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Authors

  1. Marshall, Katherine A. DNP, PMHCNS-BC, NP, CNE
  2. Hale, Deborah MSN, RN, ACNS-BC

Article Content

The Choosing Wisely program for geriatrics was developed by the American Board of Internal Medicine (ABIM) and The American Geriatrics Society (AGS) in 2013 to promote patient-centered care by encouraging patient-doctor relationships through improved communication, and to create an awareness of overutilization of medical resources in the care of older patients. The program focuses on educating consumers and promoting conversations between clinicians and their patients by providing talking points on specific and common treatments offered to older patients. Emphasis is placed on care that is evidence-based, free of harm, truly necessary, and nonduplicative of other tests and procedures already utilized (AGS, 2015).

 

According to the World Health Organization, the chronological age of geriatric or older persons in developed countries is consider to be 65 years of age and older (2016). Home care clinicians are treating and caring for patients who are 65 years of age and older with increasing frequency. As older people age and move closer to the end of life, many treatments become burdensome and even dangerous. For many older people, quality of life, rather than extension of life at all cost, may be their personal desired outcome. The Choosing Wisely talking points educate and support conversations between patients and clinicians around treatment options and quality of life. Home care clinicians are closely involved with both their patients and the treating physician. They have the opportunity to make a welcomed impact on patient care through education and support of the patient in the area of self-advocacy. It is important for patients and caregivers to question recommendations or treatment plans, as many patients tend to follow their physician's advice without asking important questions, even when they have questions.

 

The newly revised, 2015, Choosing Wisely recommendations for older adults (AGS, 2015) can be utilized by home healthcare clinicians for education purposes during patient encounters and are as follows:

 

* In lieu of recommending percutaneous feeding tubes for patients with advanced dementia, encourage oral assisted feeding. There are many social and emotional benefits to hand feeding dementia patients who are unable to feed themselves. Use of the feeding tube has been noted to cause agitation and an increase in pressure ulcers related to use of chemical and physical restraints. Home healthcare clinicians such as nurses, occupational therapists, and speech/language therapists can work with the patient and caregiver to create a pleasant environment, provide adaptive measures to promote nutritional intake and nurturing comfort measures while providing respect for the patients' wishes.

 

* Avoid the use of antipsychotics as the first choice when patients with dementia display behavioral and psychological symptoms. Home care clinicians are in an ideal position to provide primary interventions to manage dementia behaviors and educate caregivers on safety measures and dementia progression education. These timely, home-based interventions can limit, eliminate, or delay the use of antipsychotic medication.

 

* Avoid intensive glycemic control for most older patients (i.e., hemoglobin A1c <7.5%); and opt for moderate control. The AGS found that there was insufficient evidence to support tight glycemic control in older adults. Episodes of hypoglycemia placed older patients at greater risk for confusion and falls resulting in injury. Education on diet and exercise provided by home care clinicians can assist patients in better management of their blood glucose levels with decreased use of medications.

 

* Avoid benzodiazepines or other sedative-hypnotics for treatment of insomnia, agitation, or delirium when possible. Home care clinicians may intervene with nonpharmacological interventions to mediate symptoms of anxiety and insomnia by providing education and palliative strategies.

 

* It isn't always best to use antimicrobials to treat bacteriuria in older adults in the absence of specific urinary tract symptoms. Clinician provided education on urinary tract infection prevention; adequate hydration and bladder training can limit the need for treatment of urinary tract infections.

 

* Avoid use of cholinesterase inhibitors for dementia without assessing for cognitive benefits and gastrointestinal effects. Research on cholinesterase inhibitors supports only modest benefits in delaying functional and cognitive declines. Careful planning, caregiver education on dementia, and access to multiple resources such as home healthcare should be primary interventions in managing dementia.

 

* Consider life expectancy and risks before screening for breast, prostate, or colorectal cancer to avoid overdiagnosis and overtreatment. Older patients with less than a 10-year life expectancy may be exposed to more risk than benefits.

 

* There is little evidence to support the use of appetite stimulants in the medically ill and frail elderly, so avoid prescription appetite stimulants or high-calorie supplements. Instead optimize social supports, provide feeding assistance, and clarify patient goals and expectations. Home care clinicians may promote adequate hydration for comfort and education on dietary habits and multiple nutritious snacks to slow or abate weight loss.

 

* Older people use a disproportionate number of medications as compared with other populations and have an increased risk for side effects. Conduct drug reviews and medication reconciliation before prescribing medications that can be costly and may contribute to decreased adherence as the number of medications increases. Home care clinicians can offer education and reconciliation of medications to prevent side effects, duplications, and can monitor adherence in the patient's home.

 

* Injury and death can occur from the use of restraints in any patient, so avoid them when managing behavioral symptoms. Home healthcare clinicians can prevent and treat delirium related to infection and drug interactions/intoxication to prevent unnecessary hospitalizations.

 

 

The ABIM and AGS are careful to remind consumers that these talking points are not intended to substitute for medical consultation and treatment, rather they are to be used solely as an information source. Patients and families have the right to education and knowledge to make informed decisions about their healthcare. Home care clinicians can play a pivotal role in educating their patients and caregivers during home care encounters. Education should focus on providing information that promotes patient-centered care and self-advocacy. The Choosing Wisely recommendations can help patients and caregivers discuss their concerns with their providers and make choices that improve their quality of life and decrease unnecessary and burdensome treatments.

 

REFERENCES

 

American Geriatrics Society. (2015). Five things physicians and patients should question. In Choosing Wisely. Retrieved from http://www.choosingwisely.org/wp-content/uploads/2015/02/AGS-Choosing-Wisely-Lis[Context Link]

 

World Health Organization. (2016). Definition of older or elderly person. In Health Statics and Information Systems. Retrieved from http://www.who.int/healthinfo/survey/ageingdefnolder/en/