Health Promotion/Disease Prevention in Older Adults– An Evidence-Based Update Part I: Introduction and Screening
Mrs. Edna Wilson is an 82-year-old woman with a history of diet-controlled hypertension and osteoarthritis who has not seen a doctor in over 3 years. A retired teacher, she lives in a senior retirement community, where she delivers meals-on-wheels to “shut-ins” and organizes church charity events. She walks her dog twice a day, drives to the local shopping center for groceries, and manages her own household. At a recent health fair, she was told that her cholesterol level is very high. Mrs. Wilson decides to visit her physician for a routine check-up. She inquires what she can do to stay healthy, and she questions whether she should start medication to lower her cholesterol.
If you were Mrs. Wilson’s doctor, what would you do for her during this preventive visit? Are you aware of the latest health promotion guidelines for older adults? Physicians can turn to professional societies, government agencies, expert panels, and special preventive services task forces for advice. Recommendations are sometimes provided as clinical practice guidelines through subspecialty organizations. Excellent Web and palm-based resources are now available to help physicians find up-to-date information (Table I). The United States Preventive Services Task Force (USPSTF) is an independent panel of private sector experts in primary care and prevention that systematically reviews the evidence of effectiveness of a wide range of clinical preventive services. Members of the USPSTF represent a variety of fields, including family medicine, gerontology, nursing, and prevention research. In recent years, the panel has published several relevant guidelines for geriatric practice.
Recommended health promotion/disease prevention measures include five domains: screening for disease at an early stage; counseling about a healthful lifestyle (eg, diet, exercise, smoking cessation, falls prevention, safe driving); immunizations (pneumococcal, influenza, tetanus vaccines); chemoprophylaxis (aspirin, statins, diphosphonates); and system changes to promote patient safety. Current health promotion recommendations consider the burden of suffering so that common conditions of major significance tend to be the focus of efforts, as well as the potential effectiveness of the preventive intervention. Conditions causing significant morbidity and accelerated mortality in older patients are listed in Table II. Criteria for effectiveness vary by domain. For screening tests, the accuracy of the diagnostic test, effectiveness of treatment for early detected disease, and life expectancy of the patient determine whether a screening test is advised for the geriatric population.1 Recommendations are often graded based on the strength of the supporting evidence. For counseling, the efficacy of risk reduction and whether change in behavior improves outcome need to be considered. Part I of this two-part series covers recommended screening procedures. Part II will examine recommended counseling, chemoprophylaxis, immunizations, and practical ways physicians can incorporate health promotion domains into a busy clinical practice.
Screening for Disease
The purpose of screening is to detect and treat early disease so as to extend a patient’s lifespan beyond what it would be if the patient had not been screened in the first place.2 Many adult screening recommendations group all older patients (ages > 65) together. They do not distinguish the young elderly (ages 65-74) from the middle (ages 75-84) and very elderly (ages > 85). Virtually all recommendations are based on studies that were performed in middle-aged to young-older adults. Nevertheless, older patients are at high risk for several diseases that can impact on their morbidity, mortality, and quality of life. Certain malignancies are curable if detected early. Early and effective treatment of diabetes mellitus, hypertension, and glaucoma—to name a few conditions common in the geriatric population—can prevent significant morbidity (eg, blindness, stroke) in the future. Before screening elderly patients, however, physicians must consider the potential harms of screening, patient/family preferences regarding screening and treatment if a disease is detected, the patient’s functional status and comorbid conditions, and the patient’s predicted life expectancy. In order for a screening test to benefit a particular patient, the individual’s life expectancy should exceed 5 years.3
Physicians can estimate a patient’s physiologic age by using chronologic age (in years) and self-reported health status (Table III).4 Physicians can then determine a patient’s expected survival using information from Table IV for the estimated physiologic age.5 If the expected survival of a patient is more than 5 years, then screening an asymptomatic patient for a disease with a delay in disease-specific mortality is medically warranted, assuming that the patient is at risk for the disease and would accept treatment if early disease were detected.
Numerous updates have been published regarding cancer screening for potentially preventable malignancies that are common in older adults. The American Cancer Society (ACS) publishes a summary of existing recommendations for early cancer detection, including updates and/or emerging issues that are relevant to screening for cancer.6,7 Subspecialty societies publish updates periodically on specific cancer screening as do the USPSTF and the Canadian Task Force on Preventive Health Care (CTFPHC). The American Gastroenterological Association (AGA),8 the ACS,7 and the USPTSF9,10 have all released recommendations regarding colon cancer screening with fecal occult blood tests (FOBT), flexible sigmoidoscopy, barium enema, or colonoscopy. These recommendations are outlined in Table V.8 To date, no recommendation has been made regarding virtual colonoscopy, although this procedure has shown promise in initial studies.11,12
For screening purposes, Medicare will pay (fully) for FOBT once every 12 months, pay 75% of the Medicare-approved amount of flexible sigmoidoscopy once every 48 months or screening colonoscopy once every 24 months for patients at high risk, and screening colonoscopy for patients at normal risk of colon cancer once every 10 years, but not within 48 months of a screening sigmoidoscopy. Medicare will pay 80% of a barium enema cost every 24 months for high-risk patients and every 48 months for patients at normal risk. Medicare defines “high risk” as patients who have had or have a close relative with colorectal cancer, colorectal polyps, or inflammatory bowel disease. Recommendations from the USPSTF, the American Geriatrics Society (AGS), and the ACS regarding breast cancer screens are listed in Table VI.13-16 The American College of Obstetricians and Gynecologists (ACOG) has also published guidelines.17 Groups differ as to when to stop screening, frequency of screening, and whether to include clinician breast exam or breast self-exam (BSE). For example, the USPSTF recommends that mammography screening cease at age 70, whereas the AGS advises possible discontinuation at age 85 years. There is little evidence to suggest efficacy of BSE, although it raises a woman’s awareness of breast cancer.
Table VII outlines current guidelines regarding cervical cancer screening from the USPSTF, AGS, ACS, and ACOG.18-21 The first three groups recommend against screening older women if they have had adequate negative screening recently in the past and are not high risk for cervical cancer. Older women who have never had prior Pap screening should be screened with two cervical cancer screens before cessation of screening. No group recommends screening of asymptomatic women for ovarian cancer with CA-125 or transvaginal ultrasound.22-24 In 2004 the USPSTF noted there is “fair evidence” that screening with low-dose chest computed tomography (CT) scanning, chest x-ray, or sputum cytology can detect lung cancer at an earlier stage, but that the evidence is poor that any screening strategy for lung cancer decreases mortality. Screening has the potential for significant harm, so decisions regarding lung cancer screening in current or former heavy smokers between the ages of 55 and 74 need to be individualized.25
In Mrs. Wilson’s case, assuming she never smoked, there would be no need to screen for lung cancer. There is insufficient evidence for recommendations regarding the value of whole body CT scanning. Other diseases Although the USPSTF acknowledges that screening tests for dementia like the Mini-Mental State Examination can detect undiagnosed illness, there is insufficient evidence for or against screening because current treatments are only somewhat effective in slowing cognitive change.26 The USPSTF recommends screening adults for depression in clinical practices that are able to accurately diagnose, treat, and follow patients with depression. There is good evidence that screening improves diagnosis and that treatment of depression reduces morbidity in such patients.27 Because presbycusis is the third most prevalent condition among the elderly, both the USPSTF and the Canadian Task Force on the Periodic Health Examination (CTFPHE) have recommended hearing loss screens during periodic health exams. Audioscope testing is positive if the patient fails to hear 40 dB at 1 or 2 kHz in both ears or 1 and 2 kHz in one ear. Otoscopic exams and/or whispered-voice tests are also recommended. Patients should undergo cerumen disimpaction, if present, and be referred to an otolaryngologist if they have chronic otitis media or sudden hearing loss. Physicians should review patients’ medication lists for potentially ototoxic medications and refer patients who fail the screen for audiometry and hearing amplification.28
In 1995 the CTFPHE advised primary care physicians to also screen for visual acuity testing with a Snellen’s chart and to refer to ophthalmologists for funduscopy or retinal photography in elderly patients with diabetes of at least 5 years in duration. The task force advised that patients at high risk for glaucoma (positive family history, black race, severe myopia, or diabetes) undergo periodic assessment by an ophthalmologist.29 Normotensive individuals at age 55 have a 90% lifetime risk of developing hypertension. Because of the high prevalence of hypertension and atherosclerotic cardiovascular disease in older persons, screening for hypertension and treatment if detected are recommended. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) reset blood pressure goals to less than 140/90 mm Hg for patients without diabetes and to less than 130/80 mm Hg for patients with diabetes and chronic renal failure patients. The expert panel advised using diuretics as first-line therapy unless contraindications exist or there is a compelling reason to use another agent. For patients with blood pressure greater than 20/10 mm Hg over goal, the panel suggested that physicians consider starting treatment with two medications, one of which should be a diuretic.30,31 C-reactive protein, fibrinogen, and lipoprotein(a) confer increased risk of atherosclerotic cardiovascular disease, but they are not recommended for screening in the general population.32
Should Mrs. Wilson be screened for diabetes mellitus? The USPSTF reviewed this topic and published recommendations in 2003. Although the evidence is insufficient for or against routine screening in asymptomatic adults, patients like Mrs. Wilson who have hypertension, as well as those with obesity or hyperlipidemia, should be screened with a fasting plasma glucose.33 Values over 126 are considered abnormal. The American Diabetes Association (ADA)34 advises physicians to order an additional fasting plasma glucose on a separate day for those patients with borderline results or normal results with a high clinical suspicion for diabetes. The ADA suggests that physicians screen for type 2 diabetes mellitus at 3-year intervals after the age of 45, with shorter intervals for those who are at higher risk. The USPSTF also reviewed the role of screening for thyroid disease in adults and concluded that the evidence is insufficient to recommend for or against such screening. The Task Force acknowledged that the yield of screening is greater in the elderly, but found poor evidence that screening leads to clinically important benefits in asymptomatic individuals. In contrast, the American Thyroid Association (ATA) recommends screening in adults beginning at age 35 and intervals of 5 years afterward, while the American College of Physicians (ACP) recommends screening at the age of 50 years with a thyroid-stimulating hormone (TSH) level in women with one or more generalized symptoms.35
Because of the high prevalence of osteoporosis, elderly postmenopausal women are at a particularly high risk for falls and fracture. One-third of women age 85 and over break their hip during their lifetime. The USPSTF has advised routinely screening women 65 years and older for osteoporosis by dual-energy x-ray absorptiometry (DEXA) bone mineral densitometry at the femoral neck.36,37 For patients with existing osteoporosis, falls prevention is of prime importance. Patients with urinary incontinence or unsteady gait, a prior history of falls, or use of sedatives and antidepressants are at the highest risk. The AGS has also developed a Clinical Practice Guideline for the Prevention of Falls in Older Persons for physicians that includes recommendations regarding the routine care of the older person. The AGS advises clinicians to ask annually about falls; those patients with a single fall should undergo a balance and gait screen. The patient is asked to stand without using arms, walk 10 feet, and return to the chair (Get Up and Go Test). A more thorough evaluation, which includes a full neurologic and cardiovascular exam and measurement of orthostatic vital signs, is recommended for those older persons who present with recurrent falls or who have other risk factors such as an abnormal gait and balance.38
What if Mrs. Wilson were a man? There is a controversy around prostate cancer screening. Currently, there are several trials trying to answer the question, “Does prostate cancer screening prolong survival in men?” The Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial sponsored by the National Cancer Institute (NCI) has enrolled 30,000 men to answer this question of the benefits of prostate-specific antigen (PSA) in screening to prolong life. This trial will continue until 2007, in addition to years of follow-up, to determine harm versus benefit of screening in men. Meanwhile, organizations differ in their recommendations regarding prostate cancer screening: the USPSTF, ACP, NCI, and American College of Preventive Medicine (ACPM) recommend not screening, whereas the ACS, the American Urological Association (AUA), and the National Comprehensive Cancer Network (NCCN) advise offering screening to men age 50 years and older after a discussion of the benefits and risk of testing.39-43 One in 20 older men has an abdominal aortic aneurysm (AAA), one-third of which rupture if left untreated for many years. Four screening trials all showed significant reductions (from 21-68%) in death related to ruptured AAA.44,45 Given these recent results, we advise offering a one-time ultrasound screening to men age 65-74 who have ever smoked, especially if elective repair can be reserved for AAA greater than 5.5 cm. Patients with AAA on screening of 4-5.4 cm should undergo surveillance ultrasound testing every 6 months, and those with smaller AAAs should undergo surveillance every 2-3 years.
What if Mrs. Wilson lived in a nursing home? Many of the recommendations listed previously do not apply to the nursing home setting, where patients, in general, have decreased functional status and a lower life expectancy than community-dwelling elderly. In this setting, efforts need to focus on such concerns as prevention of acute illness and injury through vaccinations, infection control measures, falls prevention programs, and early recognition of depression.
Outcome of Case Presentation
During her preventive care visit, her physician could provide Mrs. Wilson with a questionnaire addressing lifestyle issues (ie, diet, exercise, alcohol intake, sexual activity, use of vitamins and other dietary supplements), dates and results of prior cancer screens, her knowledge of any other screening blood work or tests (such as the cholesterol level she mentioned or bone mineral density testing), and a review of symptoms that includes driving accidents, visual disturbances, hearing loss, changes in memory, symptoms of depression, and falls history. As part of the exam, her physician should check her blood pressure, vision, and hearing, and perform a gait and balance assessment (if she is at risk for falls). Mammography, screening colonoscopy, and cervical Pap smears would be reasonable cancer screens to consider in this woman whose self-reported health status is excellent. Blood work recommended includes fasting glucose. Checking a fasting lipid profile is advised by the National Cholesterol Education Program Adult Treatment Panel,46 but a recent meta-analysis did not show benefit in older women without underlying cardiovascular disease, so this area remains controversial.47,48