Choosing Wisely: Medical Recommendations for Patients Over 65

Jennifer Yttri, PhD
August 2013

 

As we get older, our health needs change.  Unfortunately, some patients and doctors keep doing the same tests and treatments year after year.  As a result, many tests are over-used, adding to the cost for patients and even possibly harming them. What is beneficial for one person isn’t worth the risks for another.

The best health decisions can be made when physicians take the time to talk with their patients and patients ask questions rather than just assuming the doctor always knows best.

Consumer Reports and the ABIM Foundation are working with medical specialty societies to create lists of “5 Things Physicians and Patients Should Question” as part of a national campaign called Choosing Wisely (www.choosingwisely.org). These medical groups represent more than 500,000 physicians. The lists are recommendations made by experts based on scientific evidence. Here is the list of their recommendations on medical treatment and testing for people over 65.

 

Antibiotics

Not all bacteria are bad for you. Elderly patients should not use antibiotics to get rid of bacteria detected in urine unless they are experiencing symptoms of a urinary tract infection. The antibiotics can cause more harm than the bacteria.

Medications for patients with dementia

Antipsychotic medications (such as Abilify, Seroquel, Zyprexa, Geodone, Risperdal, and Haldol) should not be used to treat behavioral symptoms of dementia or Alzheimer’s disease. Antipsychotics do not treat the cause of these diseases and can cause very serious complications, including stroke or death.

Enlarged Prostate or benign prostatic hyperplasia (BPH)

As men age, it’s common for their prostate to become enlarged, a condition called benign prostatic hyperplasia or BPH. Usually BPH does not cause problems until men are near age 60.  If patients are having problems urinating with limited or no other symptoms, only the standard prostate exam is recommended. Other tests are not recommended because having problems urinating is unlikely to cause other health problems. If symptoms change, follow-up tests, such as ultrasound, biopsy, or cystoscopy, may be useful for changing treatment.

Cervical cancer screening and Pap smears

Women over 65 should stop being screened for cervical cancer if they have not previously shown risk for disease. This includes Pap smears.

Chest X-rays before surgery

Patients without signs or symptoms of heart or lung disease do not need a chest x-ray before surgery. Chest x-rays are not costly but they do expose patients to a small amount of radiation and can lead to expensive follow-up tests if a problem is detected. Chest x-rays are recommended before surgery for patients over 70.

Colonoscopy

Screening colonoscopies are recommended every 10 years following a normal result in low-risk adults starting at age 50. Colonoscopies are very good at detecting small, low-risk polyps (less than 1 cm) that grow slowly. More frequent screening is not recommended because colonoscopies and polyp removal are expensive and risky. Colonoscopies should be repeated no more than once every 5 years for monitoring patients who have had larger polyps that were previously removed. Routine checks are not needed after age 75.

Dementia and Alzheimer’s disease

Memory loss is a natural consequence of aging. Memory loss alone, however, is not a reason to get tested for dementia or Alzheimer’s. A PET scan takes an image of the brain looking for plaques that are associated with Alzheimer’s. However, imaging is not recommended for evaluating dementia or reasons for memory loss. Plaques on a PET image do not mean you have Alzheimer’s and lack of plaques does not mean you won’t develop it in the future. Instead, have a doctor who specializes in dementia and Alzheimer’s give you a medical evaluation first.

Dialysis

The choice to start dialysis can be a difficult one. Long term dialysis is very unpleasant and may not improve survival or quality of life for older adults. Patients, families, and physicians should spend time discussing whether long term dialysis makes sense given a patient’s age, overall health, and life expectancy.

Feeding patients who have dementia

Using a feeding tube can cause distress to patients. If feeding tubes don’t work, this can cause ulcers or may require use of physical and pharmacological restraints that add to patients’ distress. Instead, patients with dementia should have someone help feed them, which makes sure they get nutrients and provides positive human interaction.

Implantable cardioverter-defibrillator (ICD)

ICDs are small, battery-powered defibrillators, similar to pacemakers, used in patients with irregular heartbeats. However, there are no guidelines for deactivating ICDs. Defibrillation can be unpleasant and there is no reason to continue their use if a patient is dying because it will not benefit the patient. It is recommended that ICDs be deactivated when patients no longer want this medical care.

Osteoporosis

DEXA (dual energy x-ray absorption) is an expensive bone-density screening test. While DEXA can detect osteoporosis, many people will be put on osteoporosis drugs without needing them. Osteoporosis drugs have risks and are unlikely to benefit most patients who have only mild bone loss. DEXA is not recommended for women under 65 or men under 70 unless they have a history of risk factors for weak bones. Healthy men (over 70) and women (over 65) can be screened every 10 years as long as risk factors do not change.

Rheumatoid Arthritis (RA)

MRI is not recommended for diagnosing or monitoring RA.  While there are cases where an MRI may provide more information than other methods of assessment, it is not cost-effective in comparison to physical exams, lab tests, and x-rays, and therefore is not recommended as general practice. After a diagnosis, it is recommended that RA be treated with methotrexate or other conventional non-biologic antirheumatic drugs for at least 3 months before considering biologic drugs. Biologics may be better options for patients with aggressive disease and poor prognosis.

Sedatives in elderly

Sedatives like benzodiazepines should not be used to treat insomnia, agitation, or delirium, especially in the elderly as they are least likely to benefit from such treatment. Instead, sedatives may increase elderly patients’ high risk for accidents, falls and hip-fractures, which can result in hospitalization and possibly death.  Sedatives should only be given to patients with alcohol withdrawal or anxiety disorders who do not respond to behavioral or psychological therapy.

Type-2 diabetes

Medications that treat diabetes by controlling blood glucose levels are only effective at lowering risk of death and artery clots after long-term use. The dose of medication prescribed for patients depends on how much is needed to maintain a specific level of glucose in the blood. For adult patients that are relatively healthy and have a long life expectancy, using medication for strong glycemic control may be worthwhile. However, as patients age (over 65) and develop other illnesses, patients are unlikely to benefit from strict control of blood sugar and are at high risk of complications from hypoglycemia.