Choosing Wisely for frail residents of long-term care homes: Six recommendations

Residents of our long-term care homes are remarkable people. They have marched with Tommy Douglas, piloted Lancaster bombers in the Second World War, raised children and grandchildren. Now their race is run, and too frail to remain at home they’ve entered long-term care. Most are close to the end of their days, and the average length of stay in a care home is now 18 to 21 months.

We take the approach that these heroes and patriarchs deserve comfort care and should not be subjected to the intensive medical interventions that may be appropriate for the rest of the population, including older adults who are not at the frail stage. This approach is also called the palliative approach to care of the frail elderly.

Care for the frail elderly in care homes is an evidence-free zone. Following existing guidelines may be downright harmful and disturbing to the residents’ comfort and peace. The Long Term Care Medical Directors Association of Canada (LTCMDAC) was therefore approached by Choosing Wisely Canada to develop recommendations for the care of frail elderly residents for use by colleagues, caregivers, patients, and family members.

How the recommendations were developed
A working group made up of two LTCMDAC physician volunteers and a patient champion was struck to develop draft recommendations that were valid and relevant for our health care system. To begin, the working group reviewed the American Medical Association’s and Canadian Geriatric Society’s lists of recommendations; however, those lists were not specific to the frail elderly in residential care. Using their experience, in an iterative process and in dialogue with Choosing Wisely Canada, the working group drafted recommendations and circulated them to the board members of the LTCMDAC for feedback. The proposed recommendations were then submitted to and accepted by Choosing Wisely Canada.

The resulting recommendations 
1. Don’t send the frail resident of a nursing home to the hospital unless their urgent comfort and medical needs cannot be met in their care home. 
Transfers to hospital for assessment and treatment of a change in condition have become customary; however, they are of uncertain benefit, and may result in increased morbidity.[1]

2. Don’t use antipsychotics as a first choice to treat behavioral and psychological symptoms of dementia. 
People with dementia can sometimes be disruptive, behave aggressively, and resist personal care. There is often a reason for this behavior and identifying and addressing the causes can make drug treatment unnecessary.[2]

3. Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI). 
Unless there are UTI symptoms, such as urinary discomfort, abdominal/back pain, frequency, ur-gency, or fever, testing should not be done. Testing often shows bacteria in the urine, with as many as 50% of those tested showing bacteria present in the absence of localizing symptoms to the genitourinary tract.[3]

4. Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat. 
Inserting a feeding tube does not prolong or improve quality of life in patients with advanced dementia. If the resident has been declining in health with recurrent and progressive illnesses, they may be nearing the end of their life and will not benefit from feeding tube placement.[4]

5. Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient. 
Long-term medications should be discontinued if they are no longer needed (e.g., heartburn drugs, anti-hypertensives), as they can reduce the resident’s quality of life while having little value for a frail elder with limited life expectancy.[5]

6. Don’t order screening or routine chronic disease testing just because a blood draw is being done. 
Unless treatment can be given that would add to quality of life, don’t do these tests. What is considered routine testing may lead to harmful overtreatment in frail residents nearing the end of their life.[6]
—Ralph Jones, MBChB
Geriatrics and Palliative Care Committee

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This article is the opinion of the Geriatrics and Palliative Care Committee, a subcommittee of Doctors of BC’s Council on Health Promotion, and is not necessarily the opinion of Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

References

1. Walker JD, Teare GF, Hogan DB, et al. Identifying potentially avoidable hospital admissions from Canadian long-term care facilities. Med Care 2009;47:250-254.

2. Seitz DP, Brisbin S, Herrmann N, et al. Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: A systematic review. J Am Med Dir Assoc 2012;13:503-506.e2. 

3. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-654.

4. Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for people with dementia: A systematic review. J Am Geriatr Soc 2011;59:463-472. 

5. Dalleur O, Spinewine A, Henrard S, et al. Inappropriate prescribing and related hospital admissions in frail older persons according to the STOPP and START criteria. Drugs Aging 2012;29:829-837.

6. Clarfield AM. Screening in frail older people: An ounce of prevention or a pound of trouble? J Am Geriatr Soc 2010;58:2016-2021.