Transcript preventive care of older adults

MEDICINE DIDACTIC LECTURE 2009
GERIATRIC PREVENTIVE
CARE
Cletus U. Iwuagwu, MD, CMD
Associate Professor of Medicine
Office of Geriatric Medicine & Gerontology
University of Toledo
CASE 1 (1 of 3)
• A healthy 68-year-old man comes to the office
for a physical examination.
• Ten years ago he had four adenomatous polyps
removed.
• Follow-up colonoscopy 5 years ago was
negative.
Slide 2
CASE 1 (2 of 3)
Which of the following is the most appropriate colon
cancer screening recommendation for this patient?
(A) Immunohistochemical fecal occult blood testing
(B) No further screening
(C) Colonoscopy
(D) Flexible sigmoidoscopy plus occult blood testing
(E) Virtual colonoscopy
Slide 3
CASE 2 (1 of 3)
• A 75-year-old smoker who recently had a
myocardial infarction comes to the office for
advice on life-style changes.
• History includes chronic obstructive pulmonary
disease with a moderately impaired FEV1.
Slide 4
CASE 2 (2 of 3)
In such patients, smoking cessation is
associated with which of the following?
(A) Improved cognition
(B) Cessation of a decline in FEV1
(C) Reduction in all-cause mortality
(D) Lung cancer risk that is the same
as that of a nonsmoker
Slide 5
CASE 3 (1 of 3)
• A 70-year-old woman comes to the office because she
is worried about her risk of stroke. Her mother died
from a stroke earlier this year.
• Her history includes hypertension and type 2 DM.
• Medications: glipizide, aspirin, enalapril, atorvastatin.
• She smokes 1 pack of cigarettes/day and doesn't
exercise.
• BP = 150/80, hemoglobin A1C = 8%, low-density
lipoprotein cholesterol = 110 mg/dL.
Slide 6
CASE 3 (2 of 3)
Which of the following is associated with the
greatest risk reduction of stroke?
(A) Achieving optimum hemoglobin A1C level
(B) Achieving optimum blood-pressure control
(C) Adding an antioxidant
(D) Quitting smoking
(E) Achieving optimum LDL cholesterol level
Slide 7
OBJECTIVES
Know and understand:
• Preventive services that are recommended for
older adults
• Additional preventive activities and services that
are potentially beneficial for older adults
• Methods for optimizing delivery of preventive
services
Slide 8
TOPICS COVERED
• Recommended Preventive Services




Screening
Counseling
Immunizations
Chemoprophylaxis
• Other Potentially Beneficial Services
• Screens and Tests Not Indicated
• Effective Delivery of Preventive Services
Slide 9
SCREENING
All older adults should be screened for:
• Hypertension
• Breast, colorectal, and cervical cancer
• Obesity, malnutrition
• Alcoholism
• Dyslipidemia
• Vision and hearing deficits
• Osteoporosis
Slide 10
SCREENING FOR HYPERTENSION
Method
• Check blood pressure at least annually
Rationale
• Prevalence  with advancing age
• Treatment of hypertension  morbidity &
mortality from left ventricular hypertrophy,
CHF, MI, & stroke
Slide 11
SCREENING FOR BREAST CANCER
Methods
• Mammography
• Breast self-examination (BSE)
Rationale
• Unclear if and at what age mammography
screening should stop
• No compelling evidence that BSE  breast
cancer morbidity & mortality
Slide 12
MAMMOGRAPHY
RECOMMENDATIONS
Organization
Frequency
USPSTF, Canadian
Biennial
Task Force
American College of
Biennial
Physicians
American Geriatrics Every 2–3 years
Society
Until Age:
70
74
85
Medicare covers annual screening mammograms
Slide 13
SCREENING FOR COLORECTAL CANCER
Methods
• FOBT or sigmoidoscopy every 5 years starting at age
65 (if not performed within previous 5 years)
• One-time colonoscopy at age 65 (if not performed within
previous 10 years) and every 10 years thereafter with
active life expectancy of 5 years or greater—becoming
the accepted modality for older people
Rationale
• Increasing prevalence of colorectal cancer with age
Medicare covers annual FOBT, biennial sigmoidoscopy,
colonoscopy every 10 years
Slide 14
SCREENING FOR CERVICAL CANCER
(1 of 2)
Method
• Papanicolaou smear every 1–3 years if woman
is sexually active, has cervix
• Cut-off after age 65 with history of normal
smears or after 2 normal smears 1 year apart
Medicare covers Pap smear
and pelvic exam every 2 years
Slide 15
SCREENING FOR CERVICAL CANCER
(2 of 2)
Rationale
• Most cost-effective
for women with
incomplete
screening
previously
• Cut-off age remains
controversial
40% of new cases & deaths
occur in women 65+
Slide 16
SCREENING FOR OBESITY
& MALNUTRITION
Method
• Measure weight & height routinely
• Calculate BMI: kg/m2
Definitions
• Obesity defined as
 BMI  27.8 kg/m2 in men
 BMI  27.3 kg/m2 in women
• Malnutrition defined as unintended weight loss of
10 lbs in 6 months
Slide 17
SCREENING FOR ALCOHOLISM
Method
• Use screening questionnaire, e.g., CAGE:
 Cut down
 Annoy
 Guilt
 Eye-opener
• Screen all older adults at least once
• Screen whenever a drinking problem is suspected
Rationale
• Older adults are more susceptible to effects
Slide 18
SCREENING FOR DYSLIPIDEMIA
(1 of 2)
Method
• Screen older adults with coronary disease annually
for abnormalities:
 Low-density lipoprotein  130 mg/dL
 High-density lipoprotein  35 mg/dL
 Triglycerides  200 mg/dL
• Target levels:
 Low-density lipoprotein < 100 mg/dL
 High-density lipoprotein > 40 mg/dL
 Triglycerides < 200 mg/dL
Slide 19
SCREENING FOR DYSLIPIDEMIA
(2 of 2)
Rationale
• Correcting lipid abnormalities  risk of
recurrence in older adults with prior MI or
angina
• No evidence of benefit of screening in
absence of clinical CAD or with few cardiac
risk factors
Slide 20
SCREENING FOR SENSORY DEFICITS
Methods
• Vision: use Snellen chart routinely to detect
uncorrected refractive errors, glaucoma, cataracts,
macular degeneration
• Hearing: question routinely to detect hearing loss;
provide information about hearing aids
Rationale
• Visual impairment  risk for falls
• Hearing loss  social isolation; may indicate
other disorders
Slide 21
COUNSELING
All older adults should be counseled at
least annually about:
• Diet
• Physical activity
• Safety and injury prevention
• Smoking cessation
• Dental care
Slide 22
DIET
• Encourage consumption of a balanced
diet high in fruits & vegetables, low in
fats, with adequate calcium
• Recommend intake appropriate for
patient’s BMI and health status
Slide 23
PHYSICAL ACTIVITY
• Emphasize advantages: promotes
mobility,  rates of CAD & osteoporosis
• Recommend a program that balances
exercise for:
 Flexibility (eg, stretching)
 Endurance (eg, walking, cycling)
 Strength (eg, weight training)
 Balance (eg, Tai Chi, dance)
Slide 24
SAFETY & PREVENTING INJURY
Encourage measures to reduce risks for falls
and other mishaps, environmental hazards
 Driving: seat belts, regular driving tests
 Alcohol: avoid when driving or using
machinery
 Home: install smoke alarms, lower hotwater temperature
Slide 25
SMOKING CESSATION &
DENTAL CARE
Smoking
• Discuss at each visit
• Emphasize that cessation at any age  rates of
COPD, many cancers, CAD
Dental Care
• Emphasize relation of dental health to
malnutrition, xerostomia, oral cancers
• Note that common problems can be detected
and treated by regular dental visits
Slide 26
IMMUNIZATIONS
Immunization for the following should be a
routine part of preventive health care for all
older adults:
• Influenza
• Pneumonia
• Tetanus
Slide 27
IMMUNIZATION FOR INFLUENZA
(1 of 2)
Method
• Annual in October to mid-November (antigenic drift,
4–5 months of protection, protects against both
influenza A & B)
• Recommended for all 65 years or <65 years with
comorbidities
Side Effects
• Fever, chills, myalgias, malaise (these are rare)
• Contraindicated: anaphylactic egg hypersensitivity
or allergic reaction to egg protein
Slide 28
IMMUNIZATION FOR INFLUENZA
(2 of 2)
Efficacy is:
70% for
illness
90% for
mortality
Slide 29
CHEMOPROPHYLAXIS DURING
INFLUENZA OUTBREAK
Method
• Start within 24 h of symptom onset
• Influenza A: zanamivir or oseltamivir
• Influenza B: zanamivir or oseltamivir
Rationale
• Can protect against influenza during the 2 weeks
right after or in absence of immunization
• Reduces duration of illness by 1 to 1.5 days
Slide 30
IMMUNIZATION FOR PNEUMONIA
Method
•
•
•
•
For all 65 years or <65 years with comorbidities
Single dose of 0.5 mg IM
Revaccinate high-risk persons every 7–10 years
Repeat in 5 years if vaccinated before age 65
Side Effects
• Rare and mild
Rationale
• Strong evidence for  risk of bacteremia
• Cost-effective for older immunocompetent adults
Slide 31
IMMUNIZATION FOR TETANUS
Method
• Primary series: 2 doses 0.5 mg IM 1–2 months apart,
then 1 dose 6–12 mo later
• Booster every 10 y (USPSTF, Canadian Task Force)
Side Effects
• Local pain, swelling
• Contraindications: previous hypersensitivity or
neurologic reactions
Rationale
• 60% of infections occur in persons 60 years
Slide 32
OTHER PREVENTIVE SERVICES
Preventive services are recommended by
specialty organizations for the following, even
though evidence for effectiveness is lacking:
•
•
•
•
•
•
•
Diabetes mellitus
Thyroid disease
Dementia
Depression
Osteoporosis
Prostate cancer
Skin cancer
Slide 33
PREVENTIVE SERVICES FOR
DIABETES AND THYROID DISEASE
Diabetes
• No routine screening for asymptomatic persons
• Fasting glucose measurement appropriate for
high-risk older adults
Thyroid Disease
• Prevalence of hyperthyroidism  with age
• Routine screening not recommended but may be
performed given high prevalence and likelihood of
missing subclinical symptoms in older adults
Slide 34
PREVENTIVE SERVICES FOR
DEMENTIA
• Use standard tools to track progressive
memory & functional impairment (Mini-Cog,
MMSE, IADLs)
• Recommend home safety assessment for
community-dwelling impaired patients
Slide 35
PREVENTIVE SERVICES FOR
DEPRESSION
• Maintain high index of suspicion for depressive
symptoms in high-risk older adults (USPSTF)
• High risk = personal or family history of
depression, chronic illness, recent loss, sleep
disorder
• Use reliable instrument (eg, Geriatric
Depression Scale)
Slide 36
PREVENTIVE SERVICES FOR
OSTEOPOROSIS
• Counsel all older women about:
 Adequate calcium and vitamin D intake
 Smoking cessation
 Exercise (weight-bearing)
 Avoiding falls & injuries
 Hormone replacement therapy (why no longer
routinely recommended)
• Recommend bone density measurement at
least once after age 65 (USPSTF)
Slide 37
PREVENTIVE SERVICES FOR
PROSTATE CANCER
• Counsel all older men about:
 Implications of  PSA or mass detected by DRE
 Potential adverse effects of treating false or even
true positives (incontinence, impotence)
• Test men ages 50 to 69 with PSA and DRE
(American College of Physicians)
Medicare covers DRE and PSA yearly for men >50
Slide 38
PREVENTIVE SERVICES FOR
SKIN CANCER
• Counsel high-risk older patients (light-skinned
or history of skin cancer) to:
 Avoid excess sun exposure
 Use protection when outdoors
• USPSTF recommends neither for or against
annual skin examination to detect early skin
cancer
Slide 39
ASPIRIN TO PREVENT
MYOCARDIAL INFARCTION
• Possibly appropriate for older patients with risk
factors for MI
• Side effects:
 Low for dosages 325 mg/day
 Adverse bleeding effects  with age
• Doses <500 mg/day not consistently shown to
 MI or cardiovascular mortality
Slide 40
PREVENTIVE SERVICES NOT
INDICATED IN OLDER ADULTS
Screening for Specific Diseases
• Bladder cancer
• Lung cancer
• Hematologic malignancies
• Ovarian cancer
• Pancreatic cancer
Routine Laboratory Testing
• Annual CBC, blood chemistry
• Annual chest x-ray, ECG
Slide 41
EFFECTIVE DELIVERY OF
PREVENTIVE SERVICES
• Characteristics of effective approaches:





Well-organized & systems-based
Interdisciplinary
Use paramedical personnel
Use various sites, means of communication
Use mailed or computer-generated reminders
• Obstacles to effective prevention:
 Lack of time
 Inadequate reimbursement
Slide 42
SUMMARY
• Physicians provide preventive information and
care that help older patients maintain
functional independence
• Recommendations about appropriate
screening, counseling, and immunizations are
available to guide physicians
• Well-organized approaches to preventive care
can overcome the barriers to effective care
Slide 43
CASE 1 (1 of 3)
• A healthy 68-year-old man comes to the office
for a physical examination.
• Ten years ago he had four adenomatous polyps
removed.
• Follow-up colonoscopy 5 years ago was
negative.
Slide 44
CASE 1 (2 of 3)
Which of the following is the most appropriate colon
cancer screening recommendation for this patient?
(A) Immunohistochemical fecal occult blood testing
(B) No further screening
(C) Colonoscopy
(D) Flexible sigmoidoscopy plus occult blood testing
(E) Virtual colonoscopy
Slide 45
CASE 1 (3 of 3)
Which of the following is the most appropriate colon
cancer screening recommendation for this patient?
(A) Immunohistochemical fecal occult blood testing
(B) No further screening
(C) Colonoscopy
(D) Flexible sigmoidoscopy plus occult blood testing
(E) Virtual colonoscopy
Slide 46
CASE 2 (1 of 3)
• A 75-year-old smoker who recently had a
myocardial infarction comes to the office for
advice on life-style changes.
• History includes chronic obstructive pulmonary
disease with a moderately impaired FEV1.
Slide 47
CASE 2 (2 of 3)
In such patients, smoking cessation is
associated with which of the following?
(A) Improved cognition
(B) Cessation of a decline in FEV1
(C) Reduction in all-cause mortality
(D) Lung cancer risk that is the same
as that of a nonsmoker
Slide 48
CASE 2 (3 of 3)
In such patients, smoking cessation is
associated with which of the following?
(A) Improved cognition
(B) Cessation of a decline in FEV1
(C) Reduction in all-cause mortality
(D) Lung cancer risk that is the same
as that of a nonsmoker
Slide 49
CASE 3 (1 of 3)
• A 70-year-old woman comes to the office because she
is worried about her risk of stroke. Her mother died
from a stroke earlier this year.
• Her history includes hypertension and type 2 DM.
• Medications: glipizide, aspirin, enalapril, atorvastatin.
• She smokes 1 pack of cigarettes/day and doesn't
exercise.
• BP = 150/80, hemoglobin A1C = 8%, low-density
lipoprotein cholesterol = 110 mg/dL.
Slide 50
CASE 3 (2 of 3)
Which of the following is associated with the
greatest risk reduction of stroke?
(A) Achieving optimum hemoglobin A1C level
(B) Achieving optimum blood-pressure control
(C) Adding an antioxidant
(D) Quitting smoking
(E) Achieving optimum LDL cholesterol level
Slide 51
CASE 3 (3 of 3)
Which of the following is associated with the
greatest risk reduction of stroke?
(A) Achieving optimum hemoglobin A1C level
(B) Achieving optimum blood-pressure control
(C) Adding an antioxidant
(D) Quitting smoking
(E) Achieving optimum LDL cholesterol level
Slide 52