medicine didactic lecture 2009 geriatric preventive care cletus u. iwuagwu, md, cmd associate...

MEDICINE DIDACTIC LECTURE 2009

GERIATRIC PREVENTIVECARE

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.

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

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.

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

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.

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

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

TOPICS COVERED

• Recommended Preventive Services Screening Counseling Immunizations Chemoprophylaxis

• Other Potentially Beneficial Services

• Screens and Tests Not Indicated

• Effective Delivery of Preventive Services

SCREENING

All older adults should be screened for:

• Hypertension• Breast, colorectal, and cervical cancer• Obesity, malnutrition• Alcoholism• Dyslipidemia• Vision and hearing deficits• Osteoporosis

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

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

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

Medicare covers annual screening mammograms

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

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 smearand pelvic exam every 2 years

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+

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

SCREENING FOR ALCOHOLISM

Method• Use screening questionnaire, e.g., CAGE:

Cut downAnnoyGuiltEye-opener

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

Rationale• Older adults are more susceptible to effects

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

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

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

COUNSELING

All older adults should be counseled at least annually about:

• Diet

• Physical activity

• Safety and injury prevention

• Smoking cessation

• Dental care

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

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)

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 hot-water temperature

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

IMMUNIZATIONS

Immunization for the following should be a routine part of preventive health care for all older adults:

•Influenza

•Pneumonia

•Tetanus

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

IMMUNIZATION FOR INFLUENZA(2 of 2)

Efficacy is:

70% for illness

90% for mortality

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

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

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

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

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

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

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)

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)

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

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

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

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

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

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

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.

CASE 1 (2 of 3)




(C) Colonoscopy



CASE 1 (3 of 3)




(C) Colonoscopy



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.

CASE 2 (2 of 3)






CASE 2 (3 of 3)






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.

CASE 3 (2 of 3)







CASE 3 (3 of 3)







medicine didactic lecture 2009 geriatric preventive care cletus u. iwuagwu, md, cmd associate...

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