Five Rules of Thumb for Fostering Safe and Appropriate Treatment in Long-Term Care: Page 2 of 2

March 15, 2013

3. Avoid using medications to achieve hemoglobin A1c <7.5% in most adults aged 65 years and older; moderate control is generally better. There is no evidence that using medications to achieve tight glycemic control in older adults with type 2 diabetes is beneficial. Among nonolder adults, except for long-term reductions in myocardial infarction and mortality with
metformin, using medications to achieve glycated hemoglobin levels less than 7% is associated with harms, including higher mortality rates. Tight control has been consistently shown to produce higher rates of hypoglycemia in older adults. Given the long timeframe to achieve theorized microvascular benefits of tight control, glycemic targets should reflect patient goals, health status, and life expectancy. Reasonable glycemic targets would be 7.0% to 7.5% in healthy older adults with long life expectancy, 7.5% to 8.0% in those with moderate comorbidity and a life expectancy <10 years, and 8.0% to 9.0% in those with multiple morbidities and shorter life expectancy. 

4. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium. Large-scale studies consistently show that the risk of motor vehicle accidents and of falls and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Patients, their caregivers, and their healthcare providers should recognize these potential harms when considering treatment strategies for insomnia, agitation, or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder that is unresponsive to other therapies.

5. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. Cohort studies have found no adverse outcomes for older men or women associated with asymptomatic bacteriuria. Antimicrobial treatment studies for asymptomatic bacteriuria in older adults demonstrate no benefits and show increased adverse antimicrobial effects. Consensus criteria has been developed to characterize the specific clinical symptoms that, when associated with bacteriuria, define urinary tract infection. Screening for and treatment of asymptomatic bacteriuria is recommended before urologic procedures for which mucosal bleeding is anticipated. 

To identify these “five things,” the AGS convened a Choosing Wisely work group, headed by the vice chair of the society’s Clinical Practice and Models of Care Committee, Paul Mulhausen, MD. The work group first conducted preliminary research and surveyed AGS members, asking which five tests or treatments should be included. The group then expanded its survey to other academics and researchers. From more than 300 individual responses, it identified the tests and treatments most recommended for inclusion in the list, then narrowed the number to 10, and, finally, consulted with AGS members with expertise in these areas to identify the final five.

We at the AGS encourage you to acquaint your staff, your residents, and their family caregivers, as appropriate, to the Choosing Wisely campaign, the society’s list, and other relevant lists on the campaign’s Website. We also encourage you to underscore the importance of discussing the potential benefits and drawbacks of any recommended treatment and to help foster such discussions.


1. Williams CM. Using medications appropriately in older adults. Am Fam Physician. 2002;66(10):1917-1925.

2. Nursing Home Licensure and Certification Section; North Carolina Department of Health and Human Services. §483.25(1) Unnecessary drugs. Published September 2006. Accessed March 6, 2013. 

3. American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society. J Am Geriatr Soc. 2012;60(10):1957-1968.

4. Bronskill SE, Gill SS, Paterson JM, Bell CM, Anderson GM, Rochon PA. Exploring variation in rates of polypharmacy across long term care homes. J Am Med Dir Assoc. 2012;13(3):309.e15-e21.