Unnecessary tests and treatments do not add value to you or your whanau. In fact, they may take away from care by potentially exposing you or your whanau to harm, leading to more testing to investigate false positives and contributing to stress.

In this section you will find lists and questions relating to specific problems and concerns – and the questions you should always ask before agreeing to a medical intervention or test.

As each situation is unique, healthcare professionals and patients should have a conversation to work out an appropriate healthcare plan together.

4 QUESTIONS FOR PATIENTS TO ASK

Some tests, treatments and procedures provide little benefit. And in some cases, they may even cause harm. These questions can help you make sure you end up with the right amount of care — not too much and not too little. As each situation is unique, a discussion with your health professional can help you develop a healthcare plan for you.

1. Do I really need this test or procedure?

Tests may help you and your doctor or other healthcare professionals determine the problem. Procedures may help to treat it. Understanding why your doctor is considering a test -and weighing up the benefits and risks – is always advisable, and is every patient’s right and responsibility.

2. What are the risks?

If you have – or don’t have – the test or procedure, what is likely to happen? Are there potential side eects? What are the chances of getting results that aren’t accurate? Could that lead to more testing or another procedure?

3. Are there simpler, safer options?

Sometimes all you need to do is make lifestyle changes, such as eating healthier foods or exercising more. Or an alternative test or treatment that might deliver useful information, while reducing any potential negative impacts for you.

4. What happens if i don’t do anything?

Ask if your condition might get worse – or better – if you don’t have the test or procedure right away.

Download a poster of these questions:

Choose Wisely A4 Poster

 

Communicating with your Health professional

Before your appointment

Make a longer appointment if the problem you want to discuss is complex, or you need to discuss several issues.

Prepare a summary of your health problems, prioritise the issues you want to discuss, and make a list of questions as you think of them.

Let your health professional know if you need an interpreter or other assistance with communicating.

During your appointment

You should expect to be listened to – and be given clear and adequate explanations of your condition, any recommended tests, treatment options and the expected results.

When you describe your problems, be as accurate, complete and honest as possible.

If your health professional recommends a test, treatment or procedure and you are not clear of its purpose or benefits, you may want to discuss this.

Asking the following questions around potential tests or procedures

  • Do I really need to have this test, treatment or procedure?
  • What are the risks?
  • Are there simpler safer options?
  • What happens if I do nothing?

If you don’t understand anything, tell your health professional – and ask them to repeat or clarify the information until you do understand.

If you don’t feel confident about your appointment, take a family/ whānau member or friend with you. Take notes if you think you may have trouble remembering important details (or ask your health professional or support person to take notes for you).

If you want to know more, ask your health professional for some written information, or suggestions of where you might find it

After your appointment

You may want to make a follow-up appointment to ask further questions, discuss continuing issues or talk to your health professional about your decisions after you’ve had time to consider the options.

If you want to discuss the issues with another health professional, don’t hesitate to get another opinion.

 

PATIENT & CONSUMER RESOURCES

Common tests, treatments and procedures you may think you need

Let’s think again

ECGs (electrocardiograms)

The problem
An ECG records the electrical activity of your heart at rest. It provides information about your heart rate and rhythm, and shows if there is enlargement of the heart due to high blood pressure (hypertension) or evidence of a previous heart attack (myocardial infarction).
The risks
The ECG will not harm you. However, it can sometimes show mild nonspecific abnormalities that are not due to underlying heart disease, but cause worry and lead to follow-up tests and treatments that you do not need.
When to consider the tests
You may need an ECG test if you have risk factors for heart disease such as high blood pressure, or symptoms such as palpitations or chest pain. Or you may need it if you already have heart disease.

Imaging tests for lower-back pain

The problem
Getting an X-ray, CT scan or MRI may seem like a good idea. But back pain usually subsides in about a month, with or without testing. For example, one study found that back pain sufferers who had an MRI in the first month were eight times more likely to have surgery, but didn’t recover faster.
The risks
X-rays and CT scans expose you to radiation, which can increase cancer risk. CT scans and X-rays of the lower back are especially worrisome for men and women of childbearing age, because they can expose testicles and ovaries to substantial radiation. Finally, the tests often reveal abnormalities that are unrelated to the pain, but can prompt needless worry and lead to unnecessary follow-up tests and treatment, sometimes even including surgery.
When to consider the tests
X-ray and CT scans often make sense if you have nerve damage, or signs of a serious underlying condition such as cancer or a spinal infection. “Red flags” that can alert your health professional that imaging may be worthwhile include a history of cancer, unexplained weight loss, recent infection, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs.

CT scans and MRIs for headaches

The problem
Many people who have headaches want a CT scan or MRI to find out if their headaches are caused by a brain tumour or other serious illness and health professionals often comply to provide reassurance. But all that’s usually needed is a careful medical history and neurological exam. Adding a CT scan or MRI rarely helps.
The risks
A CT scan of the head uses a low radiation dose. This may slightly increase the risk of harmful effects such as cancer. Risks from radiation exposure may add up, so it is best to avoid unnecessary radiation. The results of your CT scan or an MRI may also be unclear. This can lead to more tests and even treatment that you do not need.
When to consider the tests
They are often warranted if you have an abnormal result on a neurological exam, or if your health professional can’t diagnose the problem based on your symptoms and medical exam. See a health professional if you have head pain that is sudden or explosive; different from headaches you’ve had in the past; brought on by exertion; or accompanied by fever, a seizure, vomiting, loss of coordination, or a change in vision, speech or alertness.

Bone-density (DEXA) scans

The problem
Many people are routinely screened for weak bones with an imaging test called a DEXA scan. If it detects osteoporosis, the results can help patients and their health professional decide how to treat the problem. But many people learn they have only mild bone loss, a condition known as osteopenia, and for them the risk of fracture is often quite low.
The risks
A bone-density test gives out a small amount of radiation, but radiation exposure can add up. A diagnosis of osteopenia often leads to treatment with such drugs as alendronate (Fosamax), which poses risks. But there is little evidence that people with osteopenia benefit from these drugs.
When to consider the tests
Health professionals decide on who to refer for a DEXA scan based on risk factors such as age, a fracture from minor trauma, low body weight, and long-term use of corticosteroid drugs. Whether follow-up tests are needed depends on the results of the initial scan.

Ask these questions:

Do I really need to have this test, treatment or procedure?
The answer should be direct and simple. Tests should help you and your health professional decide how to treat your problem, and treatments and procedures should help you live a longer, healthier life.
What are the risks (of having or not having it)?
Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms, but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself.
Are there simpler, safer options?
Sometimes lifestyle changes will provide all the relief you need.
What happens if I do nothing?
Ask your health professional if your condition might worsen—or get better—if you don’t have the test or treatment now.

There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a conversation with your health professional today.


© 2014 Consumers Union of United States, Inc., (101 Truman Ave., Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Common tests, treatments and procedures you may think you need. Let’s think again.
Choosing Wisely do not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Health Checks – When you need them – and when you don’t

Like many people, you may schedule a yearly checkup or “annual physical” with your health professional. It usually includes a health history, physical exam and tests. It is important to have a regular health professional who helps make sure you receive the medical care that is best for your individual needs. But healthy people often don’t necessarily need annual physicals, and those checkups can do more harm than good. Here’s why:

Annual physicals usually don’t make you healthier

There have been many studies of the effects of annual checkups. In general, they probably won’t help you stay well and live longer. And usually they don’t help you avoid hospital stays or keep you from dying of cancer or heart disease.

Tests and screenings can cause problems

Most people should only have a test or exam if they have symptoms or risks factors.
One problem is getting a false-positive result. These false alarms can cause anxiety, and unnecessary follow-up tests and treatments. For example, a false-positive blood test can result in a biopsy. An electrocardiogram (ECG) that is not interpreted correctly may lead to another test that exposes you to radiation. Or you might get a procedure to show arteries in the heart that has a risk of heart attack or death in two patients for every 100 who get the test.

Set a schedule with your health professional

Your health professional best knows your health history. You can discuss with him/her the best time for any exams or tests, which you may need.
If your health professional wants to schedule an annual physical, you can ask if it is necessary. Or ask if you can wait until you have a problem or are due for a test (such as a cervical smear or blood pressure check).

So when do adults need a checkup?

You may need a checkup:

  • When you are sick
  • When you have a symptom that could mean illness
  • To manage chronic or ongoing conditions
  • To check on the effects of a new medicine
  • To help with risk factors like smoking or obesity
  • For antenatal care, if you are pregnant
  • For lifestyle issues like family planning
  • For other reasons that are based on your individual needs

People in their twenties often do not see a health professional for several years without risking their health, while older people who have developed risks for certain diseases may see a health professional more often. It is best to have a trusted health professional you see regularly who has access to your health records.

What about preventive care?

Preventive care is important. Having a regular health professional helps you get preventive care.
Everyone should get the recommended immunisations and screening tests at the times and frequencies recommended by the Ministry of Health.


© 2014 Consumers Union of United States, Inc., (101 Truman Ave., Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Health checkups: when you need them – and when you don’t, developed in cooperation with the Canadian Medical Association’s Forum on General and Family Practice Issues and College of Family Physicians of Canada.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Allergic reaction – severe

Don’t use antihistamines to treat anaphylaxis — prompt administration of adrenaline is the only treatment for anaphylaxis.
Anaphylaxis is a potentially life threatening, severe allergic reaction and should always be treated as a medical emergency.
Read more at allergy.org.au

Allergies – introducing solids to infants

Don’t delay introduction of solids to infants – start around 4-6 months.
Read more http://allergy.org.au/patients/allergy-prevention/allergy-prevention-frequently-asked-questions/a>

Alzheimer’s disease and other forms of dementia – disruptive behaviour

Antipsychotic drugs are usually not the best choice

People with Alzheimer’s disease and other forms of dementia can become restless, aggressive, or disruptive. They may believe things that are not true. They may see or hear things that are not there. These symptoms can cause even more distress than the loss of memory.
Doctors often prescribe powerful antipsychotic drugs to treat these behaviours:

  • Olanzapine (Zyprexa and generic)
  • Quetiapine (Seroquel and generic)
  • Risperidone (Risperdal and generic)

If you are uncertain if your loved one is taking one of these medications please ask their health care team. In most cases, antipsychotics should not be the first choice for treatment. Here’s why:
Antipsychotic drugs don’t help much. Studies have compared these drugs to sugar pills or placebos. These studies showed that antipsychotics usually don’t reduce disruptive behaviour in older dementia patients.
Antipsychotic drugs can cause serious side effects. Doctors can prescribe these drugs for dementia for behavioural symptoms, but they cause serious side effects.
Side effects include:

  • Drowsiness and confusion—which can reduce social contact and mental skills, and increase falls
  • Weight gain
  • Diabetes
  • Shaking or tremors (which can be permanent)
  • Pneumonia
  • Sudden death.

Other approaches often work better. It is almost always best to try other approaches first, such as the suggestions listed below.

  • Make sure the patient has a thorough exam and medicine review.
  • The cause of the behaviour may be a common condition, such as constipation, infection, vision or hearing problems, sleep problems, or pain.
  • Many drugs and drug combinations can cause confusion and agitation in older people.
Talk to an aged care health professional.

This person can help you find non-drug ways to deal with the problem. For example, when someone is startled, they may become agitated. It may help to warn the person before you touch them. For more tips, see below.

Consider other drugs first.

Talk to your doctor about the following drugs that have been approved for treatment of disruptive behaviours:

  • Drugs that slow mental decline in dementia.
  • Antidepressants for people who have a history of depression or who are depressed as well as anxious.

Consider antipsychotic drugs if:

  • Other steps have failed.
  • Patients are severely distressed.
  • Patients could hurt themselves or others.

Start the drug at the lowest possible dose. Caregivers and health professionals should watch the patient carefully to make sure that symptoms improve and that there are no serious side effects. The drugs should be stopped if they are not helping or are no longer needed.

Tips to help with disruptive behaviours.

Keep a daily routine. People with dementia often become restless or irritable around dinner time.

  • Do activities that use more energy earlier in the day, such as bathing.
  • Eat the biggest meal at midday.
  • Set a quiet mood in the evening, with lower lights, less noise, and soothing music.

Help the person exercise every day. Physical activity helps use nervous energy. It improves mood and sleep.

Don’t argue with a person who’s distressed.

  • Distract the person with music, singing, or dancing.
  • Ask the person to help with a simple task, such as setting the table or folding clothes.
  • Take the person to another room or for a short walk.

Plan simple activities and social time. Boredom and loneliness can increase anxiety. Adult daycare programmes can provide activities for older people. They also give caregivers a break.
It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from Choosing Wisely Canada (2014), Treating disruptive behaviour in people with dementia. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Alzheimer’s disease feeding tubes – when you need them and when you don’t

Most people in the last stage of Alzheimer’s disease have difficulty eating and drinking. At this time, families/whānau may wonder if a patient needs a feeding tube. Families/whānau want to do everything possible for someone who is ill. But they often get little information about feeding tubes. And they may feel pressure from doctors or nursing home staff, because feeding is simpler with a feeding tube. But feeding tubes sometimes do more harm than good. Here’s why:

Feeding tubes usually aren’t helpful for severe Alzheimer’s disease

People with severe Alzheimer’s disease can no longer communicate or do basic things. Chewing and swallowing is often hard. This can cause serious problems, such as weight loss, weakness, and pressure sores. Or food can get into the lungs, and cause pneumonia. So people often need help to eat.

In many cases, a decision is made to use a feeding tube. The tube may be put down the throat. Or it may be put through a small cut in the abdominal wall, into the stomach. The patient is then given liquid nutrition through the tube. But tube feeding is not better than careful hand feeding—and it may be worse. It does not help people live longer, gain more weight, become stronger, or regain skills. And it may increase the risk of pneumonia and pressure sores. Hand feeding gives human contact and the pleasure of tasting favourite foods.

When death is near and patients can no longer be fed by hand, families/whānau often worry that the patient will “starve to death.” In fact, refusing food and water is a natural, non-painful part of the dying process. There is no good evidence that tube feeding helps these patients live longer.

Feeding tubes can have risks
  • Tube feeding has many risks.
  • It can cause bleeding, infection, skin irritation, or leaking around the tube.
  • It can cause nausea, vomiting, and diarrhoea.
  • The tube can get blocked or fall out, and must be replaced in a hospital.
  • Many people with Alzheimer’s disease are bothered by the tube and try to pull it out. To prevent that, they are often tied down or given drugs.
  • Tube-fed patients are more likely to get pressure sores.
  • Tube-fed patients are more likely to spit up food, which may lead to pneumonia, a term called “aspiration pneumonia”.
  • At the end of life, fluids can fill the patient’s lungs, and cause breathing problems.
So when are feeding tubes a good idea?

Feeding tubes can be helpful when the main cause of the eating problem is likely to get better. For example, they can help people who are recovering from a stroke, brain injury, or surgery.
The tubes also make sense for people who have problems swallowing and are not in the last stage of an illness that can’t be cured. For example, they can help people with Parkinson’s disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease).

Caring for a person with severe Alzheimer’s disease

When caring for a person with severe Alzheimer’s disease, these steps can help with eating problems and other end-of-life concerns:

Treat conditions that cause appetite loss, such as constipation, depression, or infection.

Feed by hand. Ask a health professional about the best kinds of foods to offer and the best ways to feed by hand.

Stop unneeded medicines. Some drugs can make eating problems worse, including:

  • antipsychotics such as quetiapine (Seroquel and generic)
  • sleeping pills or anti-anxiety drugs such as lorazepam or zopiclone
  • bladder-control drugs such as oxybutynin
  • some drugs for osteoporosis such as alendronate (Fosamax and generic)
  • drugs for Alzheimer’s disease such as donepezil (Aricept and generic).

Schedule dental care. Badly fitting dentures, sore gums, and toothaches can make eating hard or painful.
Plan ahead. Every adult should have an advance directive. It lets you say what kind of care you want and who can make decisions for you if you cannot speak for yourself.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


© 2013 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057).Adapted from Consumer Reports (2013) and Choosing Wisely Canada (2014), Feeding tubes for people with Alzheimer’s disease, developed in cooperation with the Canadian Geriatrics Society.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Ankle and knee imaging

About medical imaging

The ankle and knee are joints located in the lower leg. Injuries to these joints are very common reasons why people visit their GP or physiotherapist. Injuries that frequently affect these joints include ligament sprains, muscle and tendon strains, and damage to the meniscus (cartilage) in the knee.
Although these injuries are often painful and uncomfortable, they can usually be managed with rest, ice, support and a gradual return to physical activity.
In some cases, such as when the cause of the injury is unclear or the damage to the joint is complex, an imaging test, such as an X-ray, ultrasound or magnetic resonance imaging (MRI), may be recommended. However, research shows that in most cases of acute ankle and knee sprain/strain, having an X-ray or MRI does not change the treatment you receive or how fast you recover. In addition, having an X-ray you don’t need may expose you to unnecessary radiation.
In fact, for many sprains affecting the ankles and knees, taking a history and examining the joint is all that your health professional will need to do to determine the diagnosis and guide management.

Factsheets

Ankle sprains: 10 things to know
Read 10 things you should know about ankle sprains on the NPS MedicineWise website to help you get back moving as usual.
Your knee joint injury, explained
The knee is a commonly injured part of the body. In fact, in sport it’s the most commonly injured part, with research finding that up to one in four of all sport injuries affect the knee.
Different types of medical imaging
There are several types of medical imaging tests, each with its own advantages and disadvantages. Read Know your imaging options on the NPS MedicineWise website to be informed about your medical imaging test and talk to your health professional about any questions or concerns you may have.

Questions you can ask about medical imaging

Imaging can be very useful in helping to diagnose the cause of your symptoms, but is not always necessary. Read Talking to your health professional about imaging on the NPS MedicineWise website to be well informed about your imaging and ask your doctor any questions you may have
For more information: Health Navigator.
It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2016), Ankle and knee imaging.
Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Antibiotics – Coughs, colds & sore throats

Manage symptoms without antibiotics

If you have a viral infection of the ear, nose, throat, sinuses or chest, antibiotics won’t make you feel better or recover faster. Talk to your health professional about why you probably don’t need antibiotics.

Do you need a medicine?

Coughs, colds, earaches, sinus congestion problems and sore throats are usually caused by a virus. Antibiotics kill bacteria, not viruses. Colds usually get better in 7 to 10 days, although a cough can last up to 3 weeks.
Taking antibiotics when you don’t need them can have unwanted results.
When antibiotics are necessary, the benefits far outweigh the risks, but when they are not needed, you are taking an unnecessary risk. People taking an antibiotic may experience side effects such as diarrhoea, nausea or vomiting.
Unnecessary use of antibiotics can also lead to antibiotic resistance. This means that antibiotics are no longer effective against the bacteria they once killed. If you have an antibiotic-resistant infection you:

  • will have the infection for longer
  • may be more likely to have complications of the infection
  • could remain infectious for longer and pass your infection to other people.
What can you do?

Rest
Allow your immune system to fight off the virus
Use home remedies
Inhale steam from a bath or shower in a closed room to help relieve a blocked nose. Don’t inhale steam from a bowl of hot water due to the risk of burns.
Soothe your sore throat by gargling warm salty water, sucking ice cubes or throat lozenges as needed or drinking warm water with honey and lemon.
Use symptom-relieving medicines
Take over-the-counter (non-prescription) medicines such as paracetamol or ibuprofen to relieve your pain or fever.
Use a nasal or oral decongestant to relieve a blocked nose. Cough and cold medicines should not be given to children under 6 years of age and should only be given to children aged 6 to 11 years on the advice of a health professional. Saline nasal spray or drops may be used in children. For more information on symptom-relieving medicines see the Choosing Wisely resource on medicines and treatments for bronchitis.
It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Further information

Antibiotics: Health Navigator
Antibiotic resistance: Health Navigator, Ministry of Health


Adapted from NPS MedicineWise (2016), Coughs, colds & sore throats.
Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Antibiotics for Sinusitis

The problem

People with sinusitis (congestion combined with nasal discharge and facial pain) are often prescribed antibiotics. But most people don’t need them. That’s because the problem almost always stems from a viral infection, not a bacterial one—and antibiotics don’t work against viruses.

The risks

About one in four people who take antibiotics report side effects, such as a rash, dizziness and stomach problems. In rare cases, they can cause severe allergic reactions. Overuse of antibiotics also encourages the growth of bacteria that can’t be controlled easily with drugs. That makes you more vulnerable to antibiotic-resistant infections and undermines the usefulness of antibiotics for everyone.

When to consider antibiotics

Antibiotics should usually only be considered when symptoms last longer than a week, start to improve but then worsen again, or are very severe. Worrisome symptoms that can warrant immediate antibiotic treatment include a fever over 38.6°C, extreme pain and tenderness over your sinuses, or signs of a skin infection, such as a hot, red rash that spreads quickly.

Ask these questions

Do I really need to have this test, treatment or procedure?
The answer should be direct and simple. Tests should help you and your health professional decide how to treat your problem, and treatments and procedures should help you live a longer, healthier life.
What are the risks (of having or not having it)?
Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms, but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself.
Are there simpler safer options?
Sometimes lifestyle changes will provide all the relief you need.
What happens if I do nothing?
Ask your health professional if your condition might worsen — or get better — if you don’t have the test or treatment now.
There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a healthy conversation with your health professional today.

It’s OK to ask questions

If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Further information

Antibiotics: Health Navigator
Antibiotic resistance: Health Navigator, Ministry of Health


© 2014 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Common tests, treatments and procedures you may think you need. Let’s think again. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Antibiotics for your skin

When you need them and when you don’t

Sometimes rashes and surgical wounds become infected with bacteria. Doctors treat these infections with antibiotics, which are medicines that can kill bacteria.However, doctors may prescribe antibiotics even when there is no infection. Most of the time, that’s not useful, and it can do more harm than good. Here’s why:

Antibiotics usually don’t help if your skin is not infected

Eczema causes dry, itchy, red skin. People with eczema often have high amounts of bacteria on their skin, but that doesn’t mean they have an infection. Even so, some doctors treat eczema with oral antibiotics, in pill or liquid form.
Antibiotics do not help the itching, redness, or severity of eczema. And the skin bacteria usually come back in a month or two.
You can control eczema better with moisturisers and the other steps below. To relieve itching and swelling, ask your doctor about creams or ointments containing a steroid (also called a corticosteroid) or other medicines.

Most surgical wounds don’t need antibiotics

Some doctors use antibiotic creams or ointments to prevent infection in surgical wounds. However, most surgical wounds have a very low risk of infection. Antibiotics don’t make the risk any lower. In fact, petroleum jelly (Vaseline and generic) is cheaper and less likely to irritate the wound.

Antibiotics have risks

Oral antibiotics for eczema can have side effects, including upset stomach, vomiting, diarrhoea, and vaginal yeast infections. They can also cause allergic reactions such as rashes, swelling, itching, and trouble breathing.
Antibiotic creams and ointments can actually slow down the healing of wounds. And they can cause redness, swelling, blistering, draining, and itching.
Using antibiotics when you don’t need them helps drug-resistant bacteria grow. These bacteria are harder to kill. They can cause illnesses that are harder to cure. This increases the risk of complications and side effects. The resistant bacteria can also be passed on to others.

When do you need antibiotics?

Antibiotics should be prescribed for eczema when there are signs of a bacterial infection, such as:

  • Pus-filled bumps, or cracks and sores that ooze pus
  • Honey-colored crusting
  • Very red or unusually warm skin
  • Possibly fever

Antibiotics should be prescribed for surgical wounds

  • When the wound shows signs of a bacterial infection, such as redness, pain, swelling, warmth, pus, oozing, and yellow crusting.
  • Sometimes when a patient has a fever, sweats, or chills.
  • When the wound is in an area of the body that is more likely to get infected (such as the groin).
Safeguard your skin
Eczema
  • Moisturise often during the day.
  • Use mild unscented skin cleansers and moisturisers. Avoid products with alcohol or dyes.
  • Short, cooler baths and showers are better than long hot soaks.
  • After washing, pat the skin partly dry. Then apply moisturiser right away on your damp skin.
  • Avoid things that make your skin worse. These can include scratchy fabrics, cigarette smoke, strong soaps, detergents and cleaning products.
  • Try to prevent scratching. It can lead to infection. Cut your fingernails short. Light cotton gloves can help prevent scratching at night.
Surgical wounds
  • Before you leave the hospital or doctor’s office, make sure you know how to care for your wound. Ask where to call if you have questions.
  • Always clean your hands before and after caring for your wound.
  • Don’t scratch the wound. That can slow the healing. Talk to your health professional if itching is a problem.
  • Avoid activities that could cause your wound to pull apart, such as lifting and straining.
  • Eat well to heal well. A healthy diet helps wounds heal.
Further information

Antibiotics: Health Navigator
Antibiotic resistance: Health Navigator, Ministry of Health

This report is for you to use when talking with your health professional.


© 2016 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2016), Antibiotics for your skin. When you need them — and when you don’t, developed in co-operation with the American Academy of Dermatology.Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Back pain – imaging tests

The exact cause of your acute low back pain may be difficult to identify but in most cases it is related to things like muscle strain rather than conditions like nerve or bone damage, infection or cancer. Talk to your health professional about how to manage your low back pain.

The problem

Getting an X-ray, CT scan or MRI may seem like a good idea. But back pain usually subsides in about a month, with or without testing. For example, one study found that back pain sufferers who had an MRI in the first month were eight times more likely to have surgery, but didn’t recover faster.

The risks

X-rays and CT scans expose you to radiation, which can increase cancer risk. CT scans and X-rays of the lower back are especially worrisome for men and women of childbearing age, because they can expose testicles and ovaries to substantial radiation. Finally, the tests often reveal abnormalities that are unrelated to the pain, but can prompt needless worry and lead to unnecessary follow-up tests and treatment, sometimes even including surgery.

When to consider the tests

X-ray and CT scans often make sense if you have nerve damage, or signs of a serious underlying condition such as cancer or a spinal infection. “Red flags” that can alert your health professional that imaging may be worthwhile include a history of cancer, unexplained weight loss, recent infection, loss of bowel or bladder control, abnormal reflexes, or loss of muscle power or feeling in the legs.

Ask these questions:

Do I really need to have this test, treatment or procedure?
The answer should be direct and simple. Tests should help you and your health professional decide how to treat your problem, and treatments and procedures should help you live a longer, healthier life.
What are the risks (of having or not having it)?
Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms, but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself.
Are there simpler safer options?
Sometimes lifestyle changes will provide all the relief you need.
What happens if I do nothing?
Ask your health professional if your condition might worsen—or get better—if you don’t have the test or treatment now.
There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a conversation with your health professional today.


© 2014 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Common tests, treatments and procedures you may think you need. Let’s think again.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Back pain – Managing acute lower back pain

The exact cause of your acute low back pain may be difficult to identify but in most cases it is related to things like muscle strain rather than conditions like nerve or bone damage, infection or cancer. Talk to your health professional about how to manage your low back pain.

Do you need imaging?

Your health professional might recommend an X-ray, MRI or CT scan if the test is likely to help find out what is causing your pain and how best to treat it. Imaging may be appropriate if your health professional suspects you have:

  • a broken bone in your spine
  • new back pain and a current or previous cancer diagnosis
  • other symptoms along with your acute low back pain (e.g. difficulty passing urine or weakness/numbness in your legs)
  • infection in your spine
  • ankylosing spondylitis (a form of spinal arthritis)
  • a need for imaging to evaluate or plan a surgical procedure on your spine

However, most people with acute low back pain feel better after a month – and often sooner – whether they have imaging tests done or not.
Unnecessary tests can be costly, and X-rays and CT scans involve exposure to radiation that is best avoided if the results are unlikely to help with your treatment.

What can you do?

Stay active and keep moving
Move about and stretch regularly – reduce your activities for a couple of days, but resting longer than this is not going to help you recover more quickly. Avoid staying in one position – such as sitting at your computer, watching TV or lying down – for more than 20–30 minutes at a time.
Use non-medicine treatments
Speak to your health professional about other treatments that might be right for you such as hot or cold packs, relaxation techniques and deep breathing exercises to help you to stay calm and cope with the pain or physical therapy.
Use symptom-relief medicines
Use a simple non-prescription pain reliever medicine, to reduce the pain enough to help you stay active. In most cases, regularly-taken paracetamol should be the first choice of pain reliever as it has fewer side effects than other pain relief medicines.

It’s ok to ask questions
If you have questions about your symptoms or your medicines, speak with your health professional.


Adapted from: NPS MedicineWise (2016), Imaging tests for acute short term lower back pain, such as X-rays, MRI or CT scans. When you need them – and when you don’t. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Blood tests in hospital

Having them every day may not be necessary

If you stay in a hospital overnight or longer, you may have many blood tests. Sometimes you need all the tests, especially if you are very sick. But sometimes you get more tests than you need. Here’s what you should know about blood tests in the hospital.

Common blood tests

When you’re in the hospital, you may have blood taken for two common tests.

  • A full blood count (FBC) checks your blood for signs of infection, immune system problems, bleeding problems, and anaemia (low iron).
  • A blood chemistry panel gives your doctor information about your muscles, bones, heart, and other organs. It also checks your blood sugar, calcium, and other minerals.

These tests can help your doctor identify a problem and learn if a treatment is working.
More testing doesn’t help you
If your test results stay the same after a day or two, you may not need them again. More tests won’t tell your doctor anything new, unless you’re in intensive care or your treatment changes.
Less testing doesn’t hurt you
There’s no harm in having fewer tests. One study showed that reducing common tests at the hospital did not affect patient health or safety.

Getting too many blood tests has risks

Blood tests are very safe. But they can cause other problems if you have them every day.

  • Anaemia. This can happen if you lose too much blood. With anaemia, your blood cells can’t carry enough oxygen to the rest of your body. Anaemia can make it harder for you to heal. It is especially dangerous for people with heart or lung problems.
  • Increased risk of infection. Blood tests have a low risk of infection. But the more tests you have, the more risk you have.
  • Less sleep. Nurses often wake patients up to get blood tests. Poor sleep can affect how you heal.
You may need a blood test every day if:
  • You are in intensive care.
  • The doctors don’t know what’s wrong with you.
  • You are trying a new treatment.
  • Your doctor thinks you may have internal bleeding, especially if you’re having surgery.
Other tests you may not need

If you’re scheduled to have surgery, your doctor may want you to have certain tests. These are usually done before the day of your surgery. Consider the tests below only if you have certain problems or need some kinds of surgery:

  • Blood coagulation test. May be needed if you’re having brain, cancer, heart, or spinal surgery. You may also need it if you have certain medical conditions or take blood thinners.
  • Breathing test. Recommended if you’re having lung, chest, or upper abdominal surgery. You may also need it if you have lung disease or are short of breath.
  • Cardiac stress test. May be needed if you have heart disease, especially if you are having major surgery.
  • Chest X-ray. May be needed if you smoke, have symptoms of lung or heart disease, or are older than 70, especially if you’re having major surgery.

© 2015 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057).Adapted from Consumer Reports (2015), Blood tests when you’re in the hospital, developed in co-operation with the Society of Hospital Medicine.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Bone density (DEXA) scans

The problem

Many people are routinely screened for weak bones with an imaging test called a DEXA scan. If it detects osteoporosis, the results can help patients and their health professional decide how to treat the problem. But many people learn they have only mild bone loss, a condition known as osteopenia, and for them the risk of fracture is often quite low.

The risks

A bone-density test gives out a small amount of radiation, but radiation exposure can add up. A diagnosis of osteopenia often leads to treatment with such drugs as alendronate (Fosamax), which pose risks. But there is little evidence that people with osteopenia benefit from these drugs.

When to consider the test

Health professionals decide on who to refer for a DEXA scan based on risk factors such as age, a fracture from minor trauma, low body weight, and long-term use of corticosteroid drugs. Whether follow-up tests are needed depends on the results of the initial scan.

Ask these questions

Do I really need to have this test, treatment or procedure?
The answer should be direct and simple. Tests should help you and your health professional decide how to treat your problem, and treatments and procedures should help you live a longer, healthier life.
What are the risks (of having or not having it)?
Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms, but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself.
Are there simpler, safer options?
Sometimes lifestyle changes will provide all the relief you need.
What happens if I do nothing?
Ask your health professional if your condition might worsen—or get better—if you don’t have the test or treatment now.

There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a conversation with your health professional today.


© 2014 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Common tests, treatments and procedures you may think you need. Let’s think again.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Bronchitis – What are the symptoms of Bronchitis?

If you have bronchitis, you will usually have a cough and one or more of the following symptoms:
  • a sore throat
  • tiredness
  • headaches
  • blocked nose and sinuses
  • difficulty breathing
  • a tight feeling in your chest
  • wheeziness
  • fever (a temperature of 38.5°C or higher) and chills
  • aches and pains
How long will the symptoms of bronchitis last?

Your cough can last for a few weeks after the other symptoms of bronchitis have gone. This is called acute bronchitis.
If you have a cough and are producing sputum (mucus or phlegm) for more than 2 months, this is called chronic bronchitis.
Most of the symptoms of acute bronchitis are not severe, and you may not need to see your health professional. However, some symptoms of bronchitis can be similar to those of pneumonia (an infection that causes inflammation in your lungs), so it is important to look out for any changes in your symptoms.
See your health professional if you notice a change in your symptoms or they become worse.
It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2012), What are the symptoms of Bronchitis? Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Bronchitis – What causes Bronchitis?

The viruses that cause the common cold or flu (influenza viruses A and B) usually cause bronchitis, but bacteria (e.g. Mycoplasma pneumoniae) can sometimes also cause it.
Other viruses that cause bronchitis include the parainfluenza viruses (which can also cause croup and bronchiolitis), the respiratory syncytial virus (which can also cause bronchiolitis), the coronaviruses (which can also cause colds) and the adenoviruses (which can also cause colds, pneumonia and croup).
The viruses that cause respiratory tract infections such as bronchitis are usually spread when someone infected with the virus sneezes or coughs, releasing droplets that contain the virus into the air. These droplets can be breathed in by others, or transferred to anyone who touches a surface contaminated with droplets containing the virus.
Some people are at more risk of getting bronchitis and of having more severe symptoms including people who:

  • are older
  • smoke
  • have a weakened immune system (e.g. due to HIV or some medicines)
  • are exposed to chemicals that can irritate the lung tissue (e.g. in their workplace).

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2012), What causes bronchitis? Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Bronchitis – How is Bronchitis diagnosed?

Your health professional will ask you questions about your health, for example:

  • if you have recently had a cold
  • what your symptoms are
  • what medicines you are taking
  • details of your medical history
  • any other medical conditions you may have e.g. asthma or chronic obstructive pulmonary disease (COPD).

Your health professional may examine you, and listen to your breathing using a stethoscope (a device used to listen to your breathing and heart beat). In bronchitis, the airways become inflamed and lots of mucus is produced

Laboratory tests

Throat swab
If you have a fever (a temperature of 38.5°C or higher), a sore throat and a cough, your health professional may also take a sample from your throat and nose using a sterile cotton swab, which will be sent off for laboratory tests to find out what is causing the infection.
Chest X-ray
Your health professional may recommend a chest X-ray if your symptoms get worse, as pneumonia is a common complication of bronchitis.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2012), How is bronchitis diagnosed? Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Bronchitis – Medicines and treatments

Most people with acute bronchitis have infections that can be dealt with by their immune system. They will usually only need treatment for the symptoms of bronchitis. Bronchitis is most often caused by a virus, so antibiotics won’t help, particularly if you are otherwise healthy with a normal immune system. Antibiotics do not kill viruses. There are ways you can relieve the symptoms of bronchitis (e.g. headache, aches, pains and fever), and some over-the-counter medicines that you can take. See your health professional if your symptoms change or become worse, as pneumonia is a common complication of bronchitis.

What can I do to relieve my symptoms?

You can relieve your symptoms by:

  • resting
  • drinking plenty of water and non-alcoholic fluids
  • avoiding exposure to cigarette smoke
  • inhaling steam; this can help relieve a blocked nose. Supervise your child while they breathe in steam from a hot bath or shower in a closed room.

You can help soothe a sore throat by:

  • gargling with warm salty water
  • sucking on an ice cube or a throat lozenge
  • drinking hot water with honey and lemon; this can also be a simple and effective home remedy.
Medicines to manage the symptoms of bronchitis

There are over-the-counter medicines you can take to help manage the symptoms of bronchitis. These include:

  • paracetamol, ibuprofen and aspirin for relieving pain and fever
  • decongestants and saline nasal sprays or drops for relieving a blocked nose.
Medicines for relieving pain and fever
  • Adults and children older than 1 month can take paracetamol.
  • Adults and children older than 3 months can take ibuprofen.
  • The correct dose of paracetamol or ibuprofen for children who have pain or fever is worked out according to how much your child weighs.
  • Do not give aspirin for pain or fever to children younger than 12 years as it may cause serious side effects (e.g. Reye’s syndrome, see below).
  • Do not give aspirin for fever to children 12 to 16 years old. This is because Reye’s syndrome, which can affect brain function and cause liver damage, has been associated with aspirin use in children (this is rare, i.e. fewer than 1 in 1000 people will experience the side effect).

Fevers are common in young children, especially if they have a chest infection or after a vaccination. A fever (a temperature of 38.5°C or higher) doesn’t necessarily mean you or your child has a serious illness. In fact, a fever helps the body’s immune system to fight infection.

Tips for using pain and fever medicines safely
  • Paracetamol and ibuprofen are common ingredients in some cold and flu medicines, so it’s important to check the active ingredients on the label of your medicine to avoid ‘doubling up’ and taking other medicines that also contain paracetamol or ibuprofen.
  • It’s important to tell your health professional about all the medicines you or anyone in your care is taking, including prescription, over-the-counter and complementary medicines (‘herbal’ or ‘natural’ medicines and vitamin or mineral supplements). This is because all medicines, including herbal and natural medicines, can cause side effects and may interact with other medicines.
  • Some medicines cannot be taken by people with particular medical conditions, by people who are also taking certain other medicines, by young children, during pregnancy or when breastfeeding.

Ask your pharmacist or doctor for advice about the safest medicine for you or your child, and always read the label on your medicine.

Medicines to relieve a blocked nose (nasal congestion)

Intranasal decongestants can help to relieve a blocked nose, but should not be used for more than 4 or 5 consecutive days to avoid rebound nasal congestion.
Medicated nasal decongestants must not be used in babies younger than 6 months, as rebound congestion may cause breathing difficulty. Decongestants containing pseudoephedrine, phenylephrine, oxymetazoline or xylometazoline must not be used in children younger than 6 years. Use salt water (saline) nasal sprays or drops instead of a nasal decongestant for these children.
Before using any medicine, check with a doctor or pharmacist about the safest one for you or your child. Always read the information on the label and the consumer medicine information (CMI) leaflet for your medicine if available.
See your health professional if you notice a change in your symptoms or they become worse, as pneumonia is a common complication of bronchitis.

‘Cough and cold’ medicines

Cough, and combination ‘cough and cold’, medicines are available and may relieve your symptoms, but there is not enough information from good quality clinical trials proving their effectiveness, particularly in children. Cough medicines can also sometimes cause unwanted side effects such as drowsiness, nausea, vomiting and constipation. They are not recommended for use in children under 2 years.
Before using any medicine, check with a doctor or pharmacist about the safest one for you or your child. Always read the information on the label and the consumer medicine information (CMI) for your medicine (if available).
It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2012), Medicines and treatments for bronchitis.
Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Coughs, Colds & Sore Throats – Manage symptoms without antibiotics

Manage symptoms without antibiotics

If you have a viral infection of the ear, nose, throat, sinuses or chest, antibiotics won’t make you feel better or recover faster. Talk to your health professional about why you probably don’t need antibiotics.

Do you need a medicine?

Coughs, colds, earaches, sinus congestion problems and sore throats are usually caused by a virus. Antibiotics kill bacteria, not viruses. Colds usually get better in 7 to 10 days, although a cough can last up to 3 weeks.
Taking antibiotics when you don’t need them can have unwanted results.
When antibiotics are necessary, the benefits far outweigh the risks, but when they are not needed, you are taking an unnecessary risk. People taking an antibiotic may experience side effects such as diarrhoea, nausea or vomiting.
Unnecessary use of antibiotics can also lead to antibiotic resistance. This means that antibiotics are no longer effective against the bacteria they once killed. If you have an antibiotic-resistant infection you:

  • will have the infection for longer
  • may be more likely to have complications of the infection
  • could remain infectious for longer and pass your infection to other people.
What can you do?

Rest
Allow your immune system to fight off the virus
Use home remedies
Inhale steam from a bath or shower in a closed room to help relieve a blocked nose. Don’t inhale steam from a bowl of hot water due to the risk of burns.
Soothe your sore throat by gargling warm salty water, sucking ice cubes or throat lozenges as needed or drinking warm water with honey and lemon.
Use symptom-relieving medicines
Take over-the-counter (non-prescription) medicines such as paracetamol or ibuprofen to relieve your pain or fever.
Use a nasal or oral decongestant to relieve a blocked nose. Cough and cold medicines should not be given to children under 6 years of age and should only be given to children aged 6 to 11 years on the advice of a health professional. Saline nasal spray or drops may be used in children. For more information on symptom-relieving medicines see the Choosing Wisely resource on medicines and treatments for bronchitis.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Further information

Antibiotics: Health Navigator
Antibiotic resistance: Health Navigator, Ministry of Health


Adapted from NPS MedicineWise (2016), Coughs, colds & sore throats. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Dementia – Treating disruptive behaviour

Antipsychotic drugs are usually not the best choice

People with Alzheimer’s disease and other forms of dementia can become restless, aggressive, or disruptive. They may believe things that are not true. They may see or hear things that are not there. These symptoms can cause even more distress than the loss of memory.
Doctors often prescribe powerful antipsychotic drugs to treat these behaviours:

  • Olanzapine (Zyprexa and generic)
  • Quetiapine (Seroquel and generic)
  • Risperidone (Risperdal and generic)

If you are uncertain if your loved one is taking one of these medications please ask their health care team. In most cases, antipsychotics should not be the first choice for treatment. Here’s why:
Antipsychotic drugs don’t help much. Studies have compared these drugs to sugar pills or placebos. These studies showed that antipsychotics usually don’t reduce disruptive behaviour in older dementia patients.
Antipsychotic drugs can cause serious side effects. Doctors can prescribe these drugs for dementia for behavioural symptoms, but they cause serious side effects.
Side effects include:

  • Drowsiness and confusion—which can reduce social contact and mental skills, and increase falls
  • Weight gain
  • Diabetes
  • Shaking or tremors (which can be permanent)
  • Pneumonia
  • Sudden death.

Other approaches often work better. It is almost always best to try other approaches first, such as the suggestions listed below.
Make sure the patient has a thorough exam and medicine review.

  • The cause of the behaviour may be a common condition, such as constipation, infection, vision or hearing problems, sleep problems, or pain.
  • Many drugs and drug combinations can cause confusion and agitation in older people.
Talk to an aged care health professional.

This person can help you find non-drug ways to deal with the problem. For example, when someone is startled, they may become agitated. It may help to warn the person before you touch them. For more tips, see below.

Consider other drugs first.

Talk to your doctor about the following drugs that have been approved for treatment of disruptive behaviours:

  • Drugs that slow mental decline in dementia.
  • Antidepressants for people who have a history of depression or who are depressed as well as anxious.

Consider antipsychotic drugs if:

  • Other steps have failed.
  • Patients are severely distressed.
  • Patients could hurt themselves or others.

Start the drug at the lowest possible dose. Caregivers and health professionals should watch the patient carefully to make sure that symptoms improve and that there are no serious side effects. The drugs should be stopped if they are not helping or are no longer needed.

Tips to help with disruptive behaviours.

Keep a daily routine. People with dementia often become restless or irritable around dinner time.

  • Do activities that use more energy earlier in the day, such as bathing.
  • Eat the biggest meal at midday.
  • Set a quiet mood in the evening, with lower lights, less noise, and soothing music

Help the person exercise every day. Physical activity helps use nervous energy. It improves mood and sleep.

Don’t argue with a person who’s distressed.

  • Distract the person with music, singing, or dancing.
  • Ask the person to help with a simple task, such as setting the table or folding clothes.
  • Take the person to another room or for a short walk.

Plan simple activities and social time. Boredom and loneliness can increase anxiety. Adult daycare programmes can provide activities for older people. They also give caregivers a break.
It’s OK to ask questions If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


© 2013 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2013) and Choosing Wisely Canada (2014), Treating disruptive behaviour in people with dementia, developed in cooperation with the Canadian Geriatrics Society.
Choosing Wisely do not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Ear Infection – Treatments

A middle ear infection (otitis media) will often get better by itself in a few days as the body’s immune system can take care of the infection without any treatment.

Children with a middle ear infection

Most children older than 2 years won’t need antibiotics to treat a middle ear infection — the infection will clear up by itself in a few days. However, many children younger than 2 years may need antibiotics to treat the infection.
Antibiotics won’t help relieve your child’s ear pain. Whilst a child’s ear pain will be of concern to their parents or carers, studies show that 6 out of 10 children will have no ear pain after the first 24 hours without any treatment (antibiotics or pain relief).
Pain relief medicines (such as paracetamol or ibuprofen) can help to relieve the symptoms of an ear infection, and will usually only be needed for a short time.
If your child’s symptoms don’t improve after a few days, or their symptoms get worse, see your doctor.

Antibiotics for middle ear infections in children

Antibiotics are recommended for children with middle ear infections who:

  • are younger than 6 months
  • are younger than 2 years old with an infection in both ears or fluid leaking out of their ear (called ‘otorrhoea’)
  • have a fever (a temperature of 38.5°C or higher) and are vomiting.

 

Babies and infants younger than 6 months old
Infants younger than 6 months old who have ear infections (with or without fever or vomiting) will usually be prescribed an antibiotic. Your doctor will usually ask to see your baby again in 24 hours.
Children aged 6 months to 2 years
Your doctor will advise you on how to relieve the symptoms of a middle ear infection.. Your doctor may ask to see your child after 24 hours, or contact you to ask how they are. If your child’s symptoms don’t improve after 24 hours, your doctor may prescribe antibiotics.
Children aged 2 years or older
Your doctor will advise you on how to relieve the symptoms of a middle ear infection.. If your child’s symptoms don’t improve in 2 days, your doctor will usually examine your child again and may prescribe antibiotics if necessary.

Adults with a middle ear infection

Most adults won’t need antibiotics to treat a middle ear infection — the infection will clear up by itself in a few days.
Your doctor can provide advice about how to relieve your symptoms. If your symptoms don’t improve in 2 days, your doctor will usually examine you again and may prescribe antibiotics.
Paracetamol, ibuprofen or aspirin can help relieve the pain caused by an ear infection

For more information: Health Navigator.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2016), Medicines and treatments for a middle ear infection. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

ECGs (Electrocardiogram)

The problem

An ECG records the electrical activity of your heart at rest. It provides information about your heart rate and rhythm, and shows if there is enlargement of the heart due to high blood pressure (hypertension) or evidence of a previous heart attack (myocardial infarction).

The risks

The ECG will not harm you. However, it can sometimes show mild nonspecific abnormalities that are not due to underlying heart disease, but cause worry and lead to follow-up tests and treatments that you do not need.

When to consider the tests

You may need an ECG test if you have risk factors for heart disease such as high blood pressure, or symptoms such as palpitations or chest pain. Or you may need it if you already have heart disease.

Ask these questions:

Do I really need to have this test, treatment or procedure?
The answer should be direct and simple. Tests should help you and your health professional decide how to treat your problem, and treatments and procedures should help you live a longer, healthier life.
What are the risks (of having or not having it)?
Discuss the risks as well as the chance of inaccurate results or findings that will never cause symptoms, but may require further testing. Weigh the potential complications against possible benefits and the symptoms of the condition itself.
Are there simpler, safer options?
Sometimes lifestyle changes will provide all the relief you need.
What happens if I do nothing?
Ask your health professional if your condition might worsen—or get better—if you don’t have the test or treatment now.

There may be tests, treatments and procedures you think you need, but you don’t. Let’s think again. Engage in a conversation with your health professional today.


© 2014 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Common tests, treatments and procedures you may think you need. Let’s think again.
Choosing Wisely do not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

End of Life care for advanced cancer patients

When to stop cancer treatment

When you have cancer and you have tried many treatments without success, it can be very hard to know when to stop treatment. Sometimes, even with the best care, cancer continues to spread. It is hard to accept, but the best thing for you at that point may be to stop the cancer treatment. Instead, you could focus on getting care to keep you comfortable and out of pain.
This fact sheet explains how to know when it is time to stop treatment and focus on end-of-life care. You can use this information to talk with your doctor about your options and choose the best care for you.

Cancer responds best to treatment the first time.

When you treat a tumour for the first time, there is hope that the treatment will destroy the cancer cells and keep them from returning. If your tumour keeps growing, even with treatment, there is a lower chance that more treatment will help.
This is especially true for solid tumour cancers, like breast, colon, and lung cancer, and sarcoma. Doctors know a lot about how these cancers grow or shrink over time and how they respond to treatment. They have found that treatment after treatment often offers little or no benefit.

When is it time to think about stopping cancer treatment?

If you have had three different treatments and your cancer has grown or spread, more treatment usually will not help you feel better or increase your chance of living longer. Instead, more treatment could cause serious side effects that shorten your life and reduce the quality of the time you have left.
Still, many people with advanced cancer keep getting chemotherapy—even when it has almost no chance of helping them. They end up suffering when they should not have to.

How do you know when to stop treatment?

It can be hard for the patient, caregivers and the doctor to talk about stopping treatment for the cancer and focus on end-of-life care. Your doctor may bring it up, but sometimes you may need to start the discussion. Your doctor should give you clear answers to any questions you ask.
You need to understand how advanced your cancer is. Ask your doctor about the stage of your cancer and how much it has spread. Ask about your prognosis, or how long you have to live. No one can know exactly, but your doctor usually should be able to tell you a range of months or years.
You need to know if more treatment for cancer will help you live longer. Ask your doctor to explain the risks and benefits of any treatment. Fighting the cancer may no longer be the best thing for you.
Sometimes, if there are no more known treatments and you want to continue other options, you can join a clinical trial. Clinical trials offer new, experimental treatments. Ask your doctor if you are eligible for a clinical trial.
At any time during your treatment you can get help to relieve your symptoms and improve your quality of life. This is called palliative care and it is often important while going through cancer treatment. If you decide that you don’t want more cancer treatment, then it’s time to focus even more on palliative care.

Palliative care improves your quality of life.

Palliative care is an added layer of support to help you and your loved ones live with cancer. It does not treat your cancer, but it helps reduce your pain and other symptoms. It helps you and your loved ones get the most out of the time you have left together.
With palliative care, you can get physical, emotional, and spiritual support. You can get help to relieve pain, fatigue, anxiety, shortness of breath, nausea, and depression. Sometimes your doctor can provide palliative support. Other times a trained palliative care team works with you and your doctor to provide specialist care and the services you need. For example, palliative radiation may be appropriate even when a non-active treatment approach has been adopted to treat symptoms such as pain. Ask your oncologist or palliative care team if that may be an option for you.
Palliative care services may be available in your home, in a hospice facility, or at a hospital.
Services include:

  • doctor and nursing care
  • pain management
  • medical equipment and medicines to ease symptoms
  • grief counseling for family/whānau and friends
  • social worker services
  • respite care, to give your caregivers a break.
Questions to ask your doctor

Let your doctor know how much additional information you want to know about your cancer, and when you are ready to talk about end-of-life care.
Ask your doctor:

  • How long do I have to live if I have more treatment?
  • What will happen if I do not have more treatment?
  • What is the goal of more treatment?
  • Will treatment stop or slow my cancer, or will it help with the symptoms?
  • What is the best way to manage my symptoms and side effects?
  • What can I do to make my quality of life better?
  • Should I meet with someone who knows about palliative care?

If you would like to know more about palliative care:

  • Ask your doctor for a referral to palliative care services available in your area.

For more information: www.advancecareplanning.org.nz

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


© 2016 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2016) and Choosing Wisely Canada (2014), Care at the end of life for advanced cancer patients, developed in cooperation with the Canadian Association of Medical Oncologists, Canadian Association of Radiation Oncology, Canadian Society for Surgical Oncology and Canadian Partnership Against Cancer.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Fatigue – are there tests for fatigue

Facts about fatigue
  • There is no test specific for fatigue.
  • Undiagnosed medical problems are not a common cause of fatigue.
  • In some cases of fatigue further tests may be appropriate.

Fatigue is a symptom that can have many causes, and research into fatigue has shown that most of them are not related to a medical condition.
Your health professional will use information from your medical history and from any examinations they conduct to decide what further steps may need to be taken to help treat or manage your fatigue.

Medical tests may help identify a physical cause

There is no test specific for fatigue, only tests that may help identify a physical cause. The decision about whether to have a test and what type of test to have will depend on your individual situation.
Studies have shown that a medical explanation is found in only about 4% of people with fatigue who go on to have some form of testing. So, for every 100 people who are recommended for some form of test by their health professional to help find out why they are experiencing fatigue, a medical condition will be identified in only about four cases.
It is important to understand that medical tests are not always accurate in their diagnosis. Sometimes they pick up a problem when there isn’t one (this is called a false positive), and sometimes they can miss a diagnosis (this is called a false negative).
So you may want to discuss the pros and cons of medical tests with your health professional.
For further information: Health Navigator New Zealand.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise, Are there medical tests for fatigue? Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Headaches – Imaging tests

CT and MRI examinations are called imaging tests because they take pictures, or images, of the inside of the body. Many people who have headaches want a CT scan or an MRI to find out if their headaches are caused by a serious problem, such as a brain tumor. Most of the time these tests are not needed. Here’s why:

Imaging tests rarely help

Health professionals see many patients for headaches and most of them have migraines or headaches caused by tension. Both kinds of headaches can be very painful, but a CT scan or an MRI rarely shows why the headache occurs. Having a CT scan or MRI also does not help ease the pain.
A health professional can diagnose most headaches during an office visit. They ask you questions about your health and your symptoms. This is called a medical history. Then they may do what is called a neurological exam, which includes a test of your reflexes. If your medical history and exam are normal, usually imaging tests will not show a serious problem.

Imaging tests have risks

A CT scan of the head uses a low radiation dose. This may slightly increase the risk of harmful effects such as cancer. Risks from radiation exposure may add up, so it is best to avoid unnecessary radiation.
The results of your CT scan or an MRI may also be unclear. This can lead to more tests and even treatment that you do not need.

When should you have an imaging test for headaches?

In some cases you might need a CT scan or an MRI. You might need one if your health professional cannot diagnose your headache based on your neurological exam and medical history. Or you might need one if the exam finds something that is not normal.
You may also need a CT scan or an MRI if you have unusual headaches. See your health professional right away if:

  • You suddenly develop a very severe headache which feels like something is bursting inside your head.
  • Your headaches are different from other headaches you’ve had, especially if you are age 50 or older.
  • Your headaches happen after you have been physically active.
  • You have headaches with other serious symptoms, such as a loss of control, a seizure or fit, or a change in speech or alertness.
How to treat a headache

Your health professional can advise you on how best to treat your headache. You can help most headaches by taking these steps:
Avoid triggers. Triggers are events that can cause headaches. These tips can help you avoid triggers:
If you have migraines:

  • Wear tinted glasses in bright light
  • Do not skip meals
  • Avoid alcohol, meat with added nitrates (such as cold cuts), and aged cheeses (hard, dry cheeses such as parmesan).

If you have tension headaches:

  • Avoid getting over tired
  • Hold your back and neck straight when you sit or stand
  • Keep your jaw relaxed (not clenched).

Quit smoking. Smoking can bring on either kind of headache.
Manage stress. Try meditation, yoga, stretching, or other activities that can help you relax.
Get plenty of sleep. Aim for six to eight hours of sleep each night. Set a regular time to go to bed and to wake up. Avoid watching TV or using a computer just before you go to bed.
Get plenty of exercise. Regular exercise, such as swimming, brisk walking, or cycling, can reduce stress and ease both kinds of headaches.
Non-prescription pain medicines such as the following can help:

  • paracetamol
  • ibuprofen
  • naproxen

You can buy all of these without a prescription. Try not to take any of these pills more than once or twice a week. Overuse can make headaches worse and cause side effects.
If your headaches are severe or happen often, there are medications which your health professional can prescribe to help lower the pain level and/or reduce how frequently you get them.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


© 2016 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057).Adapted from Consumer Reports (2016) and Choosing Wisely Canada (2014), Imaging tests for headaches, developed in cooperation with the Canadian Association of Radiologists.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Heartburn and Reflux

Manage your medicine

Prescription medicine for heartburn and reflux, called a proton pump inhibitor, is often only needed for 4 to 8 weeks. If your symptoms are well managed, talk to your health professional about reviewing your medicine.

Do you need a medicine?

Acid reflux – also described as heartburn – is a condition where acid from the stomach moves up into your oesophagus (food pipe). Acid reflux is very common. Many people can control their symptoms by making lifestyle changes or by taking over-the-counter (non-prescription) medicines as needed. Some people with more regular or severe symptoms – people with gastro-oesophageal reflux disease (GORD) – may need a prescription medicine known as a proton pump inhibitor (PPI).
PPI medicines work by reducing the amount of acid made by the stomach and are very effective at controlling symptoms of reflux and heartburn. However, PPIs should not be taken long term when not needed, because of the cost and possible side effects.
If you’ve been taking a PPI for more than 4 to 8 weeks, and your symptoms seem to be well managed, talk to your health professional about reviewing your medicine. Your health professional may recommend stepping down your treatment, which can include any of the following:

  • reduce your daily dose of medicine
  • limit your treatment so that you take medicine only when you experience the symptoms of heartburn and reflux (also known as on-demand therapy)
  • stop treatment completely as your symptoms may not return
What can you do?

Making changes to your lifestyle may help control your symptoms and reduce the need for medicine.
Stop smoking
Discuss ways to quit smoking with your health professional, such as nicotine replacement therapies, or call Quitline on 0800 778 778.
Other lifestyle changes

  • Identify and avoid foods and drinks that make your symptoms worse (e.g. fatty foods, spicy foods, chocolate, coffee, cola drinks, orange juice and alcohol).
  • Avoid eating large or late meals and avoid lying down immediately after meals.
  • If you experience symptoms that are worse at night and disrupt your sleep, try raising the head of your bed.
  • If you are overweight, try losing some weight.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2016), Heartburn and reflux. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Insomnia

Trouble sleeping or staying asleep for long enough, insomnia is a common problem and can be caused by many factors.
Read more at www.healthnavigator.org.nz/health-a-z/i/insomnia

Medicines – Review

A medicines review can help improve your treatment and prevent medicine problems. Ask your doctor or pharmacist to organise a review of all your medicines regularly — especially if you or someone you care for is an older person and take several different medicines.

Why should I have my medicines reviewed?

Medicine problems like side effects are more common when you get older — and can often occur when your medicines, health, or health care services change.
If you are an older person it is important that your medicines, current health problems and treatment goals are reviewed regularly. This helps to make sure you receive the best treatment.
When your doctor or pharmacist reviews your medicines they will check:

  • what medicines you are taking and why
  • how many different medicines you take
  • the dose of each medicine you take
  • how you are taking these medicines
  • how well your medicines are working
  • side effects or other problems you may have with your medicines.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2013), What is a medicines review? Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Medicines – Stopping a medicine

Stopping a medicine can seem daunting, especially if you’ve been taking the medicine for a long time. But for many older people, stopping a particular medicine may actually benefit their health. Medicine problems such as side effects and interactions are common when you are an older person. The more medicines you take, the more likely you are to experience these problems. Many older people successfully stop medicines without feeling worse. In fact, you may feel better and improve your quality of life — especially if your symptoms were being caused by your medicines.

A health professional may recommend you stop taking a medicine because:
  • the medicine is causing, or may cause, harmful side effects and medicine interactions
  • the medicine isn’t working or won’t help you achieve your treatment goals
  • the medicine is no longer needed for your current medical conditions
  • you are having difficulty taking the medicine
  • other treatment options are more suitable for you.
When should I stop taking a medicine?

Your doctor or another health professional will recommend the best way to stop your medicines when this is necessary. Their advice is very important, as your medicines may need to be stopped carefully.
You may be able to stop a medicine immediately — and this is usually recommended for any medicine that is causing you harm.
But some medicines need to be stopped gradually. This is because they can cause serious symptoms or other problems if you suddenly stop taking them. Medicines that may do this include:

  • some antidepressants
  • anxiety medicines
  • corticosteroid medicines
  • some medicines for the heart, blood, and blood vessels
  • levodopa (used for Parkinson’s disease)
  • pain relief medicines that contain opioids
  • sedatives and medicines for sleep problems.

Stopping medicines like those listed above usually involves slowly reducing your dose over time, or slowly reducing how often you take the medicine. Exactly how you do this can depend on:

  • the medicine you need to stop
  • the dose you are taking
  • how long you were taking the medicine for
  • your current health
  • previous experiences with stopping the medicine.

What you are most comfortable with is also important, so let your health professional know if you have any preferences so you can agree on a plan.

Stopping one medicine at a time

You may need to stop taking several of your medicines. This doesn’t mean they will all need to be stopped at the same time.
A health professional may advise you to stop one or two medicines at a time so it is more manageable and safer for you. Which medicine to stop first will depend on which medicine is clearly not benefiting you, is causing side effects, or is most likely to cause you harm.

Reviewing your progress

When you are stopping a medicine let your health professional know if you are experiencing any new symptoms or changes in how you feel.
A medicine may need to be restarted if you realise you were feeling better while taking it, or because you’d like to try stopping it another time.
Symptoms you develop when stopping a medicine or reducing the dose may also mean you will need to reduce the medicine more slowly. Sometimes these symptoms get better over time, without you having to restart the medicine or previous dose.

What else can I do?
  • Talk to your health professional about what you want to achieve with your health and wellbeing.
  • Discuss any problems or concerns you have about your medicines with a health professional.
  • Ask if any new symptoms you are experiencing could be due to any medicines you are taking.
  • Ask your doctor or pharmacist about having your medicines reviewed.
  • Use a medicines list to help keep track of your medicines: record any changes that are made to your medicines, and show the list to all the people involved in your health care.
  • Find out what other services and resources can help you manage your health and medicines.

You may find it helpful to have a carer or family/whānau member with you when talking to anyone involved in your health care — especially if English is not your first language.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2013), When and how to stop taking a medicine. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Medicines – When can medicine problems occur?

While problems with medicines can happen at any time, there are some situations when they are more likely to happen. Medicine mistakes are particularly common if you are going into or leaving hospital. Around half of medication errors in hospitals occur when you are admitted or discharged home. Changes in your health and your medicines can also result in more side effects, interactions and medicine mistakes. Lack of communication with — and between — the people involved in your health care often contributes to medicine problems happening. You may find it helpful to have a carer or family/whānau member with you when talking to anyone involved in your health care.

When your medicines change

Let your doctor, pharmacist and other health professionals know about:

  • any problems you experience or concerns that you have after starting a new medicine
  • any changes that are made during your treatment (e.g. changes in the dose you take).

All medicines — prescription and non-prescription — can cause side effects, interactions and other medicine problems. Non-prescription medicines include over-the-counter medicines from a pharmacy or supermarket, and complementary medicines such as herbal remedies, vitamins and minerals.

Starting a new medicine

Side effects and medicine interactions are often more likely — and can be more severe — when you first take a new medicine. This can be because your body isn’t yet used to the effects of the medicine.
Side effects that can be more problematic when you start taking a medicine include:

  • dizziness or light-headedness
  • drowsiness or reduced alertness
  • feeling agitated or restless
  • nausea or vomiting

Starting another medicine may also mean that you begin to have trouble managing all of your medicines, especially if you are already taking several different medicines.

Changes in the dose of your medicines

Side effects and medicine interactions may depend on the dose of the medicines you are taking. Generally, the more of a medicine you take, the more likely you are to experience these problems.
You may begin to experience side effects and interactions when your medicine dose increases. With some medicines, decreasing the dose could also affect another medicine you take.
Dose adjustments can mean changes to when and how much of your medicines you take, which may make it harder for you to manage your medicines, or easier to confuse and mix them up.
Having to take a medicine for a long time can cause problems too. For example, dependence on sleeping pills such as temazepam is more likely when you take them for longer than 2 weeks.

When your health changes

If you develop a new medical condition or a new symptom, you may be prescribed another medicine. This can increase your chance of side effects and medicine interactions.
Medicines you currently take for one medical condition may affect a newly diagnosed condition. For example, heart failure can be worsened by a non-steroidal anti-inflammatory medicine taken to relieve pain or inflammation.
Problems can also arise if you take a medicine left over from a previous illness or a medicine that is not prescribed or recommended for you. What’s right for another person or medical condition may not be right for you. Do not share medicines with other people, even if they have the same health problem.
Some medical conditions or symptoms can also interfere with how well you manage your medicines. Common causes of medicine problems include:

  • confusion or memory loss
  • poor eyesight or hearing
  • difficulty swallowing
  • reduced physical ability due to muscle or joint problems.
When your health care services change

Multiple health problems when you are older can mean that you will need to see more than one doctor or other health professional, and sometimes you may need to be cared for in hospital.

Going into and leaving hospital

New medicines are often started in hospital, and medicines you have been taking for a long time may be changed or stopped. This can increase your chance of medicine problems for various reasons. For example, you may:

  • end up taking more medicines after you leave hospital
  • be prescribed medicines that can cause serious problems
  • have to take your usual medicines differently, or in a more complicated way
  • be given a different brand of medicine from the one you usually take.

Lack of communication and medicine mistakes in hospital:

  • Hospital staff may not have correct or complete information about all the medicines you are currently taking.
  • You and your usual doctor may not be fully informed about changes to your medicines after you leave hospital, including new and stopped medicines.
  • Your doctor may not immediately receive the information they need about your hospital treatment.

Keeping an up-to-date medicines list is a good way to keep track of all the medicines you are taking.

Seeing many health professionals

It is important that you tell all the people involved in your health care about all the medicines you are taking. This will help to make sure that they have all the information they need when prescribing or recommending medicines for you.
For example, your GP needs to know about medicines prescribed by your specialist before they prescribe another medicine for you. This is important to help you avoid medicine problems such as side effects and interactions.

What else can I do?
  • Use a medicines list to help keep track of your medicines: record any changes that are made to your medicines, and show the list to all the people involved in your health care.
  • Talk to your health professional about your health, your wellbeing, and your medicines. Ask if any new symptoms you are experiencing could be due to any medicines you are taking.
  • Ask your doctor or pharmacist about having your medicines reviewed if you have recently spent time in hospital.
  • Find out about other ways that you and your carers can help to prevent medicine problems.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2013), When can medicine problems occur? Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on of any information in this resource.

Medicines – Working out your treatment goals

Different factors are important to different people when it comes to taking medicines. Different medicines can have different effects too.

What is a treatment goal?

Whether you start, stop or continue taking a medicine when you are an older person will depend on what you want to achieve with your health and wellbeing.
These treatment goals may be to:

  • relieve or prevent symptoms
  • avoid disease or its complications
  • treat an illness or stop it getting worse
  • maintain your physical and mental wellbeing
  • improve your quality of life
  • extend your life
How do I determine my treatment goals?

Your health, wellbeing, and ability to cope with illness or disease can be different from other people — and can change for you at any time. This can influence your treatment goals and the medicines you take.
Talk to your health professional about what you want to gain from treatment, or what it is about your current health that troubles you most. That way you and your health professional can find out if a medicine or another treatment can help.

One size does not fit all

As an older person you may be very fit and healthy, or you may have a medical condition that you are able to manage yourself. You may have disease symptoms that tire or slow you up, or that reduce your ability to carry out daily activities on your own. Or perhaps you or someone in your care is very frail, completely dependent, or near the end of life.
These differences can mean that what you want from treatment as a fit and healthy older person will be different from your needs if you are very frail or sick. Preventing disease and staying active may be most important when you are fit and healthy — while improving symptoms, mobility and quality of life may be the goal if you are frail or dependent on care.

Treatment goals can change over time

Also keep in mind that your treatment goals can change. For example, if the symptoms of your medical condition worsen, or your values, experiences or concerns about your medicines change.

What can I do?

Ask your health professional to review your medicines regularly to check they are still needed and are achieving your treatment goals. Discuss any problems with, or concerns you have, about your medicines with your doctor or other health professional at any time.
Find out about other ways that you and your carers can help to prevent medicine problems.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2013), Working out your treatment goals. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Medicines – Making decisions

Discuss your treatment options with a health professional

To determine whether a medicine or other treatment is right for you when you are older, talk to your doctor, pharmacist or other health professional.

Your doctor, pharmacist or other health professional will need to know about:
  • your current health problems
  • what you want to achieve with your health and wellbeing (your treatment goals)
  • any side effects and other medicine problems you may experience
What can I do?

You can work with your health professionals to make the best decisions about your medicines by:

  • Preparing a list of questions to ask about your health and medicines.
  • Asking for the consumer medicine information (CMI) for your prescription and pharmacist-only medicines.
  • Checking whether any non-prescription and complementary medicines can interact with your current medicines before you take them.
  • Talking about any changes in how you feel, especially when taking new medicines or doses.
  • Asking about a medicines review and any other services or resources that can help you.

Adapted from NPS MedicineWise (2013), Discuss your treatment options with a health professional. Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Medicines – Making decisions for older people

Making decisions about medicines when you are older is not always straightforward — for you, your doctor, or anyone else involved in your care. At times there will be a clear need for you to take a particular medicine, and the benefits for your health condition will likely outweigh the risk of side effects or other medicine problems. But often the decision is not so clear cut, and the balance of benefits and risks will depend on what is most important to you — including what you want to achieve with your health and wellbeing.

What do I want to achieve with my medicines?

Medicines can have different beneficial effects — from relieving your symptoms to extending your life.
What you need to gain from medical treatment should always be considered when you are deciding about medicines. This is always important even when a doctor, carer, or family/whānau member is deciding for you.
Whether you start, stop or continue taking a medicine, or make other changes (e.g. to your dose) will also depend on the risks and benefits of treatment for you.
Your doctor can work with you to help you decide:

  • how you want to improve your health and wellbeing
  • what benefits or risks there are with your treatment options
  • which medicines are likely to benefit or cause you harm.

Find out about other ways that you and your carers can help to prevent medicine problems.

Making a decision to take a medicine

‘Will it work?’ is often one of the main concerns for people who are deciding to take a medicine.
Your decision can also be shaped by your experience of health problems, your personal life, what you want to get from your treatment, and your priorities and values.
Staying active and maintaining quality of life are important considerations too. Worsening health, side effects, and the cost of your medicines may all be factors you will also need to consider.


NPS MedicineWise (2013), Making decisions about medicines for older people. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand does not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Palliative Care

Support at any time during a serious illness

Palliative care is an added layer of support to help you and your loved ones live with a serious illness.

With palliative care, you can get physical, emotional, and spiritual support

You can get help to relieve pain, fatigue, anxiety, shortness of breath, nausea, and depression. This helps you learn what to expect from your illness and decide on a treatment plan. Sometimes your doctor can provide palliative support. Other times a trained palliative care team works with you and your doctor to provide specialist care and the services you need.

Palliative care can help you at any stage of a serious illness

Examples include congestive heart failure, kidney disease, multiple sclerosis, and cancer. Doctors often wait too long or they simply don’t refer patients for added palliative care supports. Many patients who are seriously ill miss out on the benefits of palliative care.

Palliative care improves your quality of life and may help you live longer

In a study of people with advanced cancer, those who got palliative care early reported better control of pain and other symptoms. People who got palliative care had a better quality of life and less depression. They also lived longer and spent less time in the hospital than those receiving only standard treatments.
Studies suggest that there are similar benefits for people with other serious illnesses.

Palliative care is not “end-of-life” care or hospice

Palliative care can be useful no matter how long you are expected to live. You don’t have to give up other treatments for your illness.

Start palliative care early for best results

Palliative care is most helpful if you start it early during a serious illness. You should request it, no need to wait for your doctor to bring it up. It will affect your quality of care and treatment decisions.

Plan ahead! Don’t wait until you are sick to start advance care planning conversations

Advance care planning helps you think about, talk about and document wishes for health care in the event that you become incapable of consenting to or refusing medical treatments or other care.
Choose a loved one, family/whānau member or friend to communicate your wishes for you, should you become too unwell to make decisions for yourself. Talking to that person as well as your doctor and the rest of your family/whānau will help ensure your wishes are known and will help your loved ones make treatment decisions on your behalf.
Put your plans in writing.
Some people and their doctors put off talking about their wishes and values for health care. This puts you at risk of being too ill to guide your doctors and may increase the uncertainty and burden that your loved ones feel.
For more information: www.advancecareplanning.org.nz

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


© 2014 Consumers Union of United States, Inc, (101 Truman Ave, Yonkers, NY 10703-1057). Adapted from Consumer Reports (2014) and Choosing Wisely Canada (2014), Palliative care, developed in cooperation with the Canadian Society of Palliative Care Physicians.
Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.

Type 2 Diabetes

Self-monitoring your blood glucose levels is not routinely recommended if you have type 2 diabetes and are not taking insulin or a sulfonylurea. Talk to your health professional about reviewing your self-monitoring of blood glucose levels.

Do you need to test?

Type 2 diabetes is a condition where the body either cannot respond to insulin or cannot produce enough insulin to control glucose levels in the blood. Type 2 diabetes is associated with genetics and lifestyle factors (e.g. poor diet, obesity, physical inactivity).
Blood glucose levels in people with diabetes are usually checked by your doctor four times per year, using a laboratory test called HbA1c, or a ‘finger prick’ test and a blood glucose monitor. Self-monitoring is when you check your blood glucose levels at home using the ‘finger prick’ test.
If you have type 2 diabetes and are not taking insulin or a sulfonylurea, self-monitoring of your blood glucose levels is not routinely recommended.
Research shows self-monitoring of blood glucose provides only slight improvement in control of type 2 diabetes, however general well-being or general health-related quality of life is not improved. Talk to your health professional about when self-monitoring might be of benefit, such as assessing low blood sugar.
Whether you self-monitor your blood glucose or not, the following advice will help manage your diabetes.

What can you do?

Manage your weight
Know your healthy weight and, if needed, develop a healthy eating and exercise plan to achieve those goals.
Eat a healthy diet
Maintain a balanced diet that includes a wide range of vegetables, moderate amounts of high-fibre carbohydrates that have a low glycaemic index (GI), lean cuts of meat and fish, low-fat dairy products, and small amounts of high fat and sugary foods. Low GI foods release glucose into the blood slowly, which helps blood glucose levels rise steadily and avoid a glucose high.
Exercise regularly
Regularly exercising improves blood glucose control and overall health and wellbeing. Aim for at least 150 minutes per week of moderate-intensity exercise (e.g. brisk walking, aqua aerobics) or 75 minutes of vigorous activity (e.g. jogging, swimming).
Take your medicines correctly
If you have been prescribed medicines to control your blood glucose levels, it is important to take your medicines at the correct dose and times.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.


Adapted from NPS MedicineWise (2016), Type 2 diabetes. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.

Vitamin D tests and deficiency

Vitamin D is a hormone that helps your body absorb the calcium it needs to keep your bones and muscles strong and healthy. We can get some of our vitamin D requirement from food, but it is very difficult to get enough vitamin D from diet alone. We are usually able to make most of the vitamin D we need ourselves, when our bare skin is exposed to ultraviolet (UV) radiation from sunlight.

Why do I need vitamin D?

We know that vitamin D is essential for bone and muscle health. Moderate to severe vitamin D deficiency can lead to rickets (soft bones) in infants and children. In adults over the age of 50, low vitamin D levels can lead to osteoporosis (brittle bones) and increase the risk of falls and fractures (broken bones).
Many health conditions, including diabetes, heart disease and some cancers, have been linked to low vitamin D levels, but whether low levels of vitamin D cause these conditions is unclear. The benefits of increasing vitamin D intake for these health problems —through sun exposure, diet or supplements — are unknown.

Am I at high risk of vitamin D deficiency?

You may be at risk of vitamin D deficiency if you:

  • are confined indoors because of age, illness or disability — particularly residents of aged-care facilities
  • are Māori, Pacific, African or Indian
  • wear clothing that covers most of your body most of the time (e.g. for religious or cultural reasons)
  • cover your skin or avoid the sun because of a condition that places you at higher risk of skin cancer (e.g. if you have a suppressed immune system, such as after an organ transplant)
  • have a health condition that affects vitamin D absorption from your diet (e.g. cystic fibrosis, coeliac disease, Crohn’s disease)
  • take medicines that cause vitamin D to break down (e.g. some epilepsy medicines).

People with very low levels (moderate to severe deficiency) are most at risk of health problems.
Women need to maintain healthy vitamin D levels during pregnancy, as their unborn baby needs vitamin D to help bone and tooth development. Some pregnant women may be at risk of low vitamin D — this is most likely if you also have one or more of the risk factors listed above.
Breastfed babies who fall into the risk categories above or have mothers with low vitamin D may also be at risk of vitamin D deficiency. Infant formula in New Zealand is fortified with vitamin D.

How do I get vitamin D?

Sun Exposure
For most people, the simplest way to increase vitamin D levels is through sensible sun exposure on bare skin. The ideal amount of sun will vary depending on:

  • where you live — UV levels are higher in northern New Zealand (e.g. Auckland)
  • what season it is — UV levels are higher in summer than winter
  • the time of day — UV levels peak during the middle of the day
  • your skin colour — if you have dark skin, you need 3 to 6 times more sun exposure to produce the vitamin D your body needs.

During summer, most fair-skinned people can probably get enough vitamin D from a few minutes of exposure to sunlight on their face, arms and hands (or the equivalent area of skin) on either side of the peak UV periods on most days. In winter, in southern New Zealand, more sun exposure may be needed. The table below provides an approximate guide to sensible sun exposure for a person with fair skin.
Most children and teenagers can maintain healthy vitamin D levels if they play outdoor games or sport during the day. Children need sun protection — such as sunscreen, a hat, clothing, sunglasses and shading during summer.
Recommended daily sun exposure for vitamin D production for people with fair skin*

Region Dec-Jan (summer) 10am or 2pm July-Aug (winter) 10am or 2pm July-Aug (winter) Midday
Auckland 6-8 min 30-47 min 24 min
Christchurch 6-9 min 49-97 min 40 min

Diet
The natural food sources of vitamin D include liver, eggs and fatty fish such as salmon, herring and mackerel. In New Zealand, milk and other products such as margarine and cereals may be fortified with vitamin D, but if you are low in vitamin D you will not be able to correct the problem through diet alone.
Supplements
Some New Zealanders find it difficult to get enough sun to ensure adequate levels of vitamin D, especially those people identified at high risk of deficiency. In these situations, vitamin D supplements may be required.
If your health professional recommends a supplement, it’s important to take it exactly as advised.

Do I need a vitamin D test?

Studies have found that many New Zealanders have lower than recommended vitamin D levels. Whether this has any negative health effects remains to be seen.
People at low risk of deficiency do not need to be tested for vitamin D. People who are at higher risk of deficiency, such as those with darker skin, or those who wear modest dress, may need to get tested, as well as:

  • older people who have been diagnosed with osteoporosis and/or are at increased risk of falls and bone fractures
  • pregnant women and breastfeeding mothers with vitamin D risk factors, as vitamin D deficiency could affect their baby’s bone and tooth development
  • babies, children and adolescents who are at high risk of vitamin D deficiency, as their bones are still growing.

A vitamin D test is not required before a health professional prescribes a vitamin D supplement, unless severe deficiency is suspected.*
If you’re healthy but are worried your lifestyle is putting you at risk of low vitamin D, try to follow the safe sun exposure guidelines mentioned above and look after your bone and muscle health by:

  • Eating a calcium-rich diet — many people don’t consume enough calcium in their diet. The best food sources of calcium include dairy products, tinned bony fish, calcium-set tofu, nuts and some green vegetables.
  • Keeping physically active — weight-bearing and muscle-strengthening exercises such as tennis, jogging and Tai Chi are best. The exercise may also help guard against obesity, another risk factor for low vitamin D.
What does a vitamin D blood test involve?
  • A vitamin D test is a simple blood test that measures a form of vitamin D in the blood called 25-hydroxyvitamin D (25-OHD). In general, health experts agree that a vitamin D level of 50 nanomoles per litre (nmol/L) or above is adequate for bone health.
  • Vitamin D tests are best performed at the end of winter or in early spring when your body’s vitamin D levels are at their lowest. Ideally, your vitamin D level should be 50 nmol/L or above at this time, and somewhat higher in summer.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

*Source: Best Practice Journal (2011), Vitamin D supplementation: navigating the debate.


Adapted from NPS MedicineWise (2014), Vitamin D tests and deficiency. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise and Choosing Wisely New Zealand do not assume any responsibility or liability arising from any error or omission or from reliance on any information in this resource.