Prevention & Screening for Elderly Patients

tips for your busy primary care practice

University of Hawaii Geriatrics Department

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Principles of Geriatric AssessmentGoal Promote wellness, independence

Focus Function, performance (gait, balance, transfers)

Scope Physical, cognitive, psychologic, social domains

Approach Interdisciplinary and Multidisciplinary

Efficiency Ability to perform rapid screens to identify target areas

Success Maintaining or improving quality of life

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Geriatric Assessment

• Geriatric H&P • Functional • Eyes/Ears • Cognitive/Affective • Medications • Nutritional • Bone Integrity/Falls

• Strength/Sarcopenia • Continence • ETOH/Tobacco/Sex • EnviroSocial • Capacity • Prevention

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Functional Status and Disability

• Instrumental Activities of Daily Living – (IADL’s)

• Activities of Daily Living – (ADL’s)

• Executive Functioning • Gait & Balance

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Activities of Daily Living (ADLs)

• Bathing • Dressing • Toileting • Transferring • Continence • Feeding

KATZ INDEX used for assessment

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Katz Index

• 6 ACTIVITIES : Points (1 or 0) - INDEPENDENCE: (1 POINT)

• NO supervision, direction or assistance - DEPENDENCE: (0 POINTS)

• WITH supervision, direction, assistance or total care

• TOTAL POINTS = __ • 6 = High (patient independent) • 0 = Low (patient very dependent)

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Instrumental Activities of Daily Living (IADLs)

• Telephone • Shopping • Meal preparation • Housework • Laundry • Transportation • Medications • Finances

Lawton IADL Scale

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Gait & Balance• Fall assessment “Have you fallen at all in the past year?” • Get Up and Go ! • Tinetti Gait & Balance

Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-term- care facilities experience falls

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AGS Falls Prevention Guidelines• Recommendations include:

• Assessment of all older adults • Assessment of anyone with history of falls

• Multifactorial interventions including: • Exercise • Environmental modifications • Medication review • Assistive devices • Behavioral and educational programs

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Common Visual Problems

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CATARACTS GLAUCOMA

MACULAR DEGENERATION

DIABETIC RETINOPATHY

Screening for Vision Loss• If unable to read a newspaper headline and sentence while reading corrective lenses.

• Near vision: • Rosenbaum Card, 16’’

• Far vision: • Snellen Chart, 20 feet

• Fundoscopic evaluation

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Screening for Hearing Loss

• Whisper test • Questionnaires: Hearing Handicap

Inventory Screening Questionnaire • Hand held audioscope : Most appropriate screening tool

in office setting. • sensitivity of 94% and specificity between 69% and

80% for hearing loss) • Full audiometric testing- pure tone audiogram, Speech

discrimination

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NameItems/ Scoring Domains assessed Web link (accessed Oct 2012)

Mini-Cog 2 items Score = 5

Visuospatial, executive function, recall

http://geriatrics.uthscsa.edu/tools/MINICog.pdf

SLUMS 11 items Score = 30

Orientation, recall, calculation, naming, attention, executive function

http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

MoCA 12 items Score = 30

Orientation, recall, attention, naming, repetition, verbal fluency, abstraction, executive function, visuospatial

www.mocatest.org

Folstein MMSE

19 items Score = 30

Orientation, registration, attention, recall, naming, repetition, 3-step command, language, visuospatial

For purchase: www.minimental.com

Cognitive Screening Tests

Affective Status• Geriatric Depression Scale (GDS) • PHQ-2

• Over the past 2 weeks… • Have you felt down, depressed, or hopeless? • Have you felt little interest or pleasure in doing

things?

• PHQ-9

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• Rapid Screen: • “Have you lost more than 10 lbs over the

past 6 months without trying to do so?” • Weight and BMI

– Every visit for community-dwelling elder – Monthly in Long-term care facilities

• Mini-Nutritional Assessment (MNA) • Screening for feeding difficulties

Nutrition Status

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Social Assessment • Availability of a personal support system

• Caregiver burden (social worker)

• Economic well-being (social worker)

• Safety of the home environment (OT)

• Elder mistreatment (visiting nurse)

• Advance Directives / Advanced Care Planning(included in MedicareAnnual Wellness Visit)

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Preventive Care and Screening

• Immunization • Screening for Alcoholism • Cancer screening • Counseling • Other Preventive Services

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Immunization• Influenza • Pneumonia • Tetanus • Zoster

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Chemoprophylaxis in Influenza Outbreak

• Start within 24 h of symptoms • Influenza A/B:

• Zanamivir or Oseltamivir • 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

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Pneumonia

• Single dose of 0.5 mg IM • For all ≥65 years or <65 years with comorbidities/

chronic diseases • pulm, renal, liver, DM, ETOH, etc.

• Revaccinate in 5 yrs if vaccinated before 65 • Reduces risk of bacteremia, cost-effective

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Tetanus (Td/Tdap)

• Primary series: • 2 doses 0.5 mg IM 1-2 months apart, then 1 dose

6–12 mo later • Booster every 10 yrs • Rationale to vaccinate:

• 60% of infections occur in persons ≥60 yrs • 48% of the elderly lack protective antibody to tetanus

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Zoster Vaccine• Vaccine FDA approved 2006

• For prevention of zoster and post-herpetic neuralgia

• Reduced three year incidence of – Herpes zoster - 51% – Post-herpetic neuralgia - 67%

• Vaccinate immunocompetent adults > 60 yrs old

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Screening for Alcoholism• Screening questionnaire, CAGE:

• Cut down • Annoy • Guilt • Eye-opener

• Screen all older adults at least once • Screen whenever a drinking problem is

suspected • Older adults are more susceptible to effects

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Screening for Breast Cancer

• Methods: • Mammography

• Rationale • Unclear if and at what age mammography screening should stop

• Consider life expectancy • ePrognosis.ucsf.edu

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Mammography Recommendations

Organization Frequency Until Age:

USPSTF, Canadian Task Force

Biennial 70

American College of Physicians

Biennial 74

American Geriatrics Society

Every 2–3 years 85

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Medicare covers annual screening mammograms

Screening for Colorectal Cancer

• FOBT or sigmoidoscopy every 5 years starting age 65 • One-time colonoscopy at age 65 (if not performed

within previous 10 years) and every 10 years thereafter

• becoming the accepted modality for older people • Rationale:

• Increasing prevalence with age • Medicare covers annual FOBT, biennial

sigmoidoscopy, colonoscopy every 10 years

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Screening for Cervical Cancer

• Pap 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 smears and pelvic exams every 2 years

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Screening for Cervical Cancer• Rationale

– Most cost-effective for women with incomplete screening previously

– Cut-off age remains controversial

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40% of new cases & deaths occur in women 65+

Screening for Obesity • 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

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CounselingCounsel at least annually about:

• Diet &Physical activity

• Safety and injury prevention

• Smoking cessation

• Dental care

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Safety and Preventing InjuryEncourage 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 hot-water temperature

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Risk Factors for Older Drivers• Dementia • Poor visual acuity and contrast sensitivity • Impaired neck and truck rotation • Limitations of shoulders, hips, ankles • Foot abnormalities • Poor motor coordination • Poor speed of movement • Medications • Alcohol

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When an accident or driving violation occurs...

• Assess Risks • Discuss safety concerns with the older driver and with

spouse or family member, if possible • Urge consideration of other modes of transportation • Refer for formal driving evaluation

• Encourage the Driver to Reduce Risks • Avoid rush hour, congested traffic • Avoid night driving • Avoid driving in poor weather • AARP website

• Driver Online Course (discount on car insurance!)34

Other Preventive Services Preventive services are recommended by specialty

organizations for the following, even though evidence for effectiveness is lacking: • Diabetes mellitus • Thyroid disease • Osteoporosis • Prostate cancer • Skin cancer

Not mandatory in Medicare Annual Wellness Visit

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Preventive Services for Diabetes and Thyroid disease

• Diabetes – No routine screening for asymptomatic persons – Fasting glucose measurement appropriate for high-risk older

adults – Different cutoff for A1C in elderly

– healthy patients: <7.5% – coexisting chronic or 2+ IADL impairment: < 8.0% – mod to severe cognitive impairment, end stage illnesses, or 2+

ADL impairment: < 8.5%

• 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

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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 (no longer routinely recommended)

• Recommend bone density measurement at least once after age 65 (USPSTF)

• Don’t forget elderly men!

• age>70, androgen deprivation, BMI<20-25, Cigarette smoking, fragility fracture hx, low dietary Ca, corticosteroid use, physical inactivity, SCI, wt loss > 10%)

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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)

• Ages 50 to 69: PSA and DRE (American College of Physicians)

• Medicare covers DRE and PSA yearly for men >50

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