Dr. Ken’s Corner: Medical Care and the Elderly: When Less is Better

Except in a few specialties, most physicians provide care for an increasingly older population. Because geriatric training in our medical schools is still on the ‘back burner,’ it’s an area prone to mistakes and errors of judgment. Here are five recently published recommendations from the American Geriatric Society that just may change the way we treat the elderly:

1. Don’t use benzodiazepines or other sedative-hypnotics in older adults as the first choice for insomnia, agitation, or delireum. These medications more than double the risk of falls and hip fractures. Use them sparingly.

2. Don’t use antibiotics to treat bacteruria in older adults if they have no symptoms. The prevalence of asymptomatic bacteruria is much higher in elderly women and men when compared to those under the age of 65. ASB is highest in women and increases with age. For women 90 years of age and older, ASB ranges from 22% to 43%, and up to 21% of men in this age group. In this population, studies have found no adverse outcomes for not using antimicrobials in patients who have bacteruria without symptoms. Plus, by not treating ASB in the elderly, potential antimicrobial side-effects are averted.

3. Avoid using diabetic medications to achieve hemoglobin A1c levels of less than 7.5% in most adults age 65 and older; moderate control is generally better. Evidence suggests that older patients are more likely to be harmed by intensive glycemic control. Studies show, for example, that hypoglycemic episodes resulting in hospitalization are more likely in the ‘tightly controlled’ elderly diabetic.

4. Don’t recommend feeding tubes in patients with advanced dementia; offer oral assisted feeding instead. Aspiration pneumonia is the most common adverse event of tube feeding, along with agitation and the increased use of restraints and sedatives. Careful hand feeding has been shown to be superior to tube feeding, both in terms of overall patient comfort and lowering the risk of aspiration pneumonia. Studies show that nutritional benefits are not compromised when compared to patients who are tube-fed.

5. Don’t use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia in the elderly. Based on randomized control trials and expert opinion, these medications offer limited benefits in this age group. In fact, the adverse effects of antipsychotic medication use in the elderly have been shown to offset any benefits when used to treat the psychotic, aggressive, or agitated patient.

(Reference: Journal of the American Geriatric Society, Volume 61, Issue 4, pages 622-631, April 2013.)

Ken Teufel is the Medical Director for Interim Physicians