Geriatrics specialist says ’do less’ for older patients

Posted on behalf of Stewart Bell, PLLC on Apr 18, 2011 in Nursing Home Injury or Death

While our natural instinct may be to do more for our frail and elderly family members, new research says otherwise: We should do less. The study, conducted by a geriatrician from an Ivy League university, looked at the medical records of 172 residents with urinary tract infections (UTIs) in two high-quality nursing homes . The results showed that physicians routinely failed to follow treatment guidelines.

The "old school" guidelines direct physicians to treat patients with a positive urinalysis with antibiotics -- all patients, regardless of age. These guidelines were published about 20 years ago, though. Newer criteria, called the McGeer criteria, say older people are different.

It's not normal for younger people to have bacteria in their urine. Antibiotics are appropriate, then, when a younger person's urinalysis test is positive.

Older people, though, are colonized with bacteria. You can remove the "ick" factor if you remember that older people, especially people in nursing homes, are around more germs and are subject to more procedures like catheterization that can lead to infection. Just because they're colonized, though, doesn't mean they have a UTI. A urinalysis test that shows bacteria doesn't mean they're sick, and it certainly doesn't require treatment.

The McGeer criteria say antibiotics are appropriate for older patients if three of five specific symptoms are present. A patient with

  • Fever
  • Increased frequency or urgency of urination, or burning associated with urination
  • Pain behind or near the bladder
  • Change in smell or appearance of urine
  • Deteriorating function or mental state

In the nursing home study, though, 40 percent of the patients were treated with antibiotics when they didn't meet the criteria. 

The study showed that many residents were being treated unnecessarily, either because the practitioner wasn't following medical guidelines or because the practitioner was being cautious by aggressively treating the patients. UTIs are treated with antibiotics, though, and overmedication with antibiotics can actually compromise the patient's health.

The researchers found ample evidence of this in their small sample. They also found that the incorrect diagnosis of patients was just one of a handful of problems with UTI treatment. The others involved the antibiotics themselves.

More than half of the patients who were given antibiotics got the wrong drug -- drugs that are not recommended in the guidelines. About half of the treated patients received the wrong doses, and more than two-thirds took the medication for too long.

This isn't just conservative treatment, the lead author of the study says. It's dangerous for the patient.

First, treatment guidelines for a simple UTI call for a course of narrow-spectrum antibiotics. The researchers found that 56 percent of the patients in the study were prescribed broad-spectrum antibiotics. These medications kill the bad bacteria, certainly, but they also wipe out the good bacteria in the digestive tract -- the bacteria that help with digestion and that help ward off infection. Using a broad-spectrum drug is like killing an ant with a bazooka -- it's too much.

Second, women and men require different courses of treatment. Men should take the medication for one to two weeks. Women need less -- just about four days. In the study population, two-thirds of the prescriptions were incorrect.

With a prescription that's too strong and taken for too long, the patient's good bacteria hasn't got a chance. The patients then are especially vulnerable to the C difficile bacterium. The recommended treatment for C diff is, yes, more antibiotics. If overtreatment is the rule for that patient, the C diff will only take a firmer hold. The patient can go far beyond the early symptom of diarrhea into an inflamed colon.

It's hard to overstate the dangers of C diff in an elderly patient. The bacteria easily and often lead to chronic and acute conditions that take a terrible toll on the body. In the study, the patients who were over-treated were far more likely to be struck by C diff.

Aggressive treatment with aggressive antibiotics is responsible in part for the recent wave of so-called superbugs. These are germs that are impervious to the usual antibiotics. These are also germs that, like other germs, are transmitted from one person to another. The patient isn't the only one at risk -- the person down the hall, the nurse who takes care of her and the 5-year-old granddaughter who visits are all at risk.

The author's "do less" theory was further proven when the patients who received no treatment had no adverse outcomes. They didn't get kidney infections -- a major concern among younger patients with UTIs -- nor were they hospitalized. They seemed to do just fine.

Families want doctors to do everything in their power for the elderly loved one. The feeling of helplessness for family members can prompt pleas for treatment. But we all need to accept that sometimes less is good.

Source: New York Times, "A Common Infection, Commonly Overtreated," Paula Span, 04/blog/11

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