Strong evidence exists that artificial nutrition does not prolong life or improve quality of life in patients with advanced dementia. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to obtain any significant or long-term benefit from artificial nutrition. Feeding tubes are often placed after hospitalization, frequently with concerns for aspirations, and for those who are not eating. Contrary to what many people think, tube feeding does not ensure the patient’s comfort or reduce suffering; it may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems.
AMDA – The Society for Post-Acute and Long-Term Care Medicine
Five Things Physicians and Patients Should Question
Released September 4, 2013
Download PDFDon’t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings.
Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home.
SSI is a reactive way of treating hyperglycemia after it has occurred rather than preventing it. Good evidence exists that SSI is neither effective in meeting the body’s insulin needs nor is it efficient in the long-term care (LTC) setting. Use of SSI leads to greater patient discomfort and increased nursing time because patients’ blood glucose levels are usually monitored more frequently than may be necessary and more insulin injections may be given. With SSI regimens, patients may be at risk from prolonged periods of hyperglycemia. In addition, the risk of hypoglycemia is a significant concern because insulin may be administered without regard to meal intake. Basal insulin, or basal plus rapid-acting insulin with one or more meals (often called basal/bolus insulin therapy) most closely mimics normal physiologic insulin production and controls blood glucose more effectively.
Don’t obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract.
Chronic asymptomatic bacteriuria is frequent in the LTC setting, with prevalence as high as 50%. A positive urine culture in the absence of localized urinary tract infection (UTI) symptoms (i.e., dysuria, frequency, urgency) is of limited value in identifying whether a patient’s symptoms are caused by a UTI. Colonization (a positive bacterial culture without signs or symptoms of a localized UTI) is a common problem in LTC facilities that contributes to the over-use of antibiotic therapy in this setting, leading to an increased risk of diarrhea, resistant organisms and infection due to Clostridium difficile. An additional concern is that the finding of asymptomatic bacteriuria may lead to an erroneous assumption that a UTI is the cause of an acute change of status, hence failing to detect or delaying the more timely detection of the patient’s more serious underlying problem. A patient with advanced dementia may be unable to report urinary symptoms. In this situation, it is reasonable to obtain a urine culture if there are signs of systemic infection such as fever (increase in temperature of equal to or greater than 2°F [1.1°C] from baseline) leukocytosis, or a left shift or chills in the absence of additional symptoms (e.g., new cough) to suggest an alternative source of infection.
Don’t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior.
Careful differentiation of cause of the symptoms (physical or neurological versus psychiatric, psychological) may help better define appropriate treatment options. The therapeutic goal of the use of antipsychotic medications is to treat patients who present an imminent threat of harm to self or others, or are in extreme distress–not to treat nonspecific agitation or other forms of lesser distress. Treatment of BPSD in association with the likelihood of imminent harm to self or others includes assessing for and identifying and treating underlying causes (including pain; constipation; and environmental factors such as noise, being too cold or warm, etc.), ensuring safety, reducing distress and supporting the patient’s functioning. If treatment of other potential causes of the BPSD is unsuccessful, antipsychotic medications can be considered, taking into account their significant risks compared to potential benefits. When an antipsychotic is used for BPSD, it is advisable to obtain informed consent.
Don’t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.
There is no evidence that hypercholesterolemia, or low HDL-C is an important risk factor for all-cause mortality, coronary heart disease mortality, or hospitalization for myocardial infarction or unstable angina in persons older than 70 years. In fact, studies show that elderly patients with the lowest cholesterol have the highest mortality after adjusting other risk factors. In addition, a less favorable risk-benefit ratio may be seen for patients older than 85, where benefits may be more diminished and risks from statin drugs more increased (cognitive impairment, falls, neuropathy and muscle damage).
AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only professional association representing medical directors, attending physicians and others practicing in the long term care continuum. AMDA is dedicated to excellence in patient care and provides education, advocacy, information and professional development to promote the delivery of quality long term care medicine. AMDA strives to provide cutting edge education, information and tools on clinical, management and technology topics that are specific to the evolving long term care setting. AMDA offers opportunities to learn about best practices and activities that can maximize the quality of care and quality of life for patients.
How this list was created: AMDA – The Society for Post-Acute and Long-Term Care Medicine convened a work group made up of members from the Clinical Practice Committee (CPC). Members of the CPC include board certified geriatricians, certified medical directors, multi-facility medical directors, attending practitioners, physicians practicing in both office-based and nursing facility practice, physicians in rural, suburban and academic settings, those with university appointments, and more. It was important to AMDA that the workgroup chosen represent the core base of the AMDA membership. Ideas for the “five things” were solicited from the workgroup. Suggested elements were considered for appropriateness, relevance to the core of the specialty and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. A literature search was conducted to provide supporting evidence or refute the activities. The list was modified and a second round of selection of the refined list was sent to the workgroup for paring down to the final “top five” list. Finally, the work group chose its top five recommendations before submitting a final draft to the AMDA Executive Committee, which were then approved. AMDA’s disclosure and conflict of interest policy can be found at www.amda.com.
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