November 1, 2014
Doctors who specialize in treating elderly patients have compiled a list of common medical practices that consumers should talk to their doctors about. Many of their recommendations may be especially relevant for people with Alzheimer’s disease and other forms of dementia.
The Choosing Wisely campaign, from the American Geriatrics Society, aims to encourage discussions between patients and doctors about common medical practices. Sometimes these drugs or procedures are needed, but in some cases they may not be, exposing the patients to unnecessary risks. Among the group’s recommendations to doctors are these.
1. Don’t prescribe Alzheimer’s drugs without performing regular check-ups to be sure they’re still doing some good.
Drugs such as Aricept, Exelon and Razadyne are commonly prescribed to patients in the earlier stages of Alzheimer’s. But many people with Alzheimer’s do not respond to them, and they do nothing to stop the downward progression of the disease. What’s more, the group notes, these drugs may carry adverse side effects, such as painful cramps and loss of appetite.
Therefore, the group recommends that doctors should not prescribe these Alzheimer’s drugs without also performing regular check-ups to assess whether the medicines are improving thinking and memory skills. If benefits from these drugs are not apparent within 12 weeks, the group recommends that doctors should stop prescribing them. And since benefits rarely last longer than a year, patients need regular checkups to see if they are still necessary, since at that point they may be causing more harm than good.
For more information, see the alzinfo.org story “Alzheimer’s Drugs Need Not Be Taken Long Term.”
2. Don’t use antipsychotic medications or sedatives as the first choice for treating agitation, aggression, delusions and other behavioral symptoms of dementia.
People with Alzheimer’s and other forms of dementia often show aggression, resistance to care and other challenging or disruptive behaviors that can make care difficult. In such cases, doctors often prescribe antipsychotic medicines or sedatives.
But, the group notes, such medications can cause serious harm. Antipsychotic medications are known to increase the risk for fatal heart attacks. And sedatives can cause disorientation and drowsiness that increases the risk for falls and broken hips. A promising alternative may be trying an SSRI-type anti-depressant, such as citalopram (Celexa).
Non-drug approaches to easing aggression and agitation should be tried before drugs are given, they say. In some cases, agitation may be caused by painful side effects of certain medications the person may be taking, or painful underlying medical conditions such as a dental abscess or constipation.
Therefore, it’s critical that doctors carefully assess the overall health of the patients, and whether drugs are really essential. Use of these drugs, they say, should be limited to cases in which non-drug approaches to care have failed or when patients are an imminent threat to themselves or others.
3. Avoid using appetite-stimulating drugs or high-calorie food supplements to elderly patients who are having trouble eating.
Unintended weight loss is a common problem in elderly patients, including those with dementia. Though high-calorie foods like Ensure or appetite enhancing drugs can lead to weight gain and help in some cases, they have not been proven to improve quality of life, mood or survival.
People with dementia should get a medical check-up to look for health problems that may be leading to loss of appetite. Other measures, like using brightly colored plates and utensils at mealtimes, can also make it easier for people with Alzheimer’s to see their meals and feed themselves.
4. Avoid unnecessary screening tests for illnesses like colon or breast cancer.
Many elderly patients with dementia undergo screening tests for diseases like breast, colon or prostate cancer, despite having no symptoms. Procedures like mammography or colonoscopy can be uncomfortable and especially upsetting to someone with dementia.
Many of these tests are unnecessary and not recommended in elderly patients, who are unlikely to benefit from them. In such cases, the side effects of the procedures are thought to be much more risky than any benefits they might provide. Discuss with your doctor whether such tests are really necessary.
5. Avoid using restraints or tying down patients who are exhibiting agitation and delirium.
Physical restraints, like tying the hands or feet to chairs or the side of a bed to prevent thrashing or punching, can do more harm than good and may only increase agitation and aggressiveness. They may be particularly counterproductive in a patient with dementia.
While use of restraints has long been discouraged in nursing homes, they are still commonly used in hospitals, where patients often become agitated and disoriented. Behavioral approaches and caregiving support that optimize patient dignity and comfort without jeopardizing safety can often calm an agitated patient.
6. Don’t prescribe a new drug without looking at what the person is already taking.
One in five seniors takes 10 or more prescribed medications. But these drugs can cause dangerous interactions and side effects that may worsen problems with thinking and memory, produce personality changes or lead to life-threatening falls.
Therefore, it’s important to review all the medicines someone is taking before prescribing a new one. Such a review can uncover potentially harmful medications that may no longer be needed, call attention to the need for new medicines, or help doctors to adjust dosages of existing medications so that they are safer and more effective.
For more on learning about medical tests, drugs and procedures that may do more harm than good, visit the Choosing Wisely web site at www.choosingwisely.org .
Source: AGS Choosing Widely Workgroup: “American Geriatrics Society Identifies Another Five Things That Healthcare Providers and Patients Should Question.” The Journal of the American Geriatrics Society. Feb. 27, 2014.