia (sudden muscular contractions)," she said. She added that it is essential to determine the root causes of BPSD—such as hunger, pain, boredom, or fear—and address those. This calls for practitioners, caregivers, and family members to work together and share information. The Choosing Wisely® campaign, she suggested, will help encourage such communication. "These kinds of partnerships are critical in the new world of medicine. We can have productive discussions around issues such as BPSD using Choosing Wisely® as a basis," Dr. Levy said. She added, "Consumers will appreciate the evidence and expert opinion that back the recommendations in Choosing Wisely®."
5. Don't routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.
There is no evidence that hypercholesterolemia, or low HDL-C, is an important risk factor for all-cause mortality, coronary heart disease mortality, hospitalization for myocardial infarction or unstable angina in persons older than 70 years. In fact, studies show that elderly patients with the lowest cholesterol have the highest mortality after adjusting other risk factors. In addition, a less favorable risk-benefit ratio may be seen for patients older than 85, where benefits may be more diminished and risks from statin drugs more increased (cognitive impairment, falls, neuropathy and muscle damage).
"It was important to include this item as the number of older adults placed on cholesterol lowering medications has increased significantly lately," said Hosam Kamel, MD, CMD, a member of the Choosing Wisely® workgroup. He added, "While it is true that increased cholesterol has been linked to increased risk of coronary artery disease and stroke, it is important to realize that these bad effects of cholesterol take years to develop." Published data does not support that prescribing cholesterol lowering drugs helps in the primary prevention of cardiovascular disease in older adults. On the other hand, there is data to support beneficial effects in terms of secondary prevention of cardiovascular disease. I personally do not check cholesterol levels in older adults who do not have a history of diabetes, stroke, or coronary artery disease, as there is no data to support that treating elevated cholesterol in such individuals is beneficial." Dr. Kamel observed that it also is important to note that these medications are not without side effects, particularly in the elderly. "There are risks of myopathy, hepatotoxicity, and cognitive impairment among others, not to mention to high cost of these medication and the laboratory tests needed to monitor for potential adverse events," he said. "I hope that the inclusion of this item in the Choosing Wisely® campaign will shed some light on this controversial issue and remind the providers that cholesterol lowering drugs should not be prescribed routinely in older adults and that risks versus benefits should be carefully evaluated when prescribing such medications to older adults."
The most common source of bacteremia in the post-acute and long-term care (PALTC) setting is the bladder when an indwelling urinary catheter is in use. 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. Although research evaluating the impact of screening for breast, colorectal and prostate cancer in older adults in general and LTC residents in particular is scant, available studies suggest that multimorbidity and advancing age significantly alter the risk-benefit ratio. 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 (prostrate cancer). Paitents with a life expectancy shorter than this lag time are less likely to benefit from screening. 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?"). Prostrate 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.
Rates of Clostridium difficile infection (CDI) have been increasing, especially among older adults who have recently been hospitalized or who reside in the PALTC setting. Patients residing in PALTC facilities are particularly at risk for CDI because of advanced age, frequent hospitalizations and frequent antibiotic exposure. Studies show that up to 57% of patients in the PALTC setting are asymptomatic carriers of C. difficile. Furthermore, studies have also shown that 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. To limit the spread of C. difficile, care providers in the PALTC setting should concentrate on early detection of symptomatic patients and consistently use proper infection control practices, including hand washing with soap and water.
9. Don’t recommend aggressive or hospital-level care for a frail elder 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, distubance of sleep, and loss of mobility and function. These risks are often more significant for patients in the PALTC setting, who are more likely to be frail and to have multimorbidity, functional limitations and dementia. Therefore, for some frail elders, 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, indications, and the balance of risks and benefits. Advance directives such as the Physician Orders for Life Sustaining Treatment (POLST) paradigm form and Do Not Hospitalize (DNH) orders communicate a patient's preference about end-of-life care. Patients with DNH orders are less likely to be hospitalized than those who do not have these directives, 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.
10. Don't initiate antihypertensive treatment in individuals =60 years of age for systolic blood pressure (SBP) <150 mm Hg or diastolic blood pressure (DBP) <90 mm Hg.
There is strong evidence for the treatment of hypertension in older adults. Achieving a goal SBP of 150mm Hg reduces stroke incidence, all-cause mortaility and heart failure. Target SBP and DBP levels should be set cautiously, however, as data do not suggest benefit in treating more aggressively to a goal SBP of <140 mm Hg in the general population =60 years of age. Furthermore, moderate- or high-intensity treatment of hypertension has been associated with an increased risk of serious fall injury in older adults.
11. Don’t continue hospital-prescribed stress ulcer prophylaxis with ProtonPump 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 known adverse events with long-term PPI use, including pneumonia, diminished vitamin absorption and bacterial infections such as Clostridium 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 continue sedative hypnotics (Restoril, Ambien), diphenhydramine (Benadryl), benzodiazepines, or Serotonin Modulators (Trazadone) for long-term treatment of insomnia in geriatric populations. Consider the use cognitive behavioral therapy as an alternative.
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.
Long-term use of opioids is common in the PALTC setting. The Society’s 2018 Position Statement on the use of opioids states that nursing home practitioners who prescribe opioids should do so based on thoughtful inter-professional assessment indicating a clear indication for opioid use. For admitted 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 with non-pharmacologic therapies and non-opioid medications. Periodic review to evaluate risk factors for potential harms should be incorporated into the individualized plan of care. In addition, clinicians should offer alternative behavioral therapies, non-opioid analgesics and other non-pharmacologic treatments whenever available and appropriate.
To view or print the full list, including sources, click here.
Utilizing the List:
AMDA encourages its members, other health care practitioners, patients, caregivers, advocates, and other health care stakeholders to use this list as a point of reference when discussing possible tests and procedures.
AMDA has partnered with Choosing Wisely to produce free resources for patients and families related to AMDA's Choosing Wisely recommendations .