HEALTH MAINTENANCE & PREVENTION IN ELDERS Module #2

1. HEALTH MAINTENANCE & PREVENTION IN ELDERSModule #2 Ed Vandenberg, MD, CMD Geriatric Section OVAMC & Section of Geriatrics 981320 UNMC Omaha, NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512

2. 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

3. Fasting plasma glucose Fasting serum lipid profile Hemoglobin A1C D. Radiography of the chest E. Computed tomography of the chest Answer Fasting serum lipid profile Case based Geriatric Review AGS 2002 Which of the following screening maneuvers for this patient is best supported by medical evidence?Choose one answer:

4. 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 cost-effective 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

5. 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) U.S. Preventative Services Task Force Am J Prev Med 2001;20 (3S) 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 risk TC/HDL ratios.

6. 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 in any gain in life expectancy. 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!!)

7. Would you screen for hypothyroidism in all your elderly patients? • Answer……… • The USPSTF concludes the evidence isinsufficient to recommend for or against routine screening for thyroid disease in adults. USPSTF ( I) • BUT • (be suspicious and use TSH freely)

8. 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.

9. 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. 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)

10. 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 moderatephysical 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 those who engage in vigorous activity have lower risks.

11. 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

12. When would you screen for alcohol abuse? (Choose one answer) When you smell alcohol on your patients breath When you smell alcohol on your breath 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 When would you screen for alcohol abuse?

13. 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

14. 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 Vision ScreeningWhen would you recommend vision screening to be performed?

15. When would you recommend hearing screening to be performed? Annually As needed 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 Hearing screening

16. 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 Select as many as indicated to ask about or advise for injury prevention?

17. 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.

18. (Select as many as indicated) 1) Calcium 1500 mg/day & Vit D 400-800 IU/d 2) Weight bearing exercise 3) Hormone Replacement Therapy ( HRT) 4) Bone densitometry Answers: 1) Calcium 1500 mg/day & Vit D 400-800 IU/d 2) Weight bearing exercise 4) Bone densitometry Case based Geriatric Review AGS 2002 What interventions would you recommend for osteoporosis screening and prevention?

19. Current recommendations for prevention and screening Calcium 1500 mg/day & Vit D 400-800 IU/d (USPSTF) (B) Weight bearing exercise (USPSTF) (B) Bone densitometry (USPSTF) (B) US Preventive Services Task Force ( USPSTF) http://www.ahrq.gov/clinic accessed 2-2005

20. Osteoporosis screening • Routine screening for >65 (ave. risk*) (USPSTF) (B) for > 60 ( high risk*) (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. US Preventive Services Task Force ( USPSTF)

21. Osteoporosis Risk: What is the best predictor? ( choose one answer) Low body weight Low calcium intake 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. Osteoporosis screeningWhat is the best predictor of risk?

22. 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 (I) • 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

23. END of MODULE #2

24. 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? Tai Chi Swimming Resistance training Stationary bicycling Post Test 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.

25. 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.