Australian & New Zealand Society for Geriatric Medicine

The Australian and New Zealand Society for Geriatric Medicine is the professional society for geriatricians and other medical practitioners with an interest in the medical care of older people.

The Society acts to represent the needs of its members and the wider community in a bid to constantly review and improve the care of the older people in Australia and Aotearoa New Zealand. Its major functions are around education, policy development and review, and political advocacy.

Download the Australian & New Zealand Society for Geriatric Medicine's Top-5 recommendations (PDF)

Top-5 recommendations on low-value practices

1. Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.

Rationale and evidence

Rationale

People with dementia may exhibit aggression, resistance to care and other challenging or disruptive behaviours. In such instances, the modest effectiveness of atypical antipsychotics may be offset by the higher risks for adverse events and mortality. Non-pharmacological interventions can be an effective substitute for antipsychotic medications. Use of these drugs should therefore be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others.

Evidence

Ballard C, Waite J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev. 2006; (1): CD003476.

Declerq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2013; 3: CD007726.

Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a metaanalysis of randomized placebo controlled trials. J Alzheimers Dis. 2014; 42(3): 915-37.

Richter T, Myer G, Mohler R, et al. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev. 2012; 12: CD008634.

Schneider LS, Tariot PN, Dagerman K, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. New England Journal Med. 2006; 355(15): 1525-38.


2. Do not prescribe benzodiazepines or other sedative-hypnotics to older adults as first choice for insomnia, agitation or delirium.

Rationale and evidence

Rationale

There is strong evidence that use of benzodiazepines is associated with various adverse effects in elderly people such as falls and fractures. Older patients, their caregivers and their providers should recognise these potential harms when considering treatment strategies for insomnia, agitation or delirium. Thus these drugs should be prescribed with caution, and their use monitored closely.

Evidence

Allain H, Bentue-Ferrer D, Polard E, et al. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review. Drugs Aging. 2005; 22(9): 749–765.

Finkle WD, Der JS, Greenland S, et al. Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. Journal of the American Geriatric Soc. 2011; 59(10): 1883-90.

Sithamparanathan K. Adverse effects of benzodiazepine use in elderly people: A meta-analysis. Asian J Gerontol Geriatr. 2012; 7: 107–11.

Stockl KM, Le L, Zhang S, et al. Clinical and economic outcomes associated with potentially inappropriate prescribing in the elderly. American Journal Managed Care. 2010; 16(1): e1-10.


3. Do not use antimicrobials to treat bacteriuria in older adults where specific urinary tract symptoms are not present.

Rationale and evidence

Rationale

Studies have found that asymptomatic bacteriuria frequently resolves without any treatment. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and, in fact, often show increased adverse antimicrobial effects.

Evidence

Masumoto T. Urinary tract infections in the elderly. Curr Urol Rep. 2001; 2(4): 330-3

Mody L & Juthani-Mehta M. Urinary tract infections in older women: a clinical review. JAMA. 2014; 311(8): 844-54.

Nicolle LE, Mayhew WJ & Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. American Journal of Medicine. 1987; 83(1): 27–33.

Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clinical Infectious Diseases. 2005; 1;40(5): 643-54.


4. Do not prescribe medication without conducting a drug regimen review.

Rationale and evidence

Rationale

Older patients disproportionately use more prescription and non-prescription drugs than other populations, increasing the risk for side effects and inappropriate prescribing. Thus evidence shows that polypharmacy is associated with adverse drug reactions and an increased risk of hospital admissions. Medication review with follow up is recommended for optimising prescribed medication and improving quality of life in older adults with polypharmacy.

Evidence

Fried TR, O’leary J, Towle V, et al. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. Journal of American Geriatric Society. 2014; 62(12): 2261-72.

Hajjar ER, Caffiero AC, Hanlon JT, et al. Polypharmacy in elderly patients. American Journal Geriatr Pharmacotherapy. 2007; 5(4): 345-51.

Jodar-Sanchez F, Malet-Larrea A, Martin JJ, et al. Cost-Utility Analysis of a Medication Review with Follow-Up Service for Older Adults with Polypharmacy in Community Pharmacies in Spain: The conSIGUE Program. Pharmacoeconomics. 2015; Mar 15.

Lu WH, Wen YW, Chen LK, et al. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. CMAJ. 2015; 187(4): e130-7.


5. Do not use physical restraints to manage behavioural symptoms of hospitalised older adults with delirium except as a last resort.

Rationale and evidence

Rationale

There is little evidence to support the effectiveness of physical restraints to manage people with delirium who exhibit behaviours that risk injury.

Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Restraints should therefore be used as a last resort and should be discontinued at the earliest possible time, particularly given that effective non-pharmacological alternatives are available.

Evidence

Flaherty J & Little M. Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. Journal of the American Geriatric Soc. 2011; 59 Suppl 2: S295-300.

Maccolli GA, Dorman T, Brown B, et al. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies, American College of Critical Care Medicine Task Force 2001-2002. Critical Care Medicine. 2003; 31(11): 2665-76.

Mott S, Poole J & Kenrick M. Physical and chemical restraints in acute care: their potential impact on the rehabilitation of older people. Int J Nurs Pract. 2005; 11(3): 95-101.

Park M & Tang JHC. Changing the practice of physical restraint use in acute care. J Gerontol Nursing. 2007; 33(2): 9-16.

 

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