Transcript Module 2 - 96.5 KB

HEALTH
MAINTENANCE
&
PREVENTION
IN ELDERS
Module #2
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
981320 UNMC
Omaha, NE 68198-1320
[email protected]
Web: geriatrics.unmc.edu
402-559-7512
• A 69-year-old woman is 15% over
ideal body weight and has mild
hypertension. She smokes
cigarettes and has a family history
of premature heart disease
Which of the following screening maneuvers for
this patient is best supported by medical
evidence?
Choose one answer:
A. Fasting plasma glucose
B. Fasting serum lipid
profile
C. Hemoglobin A1C
D. Radiography of the
chest
E. Computed tomography of
the chest
Answer
B. Fasting serum lipid
profile
Case based Geriatric Review AGS 2002
• Limited data concerning
women and the young-old
age group suggest
potential benefits of lipid
lowering for primary
prevention.
• Evidence supports
obtaining a fasting lipid
profile in patients aged 65
to 75 who have risk factors
for coronary artery disease
(CAD
• Randomized trials have
shown that treatment of
hypercholesterolemia is
beneficial for patients with
CAD at virtually all ages
• An analysis found dietary
therapy to be costeffective in older patients
• Treatment with (statins)
were cost-effective in
higher-risk subgroups.
Aronow WS Cardiovascular Disease and disorders. Geriatric Review syllabus
Fifth edition 2002-04
Grundy SM, Coordinating Committee of the National Cholesterol Education
Program. Arch Intern Med 1999, 159:1670-1678
The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID)
Study Group.. N Engl J Med 1998;339:1349-57.
Psaty BM. JAGS 52:1630-1647;2004
• LIPIDS
Recommendations for
screening :
• men age 35 and older
(USPSTF)
(A)
• women age 45 and
older
(USPSTF)
(A)
• both sexes, all ages
with high risk or known
CHD
(B)
• What type of lipid panel
for screening?
• Recommendations for
screening:
• Total chol./HDL ratio is
best predictor
• At risk T.Chol./HDL
ratios: men>6.4,
women >5.6)
• Medicare pays?
• screening lipid panel q
5 yrs if lipids w.n.l.
•
• may do lipid panel more
often with ASCVD or
hyperlipidemia,or at
U.S. Preventative Services Task Force
Am J Prev Med 2001;20 (3S)
• Fasting plasma
glucose Treatment of
type 2 diabetes mellitus
has been shown to
reduce complications,
and the American
Diabetes Association
recommends measuring
fasting blood glucose
every 3 years in
persons aged 45 and
over.
• However, the potential
benefits of treatment
decrease with age
because of shorter life
expectancy.
• A 1998 cost-effectiveness
analysis concluded that
screening in assymptomatic
after age 65 would not result
• Chest Xray or CT:
• No data support the
screening of smokers
with chest films, and
very limited data
support screening with
computed tomography.
• TSH? In this patient,
screening for
hypothyroidism may be
indicated because the
condition is common in
elderly women and may
be subtle. (clue..obese)
• Mammography also is
indicated in this age
group. ( but we didn’t give
you a chance to give this
answer!!)
Would you screen for hypothyroidism in all your
elderly patients?
• Answer………
• The USPSTF concludes the evidence is
insufficient to recommend for or against
routine screening for thyroid disease in
adults.
USPSTF ( I)
• BUT
• (be suspicious and use TSH freely)
• A healthy 68-year-old man has no
history of heart disease and currently
walks about 20 minutes twice a day. He
also works in his garden. The patient
plans to begin an exercise program
consisting of upper- and lower-extremity
resistance exercises, stair climbing, and
brisk walking 3 days per week.
Which of the following statements describes the long-term
effects of increased physical activity on this patient’s risk for
coronary artery disease (CAD) and mortality?
(Choose on answer)
A. For someone already
engaged in moderate
daily exercise, further risk
reduction is unlikely with
more vigorous activity.
B. Risks are lower in older
persons who engage in
vigorous activity than in
those who exercise
moderately
C. All-cause mortality is
lower in older persons
who exercise moderately,
but risk for CAD is
unaffected.
D. Risks for CAD and
mortality increase in older
persons who exercise
vigorously.
• Answer
B. Risks are lower in
older persons who
engage in vigorous
activity than in those
who exercise
moderately
Case based Geriatric Review AGS 2002
• Physical activity
reduces risk of CAD
and all-cause mortality.
The greatest benefits
are seen in sedentary
persons who begin
regular moderate
physical activity, such
as brisk walking (3 to 4
mph, at an intensity of 3
to 6 metabolic
equivalents).
• Moderate level?:
30 minutes of moderate
physical activity at least
5 days per week.
• Persons who exceed
the recommendation for
moderate activity or
Why and what exercise to
recommend ?
• Why?
• Prevention of CAD risk & prevention of
osteoporosis
(A)
• What?
• 30 minutes of moderate physical activity at least
5 days per week.
• Program should combine flexibility, strength and
balance
(A)
Case based Geriatric Review AGS 2002
US Preventive Services Task Force ( USPSTF)
http://www.ahrq.gov/clinic accessed 2-2005
When would you screen for
alcohol abuse?
When would you screen for
alcohol abuse?
(Choose one answer)
1) When you smell alcohol
on your patients breath
2) When you smell alcohol
on your breath
3) At least once and as
needed
ANSWER
When?
3. At least once and
whenever you suspect a
problem
What is a good screen?
• CAGE plus questions of
quantity and frequency
• What is CAGE?
Bloom H, Edelberg HK Prevention Geriatrtic Review syllabus Fifth
edition 2002-04
CAGE
C “have you felt you ought to CUT down on
your drinking
A “Have people ANNOYED you by criticizing your
drinking?”
G “Have you ever felt bad or GUILTY about your
drinking?”
E “Have you ever had a drink first thing in the
morning EYE opener
Vision Screening
When would you recommend vision screening to
be performed?
Choose one answer:
•
•
•
•
When quality of
life is affected
Annually
Biannually
As needed
Answer
Annual vision screen with
Snellen (USPSTF)
(B)
Glaucoma screen by
specialist in age >65 y.o
(USPSTF)
(C)
Medicare covers?
Annual glaucoma screen
by specialist in age >65
y.o
Bloom H, Edelberg HK Prevention Geriatrtic Review syllabus Fifth
edition 2002-04
Hearing screening
When would you
recommend hearing
screening to be
performed?
1) Annually
2) As needed
3) When your patient
says “What?” all
the time
Answer
Screen Hearing
annually
(USPSTF)
(B)
How?
1) Questioning patient
2) Whisper test
Bloom H, Edelberg HK Prevention Geriatrtic Review
syllabus Fifth edition 2002-04
Select as many as indicated to
ask about or advise for injury
prevention?
•
•
•
•
Fall risk reduction
Seat/lap belt use
Regular driving tests
Avoid alcohol while
using machinery or
driving
• Smoke detectors
• Lower Hot water
temperature
• Home safety check
list
Bloom H, Edelberg HK Prevention Geriatrtic Review syllabus
Fifth edition 2002-04
Answer
• All (as appropriate)
Home safety check list
To obtain;
• Go to Geriatrics.unmc.edu then
to Education then to Resources
then to Home care then to
Home care checklist
• An 70-year-old woman presents to clinic for
the first time and with concerns about
osteoporosis. She went through menopause
30 years ago without any hormone
replacement therapy. Her mother had a hip
fracture at 85 years of age. Father had CAD.
The patient’s most recent mammogram was 5
years ago and Pap smear 10 years ago. She
is not taking any medications. Non smoker,
no alcohol. Her physical examination is
unremarkable except for findings of: wt: 110
#, atrophic vaginitis.
What interventions would you recommend
for osteoporosis screening and prevention?
(Select as many as indicated)
Answers:
1) Calcium 1500 mg/day 1) Calcium 1500
& Vit D 400-800 IU/d
mg/day & Vit D 4002) Weight bearing
800 IU/d
exercise
2) Weight bearing
3) Hormone
exercise
Replacement Therapy
( HRT)
4) Bone densitometry
4) Bone densitometry
Case based Geriatric Review AGS 2002
Current recommendations for prevention
and screening
Calcium 1500 mg/day & Vit D 400-800 IU/d
(USPSTF) (B)
Weight bearing exercise
Bone densitometry
(B)
US Preventive Services Task Force ( USPSTF)
http://www.ahrq.gov/clinic accessed 2-2005
(USPSTF) (B)
(USPSTF)
Osteoporosis screening
• Routine screening
for >65 (ave. risk*) (USPSTF)
for > 60 ( high risk*)
(B)
(B)
*BMD at the femoral neck and lumbar spine by
DEXA is the best predictor
• Follow up BMD Scans for Average
Risk……..………..2 or more years [i]
[i] Mauck KF. Clarke BL. Diagnosis, screening, prevention and treatment of osteoporosis.
Mayo Clin Proc M<ay 2006,; 81:662-72
Burger H, de Laet CE, Weel AE, et al.. Bone 1999;25:369-74.
Osteoporosis screening
What is the best predictor of risk?
Osteoporosis Risk:
What is the best
predictor?
( choose one answer)
1) Low body weight
2) Low calcium intake
3) Sedentary
Answer:
Best predictor:
1) low body weight
Other risk factors:
-early menopause
-white/Asian,
-sedentary,
-smoker,
-alcohol abuse,
-caffeine use,
-low calcium
-low vitamin D intake,
-family history,
-primary hyperparathyroid,
-hyperthytroid,
-corticosteroids,
-phenytoin or valproic acid
Cadarette SM, Jaglal SB, Murray T,. JAMA 2001;286(1):57-63.
Why not HRT for this lady?
(USPSTF) recommends against the use of combined estrogen and
progestin therapy for preventing cardiovascular disease and other
chronic conditions in postmenopausal women.
USPSTF (D)
(USPSTF): evidence is insufficient to recommend for or against the use
of estrogen alone for prevention of chronic conditions in
postmenopausal women who have had a hysterectomy.
USPSTF
•
•
•
Nelson H August 20, 2002, Annals of Internal Medicine
Nelson H August 21, 2002, Journal of the American Medical Association.
http://www.ahrq.gov/clinic
(I)
END of MODULE #2
Post Test
• A 67-year-old woman
undergoes dual-energy x-ray
absorptiometry (DEXA). Her
bone mineral density in the
lumbar spine and proximal
femur are found to be in the
osteopenic range, in
comparison with young
normal persons. The patient
refuses pharmacologic
treatment other than calcium
and vitamin D. You
recommend an increase in
physical activity, which she is
willing to do.
Which of the following
activities is most likely
to help maintain bone
density?
1) Tai Chi
2) Swimming
3) Resistance training
4) Stationary bicycling
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
• Correct Answer: Resistance training
• Feedback:There is good evidence that higher peak
bone mass is achieved partly by increased physical
activity early in life. The role of activity in maintaining
bone density in older women is less certain. Studies
have shown that high-impact activities, such as
resistance training with weights or weight-bearing
aerobic exercise, are most likely to help maintain or
improve bone density. Tai Chi is not aerobic, and
there have been no studies to support a beneficial
effect on bone density. Swimming is not weight
bearing and therefore has little impact on bone.
Bicycling is low-impact aerobic exercise but is less
likely to increase bone density than is resistance
training.