Transcript Office-Based Geriatric Assessment: A Practical Approach

Using Prognosis to Make
Screening Decisions
Elizabeth Eckstrom, MD, MPH
Oregon Health & Science University
Hollis Day, MD, MS
University of Pittsburgh
Objectives
• Discuss potential screening measures for
older adults
• Discuss the role of life expectancy in
deciding when to stop/continue screening
• Identify and utilize useful prognostic tools
Prevention- wow, that’s a lot!Do I just keep doing all
this on everyone till they die?
• Prevention
– flu shot
– Pneumovax
– Tetanus
– Zoster
– mammogram
– Colonoscopy
– DXA
– exercise
– Ca/ vitamin D
– seat belts, exercise, diet
– AAA
• Advanced directives
– DPAHC
– preferences for care
When should you stop screening
older adults?
• When considering screening, think about the
patient’s life expectancy and prognosis from
other illnesses. Patient may have “competing
risks” that make value of screening less
• Example: Diagnosing and treating an early
breast cancer adds:
– 18 months of life if you are 75
– 12 months of life if you are 80
– 6 months of life if you are 85
Life Expectancy Curves
Life Expectancy Curves
Mrs. Smith is 70 and healthy, when she develops breast cancer, with a 5
year mortality rate of 25% (this is a later stage breast cancer)
Finding and curing her breast cancer could add 7 years of life
It is “easy” to think about life expectancy and
prognosis when someone is healthy and
gets a single disease, but what about an
older person with multiple illnesses and
poor functional status?
Study of Prognosis:
11,000 participants
asked questions about
diseases and functional
status, followed over 4
years
Validated with a second
group of subjects
-Lee, JAMA, 2006
Mr. Jones
84 years old
Has diabetes
Smokes 1 ppd
Can walk ½ mile
What is his prognosis?
Mr. Jones
84 years old
Has diabetes
Smokes 1 ppd
Can only walk one block
What is his prognosis?
How does this translate back to
life expectancy for screening?
• It doesn’t translate perfectly
• But clearly, Mr. Jones with poorer
functional status has less than a 50%
chance of living greater than 5 years, so
colonoscopy is no longer indicated for him
• Mr. Jones with better functional status has
over a 50% chance of living 5 years, so
you might choose to continue screening
Remaining Life
Expectancy
Women
Men
Walter LC, JAMA, 2001
Guidelines and Prognosis
• No “one right answer” in diverse elderly population
– Great variation in life expectancy/preferences
• More guidelines now base recommendations on
prognosis rather than age alone
– Cancer screening (Stop if limited life expectancy)
– Diabetes Care (Higher A1c if limited life expectancy)
• Few guidelines provide tools to help
clinicians estimate prognosis
ePrognosis
• Prognostic Index: A clinical tool that quantifies the
contributions that various components of the history,
physical exam, and laboratory findings make towards a
diagnosis, prognosis, or likely response to treatment.
McGinn, JAMA, 2000
• UCSF geriatricians (led by Alex Smith) have developed a
website repository of validated geriatric prognostic
indices---ePrognosis
• Indices on website are designed for older people who do
not have a dominant terminal illness
– For patients with a dominant terminal illness (e.g.,
advanced cancer, heart failure) use prognostic indices
specifically designed for those diseases
Mr. A
75 y/o man with
CHF, smokes, and
has difficulty
bathing, walking,
and managing
finances.
Mr. A
USPSTF Changes Affecting
Your Practice
• New guidelines with geriatric component
• Consideration of how recommendations
affect elderly patients