CHOOSING WISELY® TO IMPROVE CARE FOR GERIATRIC PATIENTS

About Choosing Wisely®

First conceived by the National Physicians Alliance

Funded by an ABIM Foundation grant

Created 3 lists of steps physicians could take to promote more effective use of healthcare resources

As much as 30% of care delivered in the US may be duplicative or unnecessary1

1http://www.nap.edu/catalog.php?record_id=13444

An initiative of the ABIM Foundation

Choosing Wisely® aims to promote conversations between physicians and patients by helping patients choose care that is:

Supported by evidence

Not duplicative of other tests or procedures already received

Free from harm

Truly necessary

The Choosing Wisely® Campaign

Leading specialty societies were asked to create a list of “Things Physicians and Patients Should Question”

To date, 56 societies have released lists, some of them releasing a second or third list

Consumer Reports has worked with the ABIM Foundation to maximize reach and impact of the Choosing Wisely® campaign

Engaged coalition of consumer organizations to disseminate content and messages about appropriate use to the communities they serve

AGS’ Final Five

• Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer assisted oral feeding. 1

• Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. 2

• Avoid using medications to achieve hemoglobin A1c <7.5% in most adults age 65 and older; moderate control is generally better. 3

• Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. 4

• Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. 5

AGS’ Final Five – List 2

• Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.

6

• Don’t recommend screening for breast or colorectal cancer, nor prostate cancer (with the PSA test) without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.

7

• Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance, and clarify patient goals and expectations.

8

• Don’t prescribe a medication without conducting a drug regimen review.

9

• Avoid physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.

10

Choosing Wisely®: Appetite Stimulants

•Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance, and clarify patient goals and expectations.

8

Anorexia – Cachexia syndrome (ACS)

ACS is a complex metabolic process experienced by upto 80% of patients suffering from advanced stages of cancer.

It is important in the palliation of cancer patients, not only because of its prevalence, but also because of its significant effect on patient morbidity and psychological distress.

Anorexia – Cachexia Syndrome

“Anorexia” is defined as the uncontrolled lack or loss of the appetite for food.

“Cachexia” is defined as “anorexia, involuntary weight loss, tissue wasting and poor performance”.

Frequent Causes of Weight Loss in the Long-Term Care Setting

Acquired immunodeficiency syndrome (AIDS)

Advanced dementia21

Cancer

Chronic infections or inflammatory conditions (e.g., AIDS, rheumatoid arthritis)

Chronic obstructive pulmonary disease

Depression

Uncontrolled diabetes

Hyperthyroidism

Malabsorption syndromes (e.g., pancreatic insufficiency, gluten enteropathy)

Oral disease (including poor dentition)

Parkinson’s disease

Polypharmacy (including anorexogenic medications)

Swallowing disorders

Therapeutic diets

Unintentional weight loss

Studies from 1980s report weight loss of approximately 0.1–0.2 kg (0.22–0.44 lb) per year after age 70 due to aging*

Involuntary loss greater than 4% of body weight is independent predictor of increased mortality

In US LTC settings, CMS expects that the emergence of an unplanned weight loss problem (5% change in 30 days or 10% change in 180 days) will trigger evaluation of a significant change in status**

* Hum Biol. 1988;60:917-925. ** CMS State Operations Manual, Appendix PP.

Unintentional weight loss

Unintentional weight loss is a common experience in old age

Annual incidence of approximately 13% in elderly veterans living in the community*

Prevalence estimates as high as 27% in high-risk free-living frail elderly receiving community services**

Incidence as high as 48% in older nursing home residents***

* J Am Geriatr Soc. 1995;43(4):329-337. ** Clin Geriatr. 2005;13(5):37-47. *** J Gerontol A Biol Sci Med Sci. 2004;59(6):M633-639.

Approach to ACS

Summary of pharmacological agents studied for ACS.

Role of EPA and DHA

EPA – Eicosapentaenoic Acid

DHA – Docosahexaenoic acid.

Both of these are anti –inflammatory poly unsaturated fatty acid (PUFA).

The study failed to provide strong evidence of EPA and DHA alone can be useful treatment modality for ACS. It seems evident that multi dimensional approach to ACS is likely the most useful method.

21st-century orexigenics

Controversial for a long time

More robust evidence base

Additional clinical study

Meaningful systematic reviews

Little or modest benefit

Risk-to-benefit profiles concerning

Megestrol acetate for treatment of anorexia – cachexia syndrome

The updated review shows that

MA improves appetite and has small effect on weight gain.

MA does not improve quality of life.

Side effects are more frequent in patients treated with MA.

MA is associated with increased risk of blood clots, fluid retention and death.

In patients who take MA, approx. 1 in 4 will have an increase in appetite, 1 in 12 will have increase in their weight and 1 in 23 will die.

Time to stop using megestrol acetate for unintentional weight loss

Clinical effect Clinical impact

MA improves appetite NNT = 4

MA has a small effect on weight gain NNT = 12

MA does NOT improve quality of life

MA increases VTE risk NNH = 2–55

MA increases risk of dying NNH = 23

Dronabinol

Orally active cannabinoid

FDA-approved for anorexia with weight loss in AIDS

Evidence for positive effects in patients with HIV/AIDS is limited and may be the effects of bias

Longer-term data, and data showing a benefit in terms of survival, are lacking

Not a very “geriatric-friendly” medication

Mirtazapine

Atypical antidepressant

Increased appetite and weight gain are side effects

17% increase in appetite and 10% increase in weight

Most weight gain takes place in the first 4–8 weeks

**J Amer Geriatr Soc. 2002;50:1461-1467. *Cochrane Database Syst Rev. 2011;12:CD006528.

No evidence of weight gain in absence of depression*

Weight gain not clearly superior compared with other antidepressants**

The fringe players

Cyproheptadine Makes the 2012 Beers Criteria List

Highly anticholinergic; greater risk of confusion, dry mouth, constipation, and other anticholinergic side effects

Little evidence that it actually works as an orexigenic

Eicosapentaenoic acid Little evidence that it works as an orexigenic

Not studied in elderly

Anabolic steroids Little evidence that they work in late life or advanced progressive illness

Not studied in the elderly

Oral liquid nutrition supplements

A multibillion-dollar expense to healthcare

Main ingredients

Water

Sucrose (sugar)

Corn syrup (more sugar)

Maltodextrin (less sweet sugar)

Few oils, proteins (whey and soy), multivitamin

Liquid candy bar with vitamins

Distraction from real food?

Oral liquid supplement vs real food

Boost Ensure Low-fat yogurt

and orange

Serving size 8 oz 8 oz 8 oz + 1 orange

Calories 240 250 206

Fiber 0 g < 1 g 3 g

1st two ingredients

Water Corn syrup solids

Water Corn syrup

Low-fat milk Milk solids

Cost (San Diego 1999) $1.40 $1.43 $1.09

Taste Best = 1 to Worst = 5

4 5 1

http://thedietchannel.com/scoopon.htm

Oral liquid supplements in geriatrics

In undernourished, short-term, hospitalized patients: Fewer complications: OR 0.72 (95% CI, 0.53–0.97)

Lower mortality: OR 0.66 (95% CI, 0.49–0.90)

Disappointing impact on other circumstances of unintentional weight loss

No clear impact on functional status, mood, or length of hospital stay

No evidence for supplementation at home or in well-nourished individuals

Generally suboptimal evidence base

Multi dimensional approach

Treat the underlying cause, address each identified risk factor and potential root cause.

Address issues that may affect the eating environment in the LTC setting.

Tailor meals and food to individual preference.

Reconsider any dietary restriction.

Consider ways to supplement patient’s diet.

Consider the use of appetite stimulants on an individual basis.

Multi dimensional approach

Evaluate the risks and benefits of artificially administered nutrition and hydration by tube feeding.

So…what’s a geriatrician to do?

Understand the patient

Clinical investigation as appropriate to goals and circumstances

Target investigation for reversible causes

Assess and address commonly missed problems:

Depression

Cognitive loss

Failing social supports

Review medications for “anorexigenic” drugs

What can be done?

Bolster feeding support in those experiencing increased dependency in eating

Eliminate dietary restrictions

Help make the mealtime environmental ambience more pleasant

Work with patients, surrogate decision-makers, caregivers, and loved ones to clarify treatment goals and expectations

sources

Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc. 2011;59:463–72. Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009Apr 15;2:CD003288. DOI: 10.1002/14651858.CD003288.pub3. Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Marti S. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev. 2013 Mar 28;3:CD004310. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616–31. Mazotta P, Jeney CM. Anorexia-cachexia syndrome: a systematic review of the role of dietary polyunsaturated fatty acids in the management of symptoms, survival, and quality of life. J Pain Symptom Manage. 2009;37:1069–77. Dewey A, Baughan C, Dean TP, Higgins B, Johnson I. Eicosapentaenoic acid (EPA, an omega-3 fatty acid from fish oils) for the treatment of cancer cachexia. Cochrane Database Syst Rev. 2007 Jan 24;1:CD004597. Reid J, Mills M, Cantwell M, Cardwell CR, Murray LJ, Donnelly M. Thalidomide for managing cancer cachexia. Cochrane Database of Systematic Reviews 2012 Apr 18;4:CD008664. Yavuzsen T, Davis MP, Walsh D, LeGrand S, Lagman R. Systematic review of the treatment of cancer-associated anorexia and weight loss. J Clin Oncol. 2005;23:8500–11. Watanabe N, Omori IM, Nakagawa A, Cipriani A, Barbui C, Churchill R, Furukawa TA. Mirtazapine versus other antidepressive agents for depression. Cochrane Database Syst Rev. 2011 Dec 7;12:CD006528. Fox CB, Treadway AK, Blaszczyk, Sleeper RB. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy. 2009;29(4):383–97.