Choosing Wisely Campaign. Lynn McNicoll, MD Alpert Medical School of Brown University Division of Geriatrics and Palliative Medicine

Transcription

1 Choosing Wisely Campaign Lynn McNicoll, MD Alpert Medical School of Brown University Division of Geriatrics and Palliative Medicine

2 Disclosures None

3 Purpose of Campaign 5 items (tests, medications, procedures) that specialists in these fields (and patients seeing these patients) should avoid To Help Patients choose care that is: Supported by evidence-based decision making Not duplicative of tests or procedures already received Free from harm Truly necessary To Promote conversations between physicians and patients, NOT rationing of care

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5 JuRDkl8

6 Lists pfd will be sent via 58 specialty groups have contributed 51 patient education pamphlets Tube feeding in advanced dementia Provides brief recommendation, then rationale, then literature to support recommendation

7 Where we focus Geriatrics Part 1 Geriatrics Part 2 Palliative Medicine AMDA Post-Acute and LTC

8 Geriatrics Part 1 1. Don't recommend PEG tubes with advanced dementia, instead offer oral assisted feeding 2. Don't use antipsychotics as 1st choice for behvior/psych sx in dementia 3. Avoid use of medications to achieve A1C <7.5 in adults >65 4. Don't use benzo or other sedatives as 1st choice for insomnia, agitation, or delirium 5. Don't use ABX to tx bacteruria in older adults unless specific urinary sx

9 1. Peg tube in dementia Artificial nutrition does not prolong life or improve quality of life for advanced dementia PEGs often placed in hospital after concern for aspiration or malnutrition May cause restraints, PU, fluid overload, diarrhea, local complications, less human interaction and may increase aspiration risk Assistance with oral feeding is an evidence based approach to nutrition

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11 2. Antipsychotics for Dementia Tx should first include careful evaluation of causes of sx Only tx those who present imminent threat of harm to self or others or are in extreme distress Consider pain, constipation, environmental factors, too cold/warm, boredom If tx of potential causes is unsuccessful, then Antipsychotic may be consider Use igeriatrics as a tool

12 3. A1C No evidence that tight A1C control in elderly is beneficial using medications to get <7 may be associated with harm (including higher mortality) Hypoglycemia is more harmful than benefits of tight glu control Targets if healthy; with moderate comorbidity and life exp <10; and 8-9 with multi-morbidity and short life exp

13 4. Sleeping pills Risk of MVA, falls, hip fx, death doubles with sleeping pills Benzo reserved for alcohol withdrawal or GAD

14 5. ASB No adverse outcomes in pts with ASB Abx provide NO benefit and can cause s/e Must have urinary sx before screening Should screen for and tx if urological procedure is anticipated

15 Geriatrics Part 2 1. No ChEI for dementia without periodic assessment for benefit or adverse s/e 2. No breast/colon cancer/psa screening without considering life expectancy & risk of testing/overdx/overtx. 3. Avoid appetite stimulants or high calorie supplements for treatment of anorexia/cachexia - instead optimize social supports/assist with feeding/clarify GOC 4. Don't add meds without doing drug review 5. Avoid physical restraints for delirium

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17 1. ChEI for dementia Modest benefits in delaying cognition/function decline and dec neuropsych sx Little benefit in delay in N, QOL, & caregiver burden Always include discussion of risk/benefits, GOC, education about dementia/exs/diet/non-pharm approaches If no benefit after 12 weeks, consider D/C

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19 2. Cancer screening Assoc with short-term risks (complications from testing, overdx, overtx) esp with prostate ca Prostate CA need to be screened, 37 treated to avoid 1 death in 11 years Breast and colon cancer- need to screen 1000 pts to prevent 1 death in 10 years If life exp < 10 years, expose pt to risk with no benefit use eprognosis

20 3. Appetite Stimulants & Nutritional Supplements High cal suppl increase wt but there is no evidence that it improves outcomes (QOL, func, survival) Megace inc appetite/wt minimally and inc risk of DVT, fluid retention, death (1/12 will inc wt but 1/23 will die) on Beer's list No evidence for use of cannabinoids and anabolic steroids Remeron will inc wt and appetite with depression but no evidence if not depressed

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22 4. No meds without rx review Old people use lots of meds Polypharmacy decreases adherence, inc s/e, inc risk of cog imp, falls, func decline Med review identifies high risk meds, drug interactions, meds continued beyond need ANNUAL review of meds is indicated for all older persons

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24 5. Physical Restraints and Delirium Little evidence of benefit Can lead to serious injuries, worsen delirium/agitation Use non-pharmacological interventions from MD and RN See delirium talk Very last resort and d/c asap

25 Hospice & Palliative Medicine 1. Don't recommend PEG tubes in dementia 2. Don't delay PC because they are pursuing dx-directed therapy 3. Don't leave ICD activated if 'inconsistent' with pt/family goals 4. Don't recommend >1 XRT for uncomplicated painful bone mets 5. Don't use topical benzo/benadryl/haldol for nausea 25

26 2. Delaying PC Lots of evidence that PC improves pain/sx control, family satis, reduces cost PC does NOT accelerate death, and may even prolong life in select populations 26

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28 3. ICD 25% of pts with ICD, it fires within weeks of death For those with advanced irreversible ds, ICD firing does not prevent death, may be painful and distressing <10% hospices have policy about deactivation 28

29 4. XRT for bone mets single fraction radiation is just as effective as multiple-fraction regimens while more convenient > risk of needing retreatment (20% vs 8%) still less burdensome 29

30 5. Topical rx for nausea topical benzo/benadryl/haldol not proven effective in large PCRCT Active ingredients are not absorbed well, too erratic, no therapeutic levels, takes too long to work - therefore not appropriate for immediate relief of nausea to be used as needed Delays or prevents use of more effective interventions 30

31 AMDA Post-Acute and LTC 1. Don t insert PEG tube in individuals with advanced dementia. Instead offer oral assisted feedings 2. Don t use SSI for long-term diabetics in NH 3. Don t get urine culture unless clear S/S of UTI 4. Don t prescribe antipsychotics for behavior/psych in dementia without first assessing cause of behavior 5. Don t routinely rx lipid lowering drugs if limited life expectancy

32 2. SSI SSI is a reactive way to tx hyperglycemia SSI may be neither effective nor efficient SSI increase pt discomfort and increase nursing time because inc FBS and insulin injections Greater hyperglycemia and hypoglycemia Basal or basal/bolus therapy mimics physiological insulin and is more effective

33 3. UA and Urine cx Chronic Asx bacteriuria / colonization may be 50% in NHR Pos Cx in absence of UTI sx is useless May lead to over-use of ABX, leading to inc risk of diarrhea, resistant organisms, and c. diff May assume UTI as cause of delirium and not investigate other causes

34 5. Lipids with limited life expectancy No evidence that hyperchol or low HDL are RF for all-cause mortality, CAD mort, hosp for MI/USA in persons over 70 Low cholesterol can even increase risk Even worse for persons >85 with increased risk of s/e (cognitive impairment, falls, neuropathy, and muscle damage)