CHOOSING WISELY (1st part)

The first 5 recommendations are as follows*:

1. Do not recommend percutaneous feeding tubes in patients with advanced dementia, offering oral assisted feeding.

Adapted oral feeding is similar to percutaneous artificial feeding in patients with advanced dementia, in outcomes such as aspiration pneumonia, functional status, comfort and mortality. Feeding is the preferred nutrient. Percutaneous feeding is associated with agitation, increased use of physical and chemical restrictions, worsening pressure ulcers.

2. Do not use antipsychotics as the first choice for treatment of behavioural and psychological symptoms of dementia.

Agitation, resistance to care or other behavioural disorders are common in patients with dementia. Neuroleptics are frequently prescribed, offering limited benefits and may produce relevant side effects such as cerebrovascular disease or premature mortality. They should be used in cases where non-pharmacological behavioural measures are not sufficient, or if there is a risk to the safety of the patient or his/her environment.

3. Avoiding pharmacological strategies to achieve HbA1C <7.5% in people over 65 years of age with diabetes, moderate metabolic control is better.

Strict control of HbA1C increases the risk of hypoglycaemia and even mortality rates. It takes a long time (more than 5 years) to achieve benefits in preventing microangiopathic complications (nephro or diabetic retinopathy). Care objectives must take into consideration variables such as functional status, comorbidities and life expectancy. Thus, if life expectancy is greater than 10 years, an HbA1C of 7-7.5% can be targeted in the presence of moderate comorbidities and life expectancy under 10 years of 7.5-8%, and in the case of multiple comorbidities and short life expectancy of 8-9%.

4. Do not use benzodiazepines or sedative-hypnotics in the elderly as a first line treatment for insomnia, agitation or delirium.

The risk of traffic accidents, falls and fractures is doubled in elderly people treated with sedatives. Patients and their carers should be aware of the risks when introducing it in such cases. It is indicated in generalised anxiety disorders or in alcohol withdrawal.

5. Do not use antibiotics for the treatment of bacteriuria in the elderly without the presence of a urinary clinic.

Treatment of asymptomatic bacteriuria (AB) shows no benefit and increases the risk of side effects and antibiotic resistance. Criteria have been developed to define a urinary tract infection in the presence of a positive urine culture. Treatment is only recommended prior to urological procedures where bleeding of the urothelial mucosa will occur.

http://www.americangeriatrics.org/files/documents/Five_Things_Physicians_and_Patients_Should_Question.pdf