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AMDA’s List Of Inadvisable Interventions Cheat Sheet by

nursing     medical     healthcare     ltc     treatments     inadvisable

Introd­uction - Choose Wisely

AMDA encourages its members, other health care practi­tio­ners, patients, caregi­vers, advocates, and other health care stakeh­olders to use this list as a point of reference when discussing possible tests and proced­ures.

For complete descri­ption and refere­nces, visit the AMDA website links below.

List

■ Don’t insert percut­aneous feeding tubes in indivi­duals with advanced dementia. Instead, offer oral assisted feeding.

Strong evidence exists that artificial nutrition doesn’t prolong life or improve quality of life in patients with advanced dementia. Substa­ntial functional decline and recurrent progre­ssive medical illnesses may indicate that a patient who isn’t eating is unlikely to get a signif­icant or long-term benefit from artificial nutrition.

■ Don’t use sliding scale insulin (SSI) for long-term diabetes management for indivi­duals residing in the nursing home. SSI is a reactive way of treating hyperg­lycemia after it has occurred rather than preventing it. Good evidence exists that SSI isn’t effective in meeting the body’s insulin needs or efficient in the long term care setting.

■ Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract. Chronic asympt­omatic bacter­iuria is common in this care setting, with prevalence as high as 50 percent. A positive urine culture in the absence of localized urinary tract infection symptoms such as dysuria, frequency, or urgency is of limited value in identi­fying whether a patient’s symptoms are caused by a urinary tract infection (UTI).

Coloni­zation is a common problem in long term care facilities and contri­butes to the overuse of antibiotic therapy in this setting, leading to an increased risk of diarrhea, resistant organisms, and C. difficile infection.

■ Don’t prescribe antips­ychotic medica­tions for behavioral and psycho­logical symptoms of dementia in indivi­duals with dementia without an assessment for an underlying cause of the behavior. Careful differ­ent­iation of symptom causes may help better define approp­riate treatment options. The therap­eutic goal of antips­ychotic use is to treat patients who present an imminent threat of harm to self or others or who are in extreme distre­ss—not to treat nonspe­cific agitation or other forms of lesser distress.

■ Don’t routinely prescribe lipid-­low­ering medica­tions in indivi­duals with a limited life expect­ancy. There is no evidence that hyperc­hol­est­ero­lemia, or low HDL-C, is an important risk factor for all-cause mortality, coronary heart disease mortality, or hospit­ali­zation for myocardial infarction or unstable angina in persons older than 70 years.

In fact, studies show that elderly patients with the lowest choles­terol have the highest mortality after adjusting other risk factors.

In addition, a less favorable risk-b­enefit ratio may be seen for patients older than 85, where benefits may be more diminished and risks from statin drugs increased.
 

Conitnued

■ Don’t place an indwelling urinary catheter to manage urinary incont­inence. The most common source of bacteremia in the post-acute and long term care setting is the bladder when an indwelling urinary catheter is in use.

The federal Health Care Infection Control Practices Advisory Committee recommends minimizing urinary catheter use and duration of use in all patients, as well as not using a catheter to manage urinary incont­inence in this setting.

■ Don’t recommend screening for breast, colore­ctal, or prostate cancer if life expectancy is estimated to be less than 10 years. Although research evaluating the impact of screening for breast, colore­ctal, and prostate cancer in older adults in general and long term care residents in particular is scant, available studies suggest that multim­orb­idity and advancing age signif­icantly alter the risk-b­enefit ratio.

Preventive cancer screenings have both immediate and longer term risks (proce­dural and psycho­logical risks, false positives, identi­fic­ation of cancer that may be clinically insign­ifi­cant, treatm­ent­-re­lated morbidity, and mortal­ity).

Benefits of cancer screening occur only after a lag time of 10 years or more. Patients with a life expectancy shorter than this lag time are less likely to benefit from screening.

■ Don’t obtain a C. difficile toxin test to confirm “cure” if symptoms have resolved. Studies show that up to 57 percent of patients in the long term/p­ost­-acute care setting are asympt­omatic carriers of C. difficile and that C. diff tests may remain positive for as long as 30 days after symptoms have resolved. False positive “test-­of-­cure” specimens may complicate clinical care and result in additional courses of inappr­opriate treatment.

■ Don’t recommend aggressive or hospit­al-­level care for a frail elder without a clear unders­tanding of the indivi­dual’s goal of care and the possible benefits and burdens.

To avoid unnece­ssary hospit­ali­zat­ions, care providers should engage in advance care planning by defining goals of care for the patient and discussing the risks and benefits of various interv­ent­ions, including hospit­ali­zation, in the context of prognosis, prefer­ences, indica­tions, and the balance of risks and benefits.

■ Don’t initiate antihy­per­tensive treatment in indivi­duals >60 years of age for systolic blood pressure (SBP) <150 mmHg or diastolic blood pressure (DBP) <90 mmHg. There is strong evidence for the treatment of hypert­ension in older adults.

Achieving a goal SBP of 150 mmHg reduces stroke incidence, all-cause mortality, and heart failure. Target SBP and DBP levels should be set cautio­usly, however, as data do not suggest a benefit in treating more aggres­sively to a goal SBP of <140 mmHg in the general population ≥60 years of age.

Furthe­rmore, moderate- or high-i­nte­nsity treatment of hypert­ension has been associated with an increased risk of serious fall injury in older adults.

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