Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.
Transfers to hospital for assessment and treatment of a change in condition have become customary. However, they are often of uncertain benefit, and may result in increased morbidity. In one Canadian study, 47% of hospitalizations were considered avoidable, while a recent US study found 39% to be ‘potentially avoidable’. Transfer often results in long periods in an unfamiliar and stressful environment for the patient. Other hazards include delirium, hospital acquired infections, medication side effects, lack of sleep, and rapid loss of muscle strength while bedridden. Harms often outweigh benefits. Residents assessed and treated at their care home will receive more individualized care, better comfort and end of life care. If a transfer is unavoidable, give clear prior instructions to the hospital of the patient’s needs. Respect for patient choice is a fundamental consideration in all decisions to transfer to a 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. These goals should be discussed earlier and often with the patient and family, including whether comfort, function and quality of life are their most important goals.
Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia.
People with dementia can sometimes be disruptive, behaving aggressively and resisting personal care. There is often a reason for the behaviour (pain, for example) and identifying and addressing the causes can make drug treatment unnecessary. When drug treatment is chosen, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including premature death. These medications should be limited to cases where non-drug measures have already been tried and failed and the patients are a threat to themselves or others. When an antipsychotic has been prescribed, frequent review and attempts at reduction or discontinuation must be done to reduce harm.
Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).
Unless there are UTI symptoms such as urinary discomfort, abdominal/back pain, frequency, urgency or fever, testing should not be done. Testing often shows bacteria in the urine, with as many as 50% of those tested showing bacteria present in the absence of localizing symptoms to the genitourinary tract. Over-testing and treating asymptomatic bacteriuria with antibiotics leads to increased risk of diarrhea and infection with Clostridium difficile. Overuse of antibiotics contributes to increasing antibiotic-resistant organisms.
Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat.
Inserting a feeding tube does not prolong or improve quality of life in patients with advanced dementia. If the resident has been declining in health with recurrent and progressive illnesses, they may be nearing the end of their life and will not benefit from feeding tube placement. Feeding tubes are often placed because of fears that patients may aspirate food or become malnourished. Studies show that tube feeding does not make the patient more comfortable or reduce suffering. Tube feeding may cause fluid overload, diarrhea, abdominal pain and discomfort/injury (from the tube itself). A tube can actually increase the risk of aspiration and aspiration pneumonia. Helping people eat, rather than tube feeding, is a better way to feed patients who have advanced dementia and feeding difficulties.
Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient.
Long-term medications should be discontinued if they are no longer needed (e.g., heartburn drugs, antihypertensives) as they can reduce the resident’s quality of life while having little value for a frail elder with limited life expectancy (e.g., statins, osteoporosis drugs). Prescribing medications to meet lab test “targets” that apply to adults living in the community (e.g., blood sugar, blood pressure) may instead have dangerous effects on mobility, function, mortality and quality of life when applied to a frail elder in care.
Don’t order screening or routine chronic disease testing just because a blood draw is being done.
Unless you are sure treatment can be given that would add to quality of life, don’t do these tests. “Routine” testing may lead to harmful over-treatment in frail residents nearing the end of their life and lead to misusing healthcare resources that would do more good used wisely.
How the list was created
The Long Term Care Medical Directors Association of Canada (LTCMDAC) established its Top 6 recommendations under the leadership of their Director. LTCMDAC members were invited to participate in the list development by email. Two physician volunteers came forward to join the Director and form the Choosing Wisely Canada working group. To represent the patient voice, an articulate patient leader and Patients for Patient Safety Canada “champion” joined the working group. The American Medical Directors Association and Canadian Geriatric Society lists were reviewed as a starting point. None of these lists was specific to the frail elderly in residential care. The process aimed for recommendations that were valid and relevant for Canadian patients and our health care system. By small group discussion amongst the working group, the 6 recommendations were proposed. The document was then circulated to the members of the Board of the LTCMDAC for feedback and approval.
Walker JD, Teare GF, Hogan DB, et al. Identifying potentially avoidable hospital admissions from Canadian long-term care facilities. Med Care. 2009 Feb;47(2):250-4. PMID: 19169127.
Walsh EG, Wiener JM, Haber S, et al. Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs. J Am Geriatr Soc. 2012 May;60(5):821-9. PMID: 22458363.
Brodaty H, Arasaratnam C. Meta-analysis of nonpharmacological interventions for neuropsychiatric symptoms of dementia. Am J Psychiatry. 2012 Sep;169(9):946-53. PMID: 22952073.
Schneider LS, Dagerman K, Insel PS. Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry. 2006 Mar;14(3):191-210. PMID: 16505124.
Seitz DP, Brisbin S, Herrmann N, et al. Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: a systematic review. J Am Med Dir Assoc. 2012 Jul;13(6):503-506.e2. PMID: 22342481.
High KP, Bradley SF, Gravenstein S, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jan 15;48(2):149-71. PMID: 19072244.
Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54. PMID: 15714408.
Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012 Oct;33(10):965-77. PMID: 22961014.
Hanson LC, Ersek M, Gilliam R, et al. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc. 2011 Mar;59(3):463-72. PMID: 21391936.
Palecek EJ, Teno JM, Casarett DJ, et al. Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010 Mar;58(3):580-4. PMID: 20398123.
Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209. PMID: 19370678.
Sorrell JM. Use of feeding tubes in patients with advanced dementia: are we doing harm? J Psychosoc Nurs Ment Health Serv. 2010 May;48(5):15-8. PMID: 20415291.
Teno JM, Gozalo PL, Mitchell SL, et al. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc. 2012 Oct;60(10):1918-21. PMID: 23002947.
Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008 May 1;358(18):1887-98. PMID: 18378519.
Dalleur O, Spinewine A, Henrard S, et al. Inappropriate prescribing and related hospital admissions in frail older persons according to the STOPP and START criteria. Drugs Aging. 2012 Oct;29(10):829-37. PMID: 23044639.
James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. PMID: 24352797.
Muntner P, Bowling CB, Shimbo D. Systolic blood pressure goals to reduce cardiovascular disease among older adults. Am J Med Sci. 2014 Aug;348(2):129-34. PMID: 24978394.
Tinetti ME, Han L, Lee DS, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014 Apr;174(4):588-95. PMID: 24567036.
American Medical Directors Association (AMDA). Health maintenance in the long term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2012.
Clarfield AM. Screening in frail older people: an ounce of prevention or a pound of trouble? J Am Geriatr Soc. 2010 Oct;58(10):2016-21. PMID: 20929471.
Gill TM. The central role of prognosis in clinical decision making. JAMA. 2012 Jan 11;307(2):199-200. PMID: 22235093.
Gross CP. Cancer screening in older persons: a new age of wonder. JAMA Intern Med. 2014 Oct;174(10):1565-7. PMID: 25133660.
Moyer VA; U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Jul 17;157(2):120-34. PMID: 22801674.
Royce TJ, Hendrix LH, Stokes WA, et al. Cancer screening rates in individuals with different life expectancies. JAMA Intern Med. 2014 Oct;174(10):1558-65. PMID: 25133746.
van Hees F, Habbema JD, Meester RG, et al. Should colorectal cancer screening be considered in elderly persons without previous screening? A cost-effectiveness analysis. Ann Intern Med. 2014 Jun 3;160(11):750-9. PMID: 24887616.