The second set of recommendations for health professionals and families has been published this year on the American Geriatrics Society website, arguing the weight of evidence behind them*.
1. Do not prescribe acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine) for dementia without regular assessment of cognitive benefits and possible digestive side effects.
Clinicians, carers and patients must agree on and monitor cognitive, behavioural and functional goals. Educational aspects of dementia, dietary measures, promotion of exercise and appropriate environmental behavioural management should be ensured. It is suggested to review the beneficial effects and risks at 12 weeks.
2. Not to recommend screening for colorectal, breast or prostate cancer without considering life expectancy and risks of the test, overdiagnosis and overtreatment.
Prostate cancer requires 1055 screenings, with an NNT 37 to avoid one death in 11 years; colorectal or breast cancer requires 1000 screening patients to avoid one death in 10 years. Patients with a life expectancy of less than 10 years are exposed to immediate risks with little benefit.
3. Avoiding the use of appetite stimulants or hypercaloric supplements for the treatment of anorexia or cachexia in the elderly, social support, assistance with adequate nutrition and the definition of objectives and expectations of patients and their carers should be optimised.
Hypercaloric supplements and megestrol acetate increase weight in the elderly. There is no evidence that they improve results in quality of life, affective or functional state or survival. Megestrol acetate and cyproheptadine as appetite stimulants are listed as inappropriate drugs in the Beers 2012 criteria. Mirtazapine increases weight and appetite in patients being treated for depression.
4. Do not prescribe medication without first reviewing the prescribed treatment.
Polymedication increases the risk of side effects and inappropriate prescription, facilitating adherence problems, and increases the risk of falls, functional and cognitive impairment. Review of the active therapeutic regimen identifies high-risk medications, interactions, inappropriate drugs, as well as the need for specific therapies. The review must be at least annual, being an indicator of prescription quality.
5. Avoiding physical restraint measures for the management of behavioural symptoms in elderly patients with hospital delirium.
Delirium makes therapeutic management difficult, restriction measures have little evidence of effectiveness, with risk of generating injuries and mortality, increasing agitation. There are effective alternatives to prevent and treat it by identifying causes that generate discomfort, through environmental modifications, through an interdisciplinary team and with family support.
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/choosing_wisely2014
"There is no medicine that cures what does not cure happiness. “
Gabriel García Márquez (1927-2014)
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