The American Geriatrics Society put out a list of 10 things physicians and their patients should question.
I think that this is a important list of things that need to be talked about in regard to every older adult (over 65 years old) with dementia by that patient and/or their families.
The original list can be found by using this link - Choosing Wisely.
I am going to translate doctor talk for us “regular” people, and yes, offer a few of my own opinions.
Remember, opinions are just that- not fact!
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By Carole Larkin Alzheimer's Reading Room
- Don’t put in feeding tubes (directly into the stomach) in people with advanced dementia. Instead let them try to eat through the mouth with assistance. (Opinion) Feeding tubes do more harm than good. It doesn’t lengthen life much and they can still take the food into their lungs (aspirate) and suffocate to death.
- Don't use anti psychotics (examples: Risperdal, Abilify, Seroquel, Zyprexa and Geodone) right away when someone is agitated, combative, violent or just non compliant. Use behavioral techniques first. (Opinion) I couldn’t agree more. Many times they do more harm than good. We are such a pill popping society. I wish doctors wouldn’t just reach for the prescription pad first thing. Teaching family members techniques how to handle the behavior should occur first. Only when that fails should doctors reach for the prescription pad.
- Stop trying to achieve the perfect number in type two diabetic sugar controls. Loosen up! Consider projected life expectancy. If the person has other life shortening illnesses. (and many do!) Just use Metformin and let it go at that. (Opinion) I don’t have one! I know the intricacies of dementia, not diabetes.
- Don’t use benzodiazepines (examples: Xanax, Klonopin, Librium, Valium and Ativan) right away when someone is agitated or is up at night. Use behavioral techniques first. (Opinion) I couldn’t agree more. Many times they do more harm than good. We are such a pill popping society. I wish doctors wouldn’t just reach for the prescription pad first thing. Teaching family members techniques how to handle the behavior should occur first. Only when that fails should doctors reach for the prescription pad.
- Don't automatically prescribe antibiotics unless you have the results of a test indicating the need for a specific type of antibiotic for a person with dementia who has a UTI (urinary tract infection). (Opinion) I agree. If it’s not the right antibiotic, you are just causing the person to have the infection longer, allowing it to get worse, and wasting their money.
- Don’t prescribe cholinesterase inhibitors (examples: Aricept, Excelon and Namenda) without checking to see if there are side effects for the first few months. Also don’t prescribe them forever. Check to see if cognitive benefits from them still exist. (Opinion) Far too many people with late stage dementia (not walking or talking) are still taking these drugs. It’s a waste of money. There isn’t enough healthy brain matter left to have the medicines do any good.
- Don’t screen for breast, colorectal, prostate or lung cancer without taking into account how long the person is expected to live and the risks of treatment for it. (Opinion) I’ve got a problem with this one. I think this more has to do with pressure from health insurance companies, and maybe even Medicare to reduce spending than it has to do with the person’s health. I think the time for deciding whether to do something or not is at time for treatment, not at time for screening, I do recognize their point about false positives though. How about using more accurate screening tools though?
- Avoid using appetite stimulants or high calorie supplements (Ensure and Boost) for a person losing weight due to having dementia. Instead discontinue medications that interfere with eating, provide appealing food and encouragement to eat at meals or feeding assistance if needed. (Opinion). I think families and professionals will totally ignore this advice. They want to do something, anything, to prevent their person from starving (the thought taken to its logical end). These doctors say there is no evidence that using these things leads to an improvement in quality of life for the person with dementia. I think quality of life is not the issue being addressed by the families here, its length of life.
- Don’t prescribe a drug without checking it’s interactions with the other drugs the person is taking. (Opinion) Can I get an AMEN to that? The question is: do physicians have the time and the knowledge to do that during a patient visit? I submit, for the most part they neither have the time nor the knowledge of the details of side effects and interactions of the thousands of drugs out there in the marketplace. What could be the answer? Maybe handing the task off to another individual, either a nurse or other professional in their office, or perhaps to the pharmacist who will fill the prescription. As for the time issue? Perhaps asking Medicare for higher reimbursement to physicians so that they can see fewer patients per hour.
- Don't use physical restraints on people with delirium who are in the hospital as the first line of action. Educating nurses and other hospital personnel in behavioral and environmental approaches (like removing unnecessary monitoring devices) to calming the person down has been shown to work, so try those first. Then chemical restraints (Haldol, etc.) and finally resorting to physical restraints if all else fails. (Opinion) I agree!
Carole Larkin MA, CMC, CAEd, DCP, QDCS, EICS is an expert in Alzheimer’s and related Dementia care. She is a Certified Geriatric Care Manager who specializes in helping families with Alzheimer’s and related dementia issues. Carole can consults with families via telephone nationwide on problems related to dementia. Her company, ThirdAge Services LLC, is located in Dallas, TX.
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