Choosing Wisely Long Term Care Uniquely Canadian Family Medicine Forum, Montreal November 11, 2017 Session ID S460 Room 512 ABEF
Conflict of interest Dr. Fred Mather Waterloo Ontario Amgen Dr. Serge Gingras Montreal, Quebec None
Choosing Wisely Long Term Care Six Recommendations Released on January 18, 2017
Long Term Care is an Evidence-free Zone patients within long term care are unique. The combination of a relatively short life expectancy; a paucity of evidence; Increased medication burden, administrative pressure, and medical complexity
Avoidable Transfer to Hospital Uncertain benefit and may increase morbidity 47% of hospitalizations from LTC considered avoidable Delirium Hospital acquired infections Lack of sleep Loss of muscle mass when bedridden
Avoidable Transfer to Hospital A clear understanding of the patient s goals must be established taking into account current health status, values and preferences. This will reduce the likelihood of inappropriate transfer CWC - LTC
Avoidable Transfer to Hospital A clear understanding of the patient s goals must be established taking into account current health status, values and preferences. This will reduce the likelihood of inappropriate transfer CWC - LTC
Recommendation #2 Don t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia (BPSD) Recommendation #3 Don t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI)
http://www.dobugsneeddrugs.org/wp-content/uploads/uti-checklist.pdf
Recommendation #4 Don t insert a feeding tube in individuals with advanced dementia. Instead assist the resident to eat. Recommendation #5 Don t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient
Guidance for Prescribing in Frail Adults https://www.americangeriatrics.org/files/documents/beers/ PrintableBeersPocketCard.pdf
Polypharmacy: Guidance for Prescribing in Frail Adults Wales National Health Service Guidelines http://www.wales.nhs.uk/sites3/documents/814/prescribingforfrailadults -ABHBpracticalGuidance%5BMay2013%5D.pdf
Recommendation 6 of 10 Don t Routinely prescribe lipid lowering medications in individuals with 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).
Recommendation #6 Don t order screening of routine chronic testing just because a blood draw is being done. http://www.choosingwiselycanada.org/recommendations/long-termcare/ http://www.choosingwisely.org/wp-content/uploads/2015/02/amda- Choosing-Wisely-List.pdf
Screening and Monitoring OMA Section for Long Term Care and Care of the Elderly May 5, 2017
Screening 1. To screen (5). 2. Examination of a group of usually asymptomatic people to detect those with a high probability of having a given disease, typically by means of an inexpensive diagnostic test. 3. In the mental health professions, initial patient evaluation that includes medical and psychiatric history, mental status evaluation, and diagnostic formulation to determine the patient's suitability for a particular treatment modality.
Monitoring 1. Performance and analysis of routine measurements aimed at detecting a change in the environment or health status of a population. 2. Ongoing measurement of performance of a health service. 3. Continuous oversight of implementation of an activity.
Test Screening Interval Comment Complete blood count (CBC) Yes Annual More often in anemia Glucose, A1C Yes Six months If person Is not diabetic Creatinine Yes Annual 3 6 months in kidney disease Electrolytes Yes Annual Depends on disease and meds Albumin Yes Nutritional assessment Chest x-ray Yes Admission TB screening
Test Screenin Interval Comment g Chest x-ray Yes Admission TB screening Urinalysis No Many false positives Urine for C&S No Asymptomatic bacteriuria Lipids No Uric acid No Used to monitor gout B12 No Often done Vitamin D No TSH No 6 12 mon in thyroid disease Ferritin No Magnesium, No calcium ECG No Necessary to monitor QTc Abdominal ultrasound No