Ring in the New Year With Healthcare Screening and Preventive Strategies
As the New Year starts, it is a good time for all physicians to consider what is necessary for our patients’ care in the months ahead. Early recognition of problems through healthcare screening and preventive strategies are key to maintaining health and maximizing function throughout life. Unfortunately, many patients still fail to have simple tests and screenings that have become the standard of care. Having a list of agreed-upon recommendations in a patient’s file makes it easier to keep track of what is necessary as the year progresses. There are many places to seek recommendations, and no one source appears to have all the answers. I have always respected the opinion of the American Geriatrics Society, and have also used recommendations from many other organizations including the American Cancer Society, the U.S. Preventive Services Task Force, the American Thyroid Association, and the American College of Physicians, among others.
While the list of recommendations is too exhaustive to detail here, a few are as follows:
• Mammograms: It is recommended that women have mammograms done annually until age 75, then every 2-3 years unless life expectancy is less than 4 years.
• Cervical cancer screening: Should be done on all elderly women, unless they have had three or more negative exams in the 10 years prior to age 65. If an elderly woman has no record of these negative exams, it should be done regardless of age as long as the woman has a lifespan of several years. The American Cancer Society says to continue doing screening only until age 70.
• Colorectal cancer screening: Colorectal cancer screening appears to be beneficial throughout life, with colonoscopy suggested every 10 years or more often if an abnormal finding is noted.
• Vision and hearing screening: A good eye examination to check for glaucoma and macular degeneration is essential for all older persons, though the frequency that this is necessary depends on prior findings and coexisting illness. Physicians should assess their patients’ ability to see and hear under real-life circumstances. A false sense that all is fine may result if the physician only uses the Snellen test to assess vision and the “whisper test” to assess hearing. Just how does the older person see and hear under normal circumstances, such as reading the newspaper, watching TV, and hearing a voice in a busy restaurant or supermarket?
• Depression screening: Estimates run as high as 40% for elderly persons having mild or more significant depression. The CAGE questionnaire is also pertinent during later life, especially if life situations place one at greater risk of alcohol abuse. Elderly men who have recently lost their spouse reportedly have one of the highest rates of new alcohol abuse, and a high index of suspicion is necessary.
• Screening for cognitive function: The U.S. Preventive Services Task Force recommends that clinicians should assess cognitive function whenever cognitive impairment is suspected based on direct observation, patient report, or concerns raised by family members. Two commonly administered neuropsychological tests include the Mini-Mental Sate Examination and the Clock Drawing Test.
• Lipid screening: Suggested for those at increased risk, though there is mixed data on the value for those individuals past the age of 65 who have not had a prior abnormality noted. Lipid levels remain fairly stable during later life.
• Fall risk screening: There should be an assessment for fall risk, with some advocating that the Tinetti Balance and Gait Scale be used.
• Purified protein derivative test: Individuals with diabetes, chronic renal failure, or other immunocompromising illness should have a purified protein derivative test.
• Osteoporosis screening: All women age 65 years and older should be screened for osteoporosis. The U.S. Preventive Services Task Force suggests that this screening be done between the ages of 60 and 64 for women considered to be at high risk, though others suggest starting as early as the postmenopausal period.
• Assessments for pain, diabetes, urinary incontinence, and elder abuse or neglect should be done.
• Prostate test: The prostate-specific antigen test remains quite controversial in terms of a screening test for prostate cancer; however, an annual rectal examination is suggested for all men over age 50 and earlier in those at high risk for prostate cancer.
• Vaccinations: Pneumonia, tetanus, influenza, and herpes zoster vaccines should be given.
A checklist—perhaps computer-generated—might be useful to help monitor these recommendations and to ensure that all patients are provided with appropriate testing in a timely manner. As recommendations change, this list needs to be updated and new timeframes entered. Primary care physicians play an important role in helping to orchestrate complete care of their patients, and having an organized system in place to assist in this process will clearly help make this doable and prevent lapses in care.
This issue of Clinical Geriatrics includes two articles that focus on important screening guidelines: “Dementia Screening Tools for the Primary Care Physician” (this month’s CME article) and “Current Status of Screening for Colon Cancer in Older Adults.” Each year it appears that we identify new ways to improve our ability to detect problems that if found early enough might benefit from some intervention. Clearly, prevention is the best approach, though this is not always possible.
I hope that your New Year will be a joyous one and that you will begin with a clear plan in mind for meeting your patients’ needs!
Dr. Gambert is Chairman, Department of Medicine, and Physician-in-Chief, Sinai Hospital of Baltimore, and Professor of Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.