It tells you something about American health care that scores of medical societies have joined a major campaign aimed at telling patients and doctors what not to do.
That's not exactly the language the Choosing Wisely initiative uses, admittedly. It has recruited more than 60 groups, representing specialties from dermatology to thoracic surgery, to come up with lists delicately called "Five Things Physicians and Patients Should Question."
"Question" sounds better than "flee," doesn't it? And it allows for individual differences in a way that a campaign called "Danger: Unacceptable Side Effects Ahead," or "Watch Out: Useless Procedures," might not.
Still, Choosing Wisely wants to help us select drugs and tests and procedures that are backed by evidence, that don't duplicate other treatments, that are "truly necessary" and won't hurt us. Since 2012, its lists have included hundreds of drugs, tests and practices that fail to meet those standards, with more to come. Point made.
We reported the American Geriatrics Society's first "Five Things" list last year. The society has just published its second list, so I again turned to Dr. Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the panel that developed both lists, to help explain what else older adults should be dodg — um, questioning. (You can see all 10 items here.)
Topping this year's list is a caution against dementia drugs called cholinesterase inhibitors — Arricept is the most widely used — without following up to see whether they're really helping. Dementia is so feared, and the eventual prognosis so grim, that doctors and patients want to do something, anything, to stop its progress.
But while the drug may produce cognitive improvement that is statistically significant in a clinical trial, "it's not clear that it's big enough for a caregiver to even notice, or big enough to make a difference in a patient's quality of life," Dr. Lee said. "We're learning, after more experience with these drugs, that they benefit a minority of patients."
On the other side of the equation, most patients who take them will experience gastrointestinal problems like nausea, cramping and diarrhea that often cause weight loss. So the society urges extensive discussion before doctors prescribe cholinesterase inhibitors and suggests no more than a three-month trial. If there's no meaningful improvement by then, there won't be later. "This is not a medication to start and then forget about," Dr. Lee cautioned.
Grouped second on the list are several tests we've often written about: mammograms for breast cancer, colon cancer screenings and P.S.A. tests for prostate cancer. Older people who are already frail or coping with several chronic diseases, and have life expectancies of less than 10 years, are not likely to benefit from finding such cancers — but they will face the short-term risks of complications and overtreatment from screening. "It may not make sense to expose them to these harms," Dr. Lee said.
Next to avoid: appetite stimulants in cases of weight loss, including high-calorie supplements like Boost and Ensure, or prescription drugs like megestrol acetate (brand name Megace) or the antidepressant Remeron. "The evidence that they actually improve outcomes is very, very thin," Dr. Lee said.
For the few patients who have trouble swallowing because they have head and neck cancer or esophageal cancer, these drugs or supplements may make sense. But in general, they may add a couple of pounds without improving survival or quality of life, because they don't address the underlying reasons for weight loss.
"Sometimes, families think patients are dying because they're losing weight," Dr. Lee said. "I tell them, they're losing weight because they're dying of something else." There's no evidence that adding calories, increasing fat but not muscle mass, will help them recover. And the drugs have side effects; the hormone-based Megace increases the risk of blood clots, for instance.
The geriatrics society's list also warns doctors not to prescribe new medications without reviewing the drugs that older patients are already taking, since so many can interact in harmful ways.
"In a busy practice, it's hard to look at everything someone is on, every time you prescribe a new drug," Dr. Lee acknowledged. Older adults can be taking a dozen drugs daily. But at the least, the panel said, doctors should review all medications annually.
Finally, the list concludes by cautioning against the use of restraints — tying down hands or legs, using vests or mitts, keeping people in beds with rails or in reclining chairs they can't climb out of. Federal regulations already largely prohibit restraints in nursing homes, but they're still widely used in hospitals, especially in intensive care units, where older patients frequently develop delirium.
But when agitated patients are in restraints, "they generally get more agitated," Dr. Lee said. And when forced to remain in bed, "they can lose strength and muscle mass very quickly. Instead of restraints, we should be thinking about keeping them as active as possible." Family members or "sitters" who can help them walk safely would help, along with tested anti-delirium strategies.
You can read fuller explanations of the list in the current issue of The Journal of the American Geriatrics Society.
Overall, Dr. Lee said, these aren't things that should never happen. "They're things that may be appropriate rarely but are being done frequently," he said, "things that are commonplace and should be much, much less common."
Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."
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