Long-Term Care and Questions about Prescription Drugs

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Your long-term care plans could include plans for managing prescription drugs. Given the well-known and serious risks of polypharmacy in older adults, it is not surprising that among the American Geriatric Society's “Five Things Physicians and Patients Should Question,” medications accounted for four of the five items.

This list is part of the “Choosing Wisely” Initiative of the American Board of Internal Medicine Foundation, in which various medical for specialties came up with their own list of common but questionable practices in their field.

Four of the five recommendations concerned medications, and the first is a common medical procedure:

  • Don't recommend percutaneous (tube) feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding. Tube feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers. Careful hand-feeding for people with severe dementia is at least as good as tube feeding in terms of the outcomes of death, aspiration pneumonia, functional status, and comfort.

    Tube feeding is a procedure that has emotional and ethical as well as medical implications; the AGS recommendation focuses on the medical risks and benefits. It is particularly important for nursing home practice where tube feeding is sometimes a method of convenience, not a medical or ethical choice.

  • Don't use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. These drugs provide limited benefit and can cause serious harm, including stroke and premature death. Identifying and addressing causes of behavior change can make drug treatment unnecessary.

  • Avoid using medications to achieve hemoglobin A1c >7.5% in most adults age 65 and older; moderate control is generally better. The A1C test, which has other names, is a common blood test used to diagnose type 1 and type 2 diabetes and then to gauge how well you're managing your diabetes. The A1C test result reflects your average blood sugar level for the past two to three months.

    Specifically, the A1C test measures what percentage of your hemoglobin — a protein in red blood cells that carries oxygen — is coated with sugar (glycated). Some studies have shown that efforts to reduce the A1c levels to less than 7 percent have resulted in higher mortality.

    Don't use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium. Large-scale studies have consistently shown rates of motor vehicle accidents, falls, and hip fractures leading to hospitalization and death can more than double in older adults taking these drugs. Their use should be limited to alcohol withdrawal or severe anxiety disorder unresponsive to other therapies.

  • Don't use antimicrobials to treat bacteriuria (the presence of bacteria in the urine) in older adults unless specific urinary tract symptoms are present. Urinary tract infection is diagnosed with specific clinical symptoms.

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