- Email: [email protected]
Choosing Wisely revisited: Finally the support we have been waiting for in geriatrics
Geriatric Nursing 36 (2015) 91e94
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
From the Editor
Barbara Resnick, PhD, CRNP, FAAN, FAANP
Choosing Wisely revisited: Finally the support we have been waiting for in geriatrics I know I shared with you in an editorial in 2013 information about the Choosing Wisely campaign and the fact that nurses were not part of the initial development of the Choosing Wisely campaign or any of the lists. I encouraged nurses, however, to participate in dissemination of this information.1 Well. since that time we have come a long way in terms of our involvement in this campaign. The American Academy of Nursing (AAN) recently submitted a list of 5 Choosing Wisely items to consider as did our nonphysician colleagues in physical therapy, the American Physical Therapy Association (APTA). If you have not reviewed these Choosing Wisely lists, and the other lists (totaling 40 now), I strongly encourage you to do so. Many of the lists are very relevant to older adults. To make it easy for you though I have provided the lists from AAN and APTA as well as the two lists from the American Geriatrics Society (Table 1) as these are what I believe in geriatric nursing we have been waiting for! The support to do what is best for older patients or residents and their families. I strongly encourage you all to review these lists and utilize these recommendations in your care of older adults, in your teaching and in your research endeavors. I personally am not seeing them consistently carried over into real world settings. The Work of the American Academy of Nursing First kudos to the American Academy of Nursing (AAN) for developing and submitting this list and for having it accepted into the Choosing Wisely Campaign. In addition, kudos to the group for focusing four out of their five wishes on issues and care related to older adults. Wow! The one other item on the list for the AAN was focused on neonates. I was particularly struck by the encouragement to get older adults up and walking when hospitalized. We know it, we know it, we know it yet . it simply is not happening in the way and at the rate it should. Fear that harm may befall a patient during the transfer, let alone during ambulation, fear of untethering an individual from an intravenous line, pulse oximetry 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.02.007
or continuous cardiac monitoring or resistance on the part of the patient to get up is stopping this critically important intervention from happening. Say NO to the fear and do what is best and right for the patient. Work with your physical therapy colleagues to safely perform a transfer. You may only see these patients for a day in the acute care setting but show you care by considering their long-term recovery and get them up, walk them to the bathroom . even when it seems hard for you both. The other nursing recommendations seem so obvious and logical and yet again these are not done. Specifically, the additional recommendations encourage nurses to: . not use physical restraints with an older hospitalized patient; not wake the patient for routine care unless the patient’s condition or care specifically requires it; and not place or maintain a urinary catheter in a patient unless there is a specific indication to do so. Unfortunately, acute care particularly continues to focus on the convenience of the caregivers versus being person centered. Quick fixes such as rehydrating individuals with intravenous fluids versus oral rehydration (in individuals who with time, love and patience can drink!) still occurs even if it means restraining arms in the process. I encourage you all to fight back and recommend alternative options. Engage families in rehydration, every nurse, physician, administrator, therapist or transportation staff to help out. Each of these individuals can be taught how to safely help an older adult drink. Likewise, fight back when the surgical team wants to do rounds on the patients at 7 am, especially in the winter months when it is barely getting light out! Block the doors of those patients who are asleep and need to remain so! I would add to this list, let them EAT and drink when under your care. Given what we know about sarcopenia in aging it is particularly critical that these individuals eat approximately 30 g of protein with each meal to avoid excessive muscle loss.2 To meet the recommendation associated with use of urinary catheters, I encourage you to review the recently developed and released Streamlined Evidence-Based RN
92
From the Editor / Geriatric Nursing 36 (2015) 91e94
Table 1 Choosing Wisely recommendations from American Academy of Nursing; American Physical Therapist Association; and the American Geriatrics Association. Nursing: American Academy of Nursing Don’t let older adults lay in bed or only get up to a chair during their hospital stay.
Don’t use physical restraints with an older hospitalized patient
Don’t wake the patient for routine care unless the patient’s condition or care specifically requires it
Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so
American Physical Therapy Association Don’t recommend bed rest following diagnosis of acute deep vein thrombosis (DVT) after the initiation of anti-coagulation therapy, unless significant medical concerns are present Don’t use continuous passive motion machines for the post-operative management of patients following uncomplicated total knee replacement
Don’t use whirlpools for wound management
American Geriatrics Society Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding
Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia
Up to 65% of older adults who are independent in their ability to walk will lose their ability to walk during a hospital stay. Walking during the hospital stay is critical for maintaining functional ability in older adults. Loss of walking independence increases the length of hospital stay, the need for rehabilitation services, new nursing home placement, risk for falls both during and after discharge from the hospital, places higher demands on caregivers and increases the risk of death for older adults. Bed rest or limited walking (only sitting up in a chair) during a hospital stay causes deconditioning and is one of the primary factors for loss of walking independence in hospitalized older adults. Older adults who walk during their hospital stay are able to walk farther by discharge, are discharged from the hospital sooner, have improvement in their ability to independently perform basic activities of daily living, and have a faster recovery rate after surgery Restraints cause more problems than they solve, including serious complications and even death. Physical restraints are most often applied when behavioral expressions of distress and/or a change in medical status occur. These situations require immediate assessment and attention, not restraint. Safe, quality care without restraints can be achieved when multidisciplinary teams and/or geriatric nurse experts help staff anticipate, identify and address problems; family members or other caregivers are consulted about the patient’s usual routine, behavior and care; systematic observation and assessment measures and early discontinuation of invasive treatment devices are implemented; staff are educated about restraints and the organizational culture and structure support restraint-free care Studies show sleep deprivation negatively affects breathing, circulation, immune status, hormonal function and metabolism. Sleep deprivation also impacts the ability to perform physical activities and can lead to delirium, depression and other psychiatric impairments. Multiple environmental factors affect a hospitalized person’s ability for normal sleep. Factors include noise, patient care activities and patient-related factors such as pain, medication and co-existing health conditions Catheter-associated urinary tract infections (CAUTIs) are among the most common health care-associated infections in the United States. Most CAUTIs are related to urinary catheters so the infections can largely be prevented by reduced use of indwelling urinary catheters and catheter removal as soon as possible. CAUTIs are responsible for an increase in U.S. health care costs and can lead to more serious complications in hospitalized patients Given the clinical benefits and lack of evidence indicating harmful effects of ambulation and activity both are recommended following achievement of anticoagulation goals unless there are overriding medical indications. Patients can be harmed by prolonged bed rest that is not medically necessary Continuous passive motion (CPM) treatment does not lead to clinically important effects on short- or long-term knee extension, long-term knee flexion, long-term function, pain and quality of life in patients undergoing total knee arthroplasty (TKA). With rehabilitation protocols now supporting early mobilization, the use of CPM following uncomplicated total knee arthroplasty should be questioned unless medical and/or surgical complication exist that limit or contraindicate rehabilitation protocols that foster early mobilization. The cost, inconvenience and risk of prolonged bed rest with CPM should be weighed carefully against its limited benefit. As members of interprofessional teams involved in post-operative rehabilitation of patient following total knee replacement, physical therapists have a responsibility to advocate for effective alternatives to CPM for most patients Whirlpools are a non-selective form of mechanical debridement. Utilizing whirlpools to treat wounds predisposes the patient to risks of bacterial crosscontamination, damage to fragile tissue from high turbine forces and complications in extremity edema when arms and legs are treated in a dependent position in warm water. Other more selective forms of hydrotherapy should be utilized, such as directed wound irrigation or a pulsed lavage with suction Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Food is the preferred nutrient. Tube-feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke and premature death. Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary (continued on next page)
From the Editor / Geriatric Nursing 36 (2015) 91e94
93
Table 1 (continued ) Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better
Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium
Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present
Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects
Don’t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment
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
Don’t prescribe a medication without conducting a drug regimen review
There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0e7.5% in healthy older adults with long life expectancy, 7.5e8.0% in those with moderate comorbidity and a life expectancy <10 years, and 8.0e9.0% in those with multiple morbidities and shorter life expectancy Large scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated In randomized controlled trials, some patients with mild-to-moderate and moderate-to-severe Alzheimer’s disease (AD) achieve modest benefits in delaying cognitive and functional decline and decreasing neuropsychiatric symptoms. The impact of cholinesterase inhibitors on institutionalization, quality of life and caregiver burden are less well established. Clinicians, caregivers and patients should discuss cognitive, functional and behavioral goals of treatment prior to beginning a trial of cholinesterase inhibitors. Advance care planning, patient and caregiver education about dementia, diet and exercise and non-pharmacologic approaches to behavioral issues are integral to the care of patients with dementia, and should be included in the treatment plan in addition to any consideration of a trial of cholinesterase inhibitors. If goals of treatment are not attained after a reasonable trial (e.g., 12 weeks), then consider discontinuing the medication. Benefits beyond a year have not been investigated and the risks and benefits of long-term therapy have not been well-established Cancer screening is associated with short-term risks, including complications from testing, overdiagnosis and treatment of tumors that would not have led to symptoms. For prostate cancer, 1055 men would need to be screened and 37 would need to be treated to avoid one death in 11 years. For breast and colorectal cancer, 1000 patients would need to be screened to prevent one death in 10 years. For patients with a life expectancy under 10 years, screening for these three cancers exposes them to immediate harms with little chance of benefit Unintentional weight loss is a common problem for medically ill or frail elderly. 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. Use of megestrol acetate results in minimal improvements in appetite and weight gain, no improvement in quality of life or survival, and increased risk of thrombotic events, fluid retention and death. In patients who take megestrol acetate, one in 12 will have an increase in weight and one in 23 will die. The 2012 AGS Beers criteria lists megestrol acetate and cyproheptadine as medications to avoid in older adults. Systematic reviews of cannabinoids, dietary polyunsaturated fatty acids (DHA and EPA), thalidomide and anabolic steroids, have not identified adequate evidence for the efficacy and safety of these agents for weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat depression, but there is little evidence to support its use to promote appetite and weight gain in the absence of depression Older patients disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Polypharmacy may lead to diminished adherence, adverse drug reactions and increased risk of cognitive impairment, falls and functional decline. Medication review identifies high-risk medications, drug interactions and those continued beyond their indication. Additionally, medication review elucidates unnecessary medications and underuse of medications, and may reduce medication burden. Annual review of medications is an indicator for quality prescribing in vulnerable elderly (continued on next page)
94
From the Editor / Geriatric Nursing 36 (2015) 91e94
Table 1 (continued ) Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium
Persons with delirium may display behaviors that risk injury or interference with treatment. There is little evidence to support the effectiveness of physical restraints in these situations. 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. Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraintfree approach to patients with delirium. This approach includes continuous observation; trying re-orientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions are occasionally utilized after evaluation by a medical provider at the bedside, if a patient presents harm to him or herself or others. Physical restraints should only be used as a very last resort and should be discontinued at the earliest possible time
Tool: Catheter Associated Urinary Tract Infection (CAUTI) Prevention3 available on the American Nurses Association website. I found the recommendations from the American Physical Therapy Association to be just as exciting as those in nursing. Finally there are clear recommendations for NOT forcing patients/ residents into beds when they are diagnosed with a deep vein thrombosis. As an advanced practice nurse in long-term care I find that nurses and therapists often want to restrict activity among residents with a newly diagnosed deep vein thrombosis. With regard to the recommendations around use of continuous passive motion for individuals post joint replacement or recommendations related to wound care treatments, nurses now can question orders that contradict these proposed and evidence based physical therapy recommendations. Don’t forget to utilize and disseminate the 10 items on the lists from the American Geriatric Society. These include such things as avoiding tube feedings, benzodiazepines or antipsychotics when working with older adults. Lastly, please go online and thank the American Board of Internal Medicine Foundation for revising the webpage and guidelines to be inclusive of all providers. I hope we in
nursing can lead the way in disseminating the Choosing Wisely information and implementing it into clinical practice, teaching and research. References 1. Resnick B, Fick D. The Choosing WiselyÒ campaign and nurses role in dissemination. Geriatr Nurs. 2013;34(3):179e180. 2. Symons TB, Sheffield-Moore M, Wolfe RR, Paddon-Jones D. A moderate serving of high-quality protein maximally stimulates skeletal muscle protein synthesis in young and elderly subjects. J Am Diet Assoc. 2009;109(9):1582e1586. 3. Available at the American Nurses Association CAUTI website: http:// nursingworld.org/ANA-CAUTI-Prevention-Tool. Accessed 01/15.
Barbara Resnick, PhD, CRNP, FAAN, FAANP School of Nursing University of Maryland 655 West Lombard Street Baltimore, MD 21201, USA E-mail address: [email protected]
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
From the Editor
Barbara Resnick, PhD, CRNP, FAAN, FAANP
Choosing Wisely revisited: Finally the support we have been waiting for in geriatrics I know I shared with you in an editorial in 2013 information about the Choosing Wisely campaign and the fact that nurses were not part of the initial development of the Choosing Wisely campaign or any of the lists. I encouraged nurses, however, to participate in dissemination of this information.1 Well. since that time we have come a long way in terms of our involvement in this campaign. The American Academy of Nursing (AAN) recently submitted a list of 5 Choosing Wisely items to consider as did our nonphysician colleagues in physical therapy, the American Physical Therapy Association (APTA). If you have not reviewed these Choosing Wisely lists, and the other lists (totaling 40 now), I strongly encourage you to do so. Many of the lists are very relevant to older adults. To make it easy for you though I have provided the lists from AAN and APTA as well as the two lists from the American Geriatrics Society (Table 1) as these are what I believe in geriatric nursing we have been waiting for! The support to do what is best for older patients or residents and their families. I strongly encourage you all to review these lists and utilize these recommendations in your care of older adults, in your teaching and in your research endeavors. I personally am not seeing them consistently carried over into real world settings. The Work of the American Academy of Nursing First kudos to the American Academy of Nursing (AAN) for developing and submitting this list and for having it accepted into the Choosing Wisely Campaign. In addition, kudos to the group for focusing four out of their five wishes on issues and care related to older adults. Wow! The one other item on the list for the AAN was focused on neonates. I was particularly struck by the encouragement to get older adults up and walking when hospitalized. We know it, we know it, we know it yet . it simply is not happening in the way and at the rate it should. Fear that harm may befall a patient during the transfer, let alone during ambulation, fear of untethering an individual from an intravenous line, pulse oximetry 0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2015.02.007
or continuous cardiac monitoring or resistance on the part of the patient to get up is stopping this critically important intervention from happening. Say NO to the fear and do what is best and right for the patient. Work with your physical therapy colleagues to safely perform a transfer. You may only see these patients for a day in the acute care setting but show you care by considering their long-term recovery and get them up, walk them to the bathroom . even when it seems hard for you both. The other nursing recommendations seem so obvious and logical and yet again these are not done. Specifically, the additional recommendations encourage nurses to: . not use physical restraints with an older hospitalized patient; not wake the patient for routine care unless the patient’s condition or care specifically requires it; and not place or maintain a urinary catheter in a patient unless there is a specific indication to do so. Unfortunately, acute care particularly continues to focus on the convenience of the caregivers versus being person centered. Quick fixes such as rehydrating individuals with intravenous fluids versus oral rehydration (in individuals who with time, love and patience can drink!) still occurs even if it means restraining arms in the process. I encourage you all to fight back and recommend alternative options. Engage families in rehydration, every nurse, physician, administrator, therapist or transportation staff to help out. Each of these individuals can be taught how to safely help an older adult drink. Likewise, fight back when the surgical team wants to do rounds on the patients at 7 am, especially in the winter months when it is barely getting light out! Block the doors of those patients who are asleep and need to remain so! I would add to this list, let them EAT and drink when under your care. Given what we know about sarcopenia in aging it is particularly critical that these individuals eat approximately 30 g of protein with each meal to avoid excessive muscle loss.2 To meet the recommendation associated with use of urinary catheters, I encourage you to review the recently developed and released Streamlined Evidence-Based RN
92
From the Editor / Geriatric Nursing 36 (2015) 91e94
Table 1 Choosing Wisely recommendations from American Academy of Nursing; American Physical Therapist Association; and the American Geriatrics Association. Nursing: American Academy of Nursing Don’t let older adults lay in bed or only get up to a chair during their hospital stay.
Don’t use physical restraints with an older hospitalized patient
Don’t wake the patient for routine care unless the patient’s condition or care specifically requires it
Don’t place or maintain a urinary catheter in a patient unless there is a specific indication to do so
American Physical Therapy Association Don’t recommend bed rest following diagnosis of acute deep vein thrombosis (DVT) after the initiation of anti-coagulation therapy, unless significant medical concerns are present Don’t use continuous passive motion machines for the post-operative management of patients following uncomplicated total knee replacement
Don’t use whirlpools for wound management
American Geriatrics Society Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding
Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia
Up to 65% of older adults who are independent in their ability to walk will lose their ability to walk during a hospital stay. Walking during the hospital stay is critical for maintaining functional ability in older adults. Loss of walking independence increases the length of hospital stay, the need for rehabilitation services, new nursing home placement, risk for falls both during and after discharge from the hospital, places higher demands on caregivers and increases the risk of death for older adults. Bed rest or limited walking (only sitting up in a chair) during a hospital stay causes deconditioning and is one of the primary factors for loss of walking independence in hospitalized older adults. Older adults who walk during their hospital stay are able to walk farther by discharge, are discharged from the hospital sooner, have improvement in their ability to independently perform basic activities of daily living, and have a faster recovery rate after surgery Restraints cause more problems than they solve, including serious complications and even death. Physical restraints are most often applied when behavioral expressions of distress and/or a change in medical status occur. These situations require immediate assessment and attention, not restraint. Safe, quality care without restraints can be achieved when multidisciplinary teams and/or geriatric nurse experts help staff anticipate, identify and address problems; family members or other caregivers are consulted about the patient’s usual routine, behavior and care; systematic observation and assessment measures and early discontinuation of invasive treatment devices are implemented; staff are educated about restraints and the organizational culture and structure support restraint-free care Studies show sleep deprivation negatively affects breathing, circulation, immune status, hormonal function and metabolism. Sleep deprivation also impacts the ability to perform physical activities and can lead to delirium, depression and other psychiatric impairments. Multiple environmental factors affect a hospitalized person’s ability for normal sleep. Factors include noise, patient care activities and patient-related factors such as pain, medication and co-existing health conditions Catheter-associated urinary tract infections (CAUTIs) are among the most common health care-associated infections in the United States. Most CAUTIs are related to urinary catheters so the infections can largely be prevented by reduced use of indwelling urinary catheters and catheter removal as soon as possible. CAUTIs are responsible for an increase in U.S. health care costs and can lead to more serious complications in hospitalized patients Given the clinical benefits and lack of evidence indicating harmful effects of ambulation and activity both are recommended following achievement of anticoagulation goals unless there are overriding medical indications. Patients can be harmed by prolonged bed rest that is not medically necessary Continuous passive motion (CPM) treatment does not lead to clinically important effects on short- or long-term knee extension, long-term knee flexion, long-term function, pain and quality of life in patients undergoing total knee arthroplasty (TKA). With rehabilitation protocols now supporting early mobilization, the use of CPM following uncomplicated total knee arthroplasty should be questioned unless medical and/or surgical complication exist that limit or contraindicate rehabilitation protocols that foster early mobilization. The cost, inconvenience and risk of prolonged bed rest with CPM should be weighed carefully against its limited benefit. As members of interprofessional teams involved in post-operative rehabilitation of patient following total knee replacement, physical therapists have a responsibility to advocate for effective alternatives to CPM for most patients Whirlpools are a non-selective form of mechanical debridement. Utilizing whirlpools to treat wounds predisposes the patient to risks of bacterial crosscontamination, damage to fragile tissue from high turbine forces and complications in extremity edema when arms and legs are treated in a dependent position in warm water. Other more selective forms of hydrotherapy should be utilized, such as directed wound irrigation or a pulsed lavage with suction Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Food is the preferred nutrient. Tube-feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including stroke and premature death. Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary (continued on next page)
From the Editor / Geriatric Nursing 36 (2015) 91e94
93
Table 1 (continued ) Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better
Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium
Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present
Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects
Don’t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment
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
Don’t prescribe a medication without conducting a drug regimen review
There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among non-older adults, except for long-term reductions in myocardial infarction and mortality with metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0e7.5% in healthy older adults with long life expectancy, 7.5e8.0% in those with moderate comorbidity and a life expectancy <10 years, and 8.0e9.0% in those with multiple morbidities and shorter life expectancy Large scale studies consistently show that the risk of motor vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to other therapies Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated In randomized controlled trials, some patients with mild-to-moderate and moderate-to-severe Alzheimer’s disease (AD) achieve modest benefits in delaying cognitive and functional decline and decreasing neuropsychiatric symptoms. The impact of cholinesterase inhibitors on institutionalization, quality of life and caregiver burden are less well established. Clinicians, caregivers and patients should discuss cognitive, functional and behavioral goals of treatment prior to beginning a trial of cholinesterase inhibitors. Advance care planning, patient and caregiver education about dementia, diet and exercise and non-pharmacologic approaches to behavioral issues are integral to the care of patients with dementia, and should be included in the treatment plan in addition to any consideration of a trial of cholinesterase inhibitors. If goals of treatment are not attained after a reasonable trial (e.g., 12 weeks), then consider discontinuing the medication. Benefits beyond a year have not been investigated and the risks and benefits of long-term therapy have not been well-established Cancer screening is associated with short-term risks, including complications from testing, overdiagnosis and treatment of tumors that would not have led to symptoms. For prostate cancer, 1055 men would need to be screened and 37 would need to be treated to avoid one death in 11 years. For breast and colorectal cancer, 1000 patients would need to be screened to prevent one death in 10 years. For patients with a life expectancy under 10 years, screening for these three cancers exposes them to immediate harms with little chance of benefit Unintentional weight loss is a common problem for medically ill or frail elderly. 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. Use of megestrol acetate results in minimal improvements in appetite and weight gain, no improvement in quality of life or survival, and increased risk of thrombotic events, fluid retention and death. In patients who take megestrol acetate, one in 12 will have an increase in weight and one in 23 will die. The 2012 AGS Beers criteria lists megestrol acetate and cyproheptadine as medications to avoid in older adults. Systematic reviews of cannabinoids, dietary polyunsaturated fatty acids (DHA and EPA), thalidomide and anabolic steroids, have not identified adequate evidence for the efficacy and safety of these agents for weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat depression, but there is little evidence to support its use to promote appetite and weight gain in the absence of depression Older patients disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Polypharmacy may lead to diminished adherence, adverse drug reactions and increased risk of cognitive impairment, falls and functional decline. Medication review identifies high-risk medications, drug interactions and those continued beyond their indication. Additionally, medication review elucidates unnecessary medications and underuse of medications, and may reduce medication burden. Annual review of medications is an indicator for quality prescribing in vulnerable elderly (continued on next page)
94
From the Editor / Geriatric Nursing 36 (2015) 91e94
Table 1 (continued ) Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium
Persons with delirium may display behaviors that risk injury or interference with treatment. There is little evidence to support the effectiveness of physical restraints in these situations. 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. Nursing educational initiatives and innovative models of practice have been shown to be effective in implementing a restraintfree approach to patients with delirium. This approach includes continuous observation; trying re-orientation once, and if not effective, not continuing; observing behavior to obtain clues about patients’ needs; discontinuing and/or hiding unnecessary medical monitoring devices or IVs; and avoiding short-term memory questions to limit patient agitation. Pharmacological interventions are occasionally utilized after evaluation by a medical provider at the bedside, if a patient presents harm to him or herself or others. Physical restraints should only be used as a very last resort and should be discontinued at the earliest possible time
Tool: Catheter Associated Urinary Tract Infection (CAUTI) Prevention3 available on the American Nurses Association website. I found the recommendations from the American Physical Therapy Association to be just as exciting as those in nursing. Finally there are clear recommendations for NOT forcing patients/ residents into beds when they are diagnosed with a deep vein thrombosis. As an advanced practice nurse in long-term care I find that nurses and therapists often want to restrict activity among residents with a newly diagnosed deep vein thrombosis. With regard to the recommendations around use of continuous passive motion for individuals post joint replacement or recommendations related to wound care treatments, nurses now can question orders that contradict these proposed and evidence based physical therapy recommendations. Don’t forget to utilize and disseminate the 10 items on the lists from the American Geriatric Society. These include such things as avoiding tube feedings, benzodiazepines or antipsychotics when working with older adults. Lastly, please go online and thank the American Board of Internal Medicine Foundation for revising the webpage and guidelines to be inclusive of all providers. I hope we in
nursing can lead the way in disseminating the Choosing Wisely information and implementing it into clinical practice, teaching and research. References 1. Resnick B, Fick D. The Choosing WiselyÒ campaign and nurses role in dissemination. Geriatr Nurs. 2013;34(3):179e180. 2. Symons TB, Sheffield-Moore M, Wolfe RR, Paddon-Jones D. A moderate serving of high-quality protein maximally stimulates skeletal muscle protein synthesis in young and elderly subjects. J Am Diet Assoc. 2009;109(9):1582e1586. 3. Available at the American Nurses Association CAUTI website: http:// nursingworld.org/ANA-CAUTI-Prevention-Tool. Accessed 01/15.
Barbara Resnick, PhD, CRNP, FAAN, FAANP School of Nursing University of Maryland 655 West Lombard Street Baltimore, MD 21201, USA E-mail address: [email protected]