MEDICINE DIDACTIC LECTURE 2009 GERIATRIC PREVENTIVE CARE

1. MEDICINE DIDACTIC LECTURE 2009 GERIATRIC PREVENTIVECARE Cletus U. Iwuagwu, MD, CMD Associate Professor of Medicine Office of Geriatric Medicine & Gerontology University of Toledo

2. 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.

3. 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

4. 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.

5. 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

6. 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.

7. 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

8. 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

9. TOPICS COVERED • Recommended Preventive Services • Screening • Counseling • Immunizations • Chemoprophylaxis • Other Potentially Beneficial Services • Screens and Tests Not Indicated • Effective Delivery of Preventive Services

10. SCREENING • All older adults should be screened for: • Hypertension • Breast, colorectal, and cervical cancer • Obesity, malnutrition • Alcoholism • Dyslipidemia • Vision and hearing deficits • Osteoporosis

11. 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

12. 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

13. MAMMOGRAPHY RECOMMENDATIONS Medicare covers annual screening mammograms

14. 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

15. 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 smear • and pelvic exam every 2 years

16. 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+

17. 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

18. SCREENING FOR ALCOHOLISM • Method • Use screening questionnaire, e.g., CAGE: • Cut down • Annoy • Guilt • Eye-opener • Screen all older adults at least once • Screen whenever a drinking problem is suspected • Rationale • Older adults are more susceptible to effects

19. 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

20. 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

21. 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

22. COUNSELING • All older adults should be counseled at least annually about: • Diet • Physical activity • Safety and injury prevention • Smoking cessation • Dental care

23. 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

24. 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)

25. 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

26. 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

27. IMMUNIZATIONS • Immunization for the following should be a routine part of preventive health care for all older adults: • Influenza • Pneumonia • Tetanus

28. 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

29. IMMUNIZATION FOR INFLUENZA(2 of 2) • Efficacy is: 70% for illness 90% for mortality

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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)

37. 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)

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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.

45. 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

46. CASE 1 (3 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

47. 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.

48. 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

49. CASE 2 (3 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

50. 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.