RECOMMENDED PREVENTIVE SERVICES
OTHER PREVENTIVE SERVICES TO CONSIDER
PREVENTIVE SERVICES NOT INDICATED IN OLDER ADULTS
DELIVERY OF PREVENTIVE SERVICES
As the population ages and the average active life expectancy increases, issues of primary and secondary prevention become increasingly important. The prevalence of undetected, correctable conditions and comorbid diseases is high in older adults. Moreover, a growing number of older adults are highly motivated about disease prevention and health promotion. The clinician provides the information and opportunity for preventive care that helps older patients to maintain functional independence for as long as possible. Additionally, clinicians must understand the significant heterogeneity of the aging population. Recommendations for screening community-dwelling, cognitively and functionally intact individuals will necessarily be quite different from those dealing with functionally dependent and cognitively impaired nursing-home residents with multiple comorbidities.
Many findings from research on preventive care and the appropriate components of periodic health examinations are inconclusive. In addition, older persons are typically not included in clinical trials of preventive strategies, which has limited the clinician’s ability to adjust guidelines for preventive practices for patients aged 65 and older on the basis of new scientific findings. Primary care physicians are consequently compelled to rely on clinical judgment in planning the preventive care of their older patients.
A number of factors, including age, functional status, comorbidity, patient preference, socioeconomic status, and the availability of care, affect health care decisions of the older adult. Unlike chronologic age, physiologic age may be determined by self-rated health and overall medical condition. Classifications that are based on life expectancy, physiologic age, and functional status may facilitate medical decision making with older patients. For example, the clinician might strongly recommend fecal occult blood testing (FOBT) to a healthy, functionally independent patient; discuss the potential pros and cons of FOBT and offer the test to a chronically ill, partially dependent patient; and actually recommend against FOBT for a severely frail, demented patient. It is important to consider all relevant issues in determining which conditions to screen for, the appropriate screening interval, and when (if ever) to discontinue screening in an older patient.
The risks of screening and its follow-up diagnostics and treatments (eg, perforation from colonoscopy; impotence or incontinence from prostate surgery) need more emphasis when discussions regarding screening recommendations occur. Also, attention to all-cause mortality, as opposed to disease-specific mortality, must be taken into account. For example, finding a preventable cancer that might result in death in 5 to 10 years if not detected early is of no benefit (and can result in actual harm and considerable cost) in an individual whose life expectancy is less than 5 years. It is important, too, that the values, beliefs, and preferences of older patients be factored into discussions, as should issues regarding quality of life.
Attention to the underlying principles of primary and secondary prevention is important for patients of any age. Screening measures should be systematically performed when the prevalence and morbidity or mortality of the condition outweighs both the economic cost and potential consequences of a falsely positive or negative test result. Some recommendations may be applicable only to high-risk individuals, not to the general population. (See also the discussion of cancer screening in Oncology, and definitions of terms used to access screening tests in the Appendix.)
Increasingly important is the clinician’s responsibility to counsel against the often grossly exaggerated and unproven claims of the anti-aging industry. The dollar costs and potential psychologic and physical damage associated with this burgeoning area are staggering and very worrisome.
A number of preventive services have been shown to be effective in the care of older persons and are widely endorsed. Table 9.1 summarizes these preventive activities, which are discussed below.
Routine measurement of height and weight can be used to calculate body mass index (BMI = kg/m2). Obesity has been defined in men as a BMI ≥ 27.8 and in women as a BMI ≥ 27.3. An unintentional weight loss of 10 pounds in 6 months can indicate malnutrition or a serious occult illness. (See also Malnutrition.)
The prevalence of hypertension increases with advancing age. The treatment of hypertension in older adults has been associated with a reduction in morbidity and mortality from left ventricular hypertrophy, heart failure, myocardial infarction, and stroke. However, older adults are more susceptible to adverse effects of antihypertensive therapy, such as hyponatremia, hypokalemia, depression, confusion, or postural hypotension. (See also Hypertension.) This susceptibility is especially true for the oldest-old patients and those with multiple comorbidities and taking multiple medications.
Uncorrected refractive errors, glaucoma, cataracts, and macular degeneration account for most undetected visual disorders. Routine screening with a Snellen chart is recommended by the U.S. Preventive Services Task Force (USPSTF). Undetected hearing loss can lead to social isolation and may indicate other underlying disorders. The USPSTF recommends periodically questioning older adults about their hearing and counseling them about the availability of hearing aid devices. The evidence for routine audiometry as a screening tool is unproven. (See also Visual Impairment, and Hearing Impairment.)
Depression is a disease with significant morbidity and mortality in the older age group. Treatment can be highly effective. The USPSTF recommends screening of the general adult population. Importantly, they add the recommendation that clinicians who do screen for depression have systems in place to assure accurate diagnosis, effective treatment, and follow-up. There are several reliable and valid depression screening instruments for older persons, including the Geriatric Depression Scale. (See the Appendix; see also Depression and Other Mood Disorders).
All older adults should be screened for alcohol abuse at least once and whenever a drinking problem is suspected. Screening questionnaires such as the CAGE (see Table 39.1) can be useful in detecting alcohol problems. (See also Alcohol and Drug Abuse.)
There is good evidence that in elderly persons with prior myocardial infarction or angina, correcting lipid abnormalities (ie, levels of low-density lipoprotein ≥ 130 mg/dL, of high-density lipoprotein ≤ 35 mg/dL, of triglycerides ≥ 200 mg/dL) lowers the risk of recurrent cardiac events. These persons should be screened for lipid abnormalities; treatment goals for those found to have dyslipidemia should be low-density lipoprotein levels of < 100 mg/dL, high-density lipoprotein levels of > 40 mg/dL, and triglyceride levels of < 200 mg/dL. There is no evidence that screening older adults who are clinically free of coronary artery disease (CAD) or who have few cardiac risk factors for primary prevention of CAD is effective. (See also Cardiovascular Diseases and Disorders.)
The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 years who have ever smoked. Evidence shows that screening for AAA and surgical repair of large AAAs (≥ 5.5 cm) in men aged 65 to 75 years who have ever smoked (current and former smokers) leads to decreased AAA-specific mortality. Because of the potential harms of screening and early treatment (including an increased number of surgeries with associated clinically significant morbidity and mortality), the USPSTF makes no recommendation for or against screening for AAA in men aged 65 to 75 years who have never smoked. Since women have a low prevalence of large AAAs, the USPSTF recommends against routine screening for AAA in women.
The USPSTF now recommends that women aged 65 and older be screened routinely for osteoporosis by the use of bone density measurements. For those at high risk for osteoporotic fractures, the task force recommends beginning screening at age 60. Clinician counseling regarding adequate calcium intake, smoking cessation, exercise, and avoidance of falls is also recommended. (See also Osteoporosis and Osteomalacia.)
Despite considerable controversy regarding the efficacy of screening mammography, almost all government-sponsored groups, medical societies, and advocacy groups do recommend routine mammography for women aged 65 and older. How often to screen and at what age to stop remain unresolved. Mammography every 2 to 3 years for older women with an active life expectancy of 5 or more years is a reasonable guideline. For high-risk individuals, yearly screening is prudent. Medicare covers annual screening mammograms.
Clinician breast examination is not uniformly recommended for screening, and breast self-examination has not been shown to be efficacious.
(See also the section of breast cancer in Oncology.)
Approximately 40% of new cases of invasive cervical cancer and deaths from cervical cancer occur in women aged 65 years and over. The Papanicolaou smear is most cost-effective in older patients who have previously had incomplete screening. Between 4% and 8% of cervical cancers are found in the cervical stump in women who have undergone incomplete hysterectomy. Regular Pap smears every 1 to 3 years are recommended for all women who are or have been sexually active and who have a cervix. Medicare has covered triennial screening without age limit since 1990. The appropriate cut-off age for screening remains controversial, although most experts recommend cessation of screening after age 65 if the patient has had a history of regularly normal smears. In older women never previously screened, screening can cease after two normal Pap smears are obtained 1 year apart.
Although evidence is not yet definitive, screening for colorectal cancer by colonoscopy is the preferred method for older persons. The entire colon can be examined expeditiously by an experienced endoscopist and any appropriate biopsies can be obtained.
Medicare will pay for a screening colonoscopy every 10 years for all beneficiaries. In addition, Medicare provides coverage for annual FOBT and biennial flexible sigmoidoscopy. A double-contrast or air-contrast screening barium enema may be substituted for either a screening flexible sigmoidoscopy or a screening colonoscopy. When FOBT is recommended, instructions regarding proper diet, medication usage, and vitamin usage before and during stool collections and proper collection technique are crucial in order to avoid false positives and negatives. “Virtual” colonoscopy, a new method using thin-section, helical computed tomography, is currently under investigation as a screening tool for colorectal cancer.
Studies have refuted the concept that a low-fat, high-fiber diet plays a role in preventing colorectal cancer. Although epidemiologic data suggest that aspirin or nonsteroidal anti-inflammatory drugs may be protective against colorectal cancer, there is insufficient evidence to support the routine use of these medications for primary prevention. However, for individuals wanting to maximize prevention and having no contraindications, one aspirin daily is reasonable and justifiable. This does not replace screening, FOBT, sigmoidoscopy, or colonoscopy.
(See also the section on colon cancer in Oncology.)
Smoking cessation at any age reduces rates of chronic obstructive pulmonary disease, many cancers, and CAD. All older adult smokers should be encouraged to and helped with smoking cessation at each office visit. (See also Alcohol and Drug Abuse, and Respiratory Diseases and Disorders.)
Many common problems can be detected and effectively treated by regular dental visits, including periodontitis, xerostomia, and oral cancers. (See also Oral Diseases and Disorders.)
The importance of a well-balanced diet should be addressed routinely with older adults. An appropriate diet is high in fruits and vegetables and low in fat and salt, and it has adequate calcium content. Also, it is important not to overly restrict the diet of those who are underweight or frail. Restrictions in these situations can be counterproductive and lead to increased morbidity. (See also Malnutrition.)
Increasing evidence supports the importance of physical activity for both physical health and sense of well-being. Physical activity has been associated with greater mobility and lower rates of CAD and osteoporosis. Older adults should be counseled about an exercise program that balances modalities of flexibility (eg, stretching), endurance (eg, walking or cycling), strength (weight training), and balance (eg, Tai Chi or dance therapy). (See also Physical Activity.)
The USPSTF recommends counseling older persons on measures to reduce the risk of falling (see also Falls, Gait Impairment, and the Appendix for details about preventing falls), safety-related skills and behaviors, and environmental hazard reduction. Safety-related behaviors include the regular use of seat and lap belts in automobiles, regular driving tests, and avoidance of alcohol use while driving or operating machinery. Environmental hazard reduction might include lowering hot-water temperature to prevent serious burns, installing smoke detectors, and, in homes of demented persons, installing alarms and automatic shut-off features on appliances, and removing or safely storing firearms. A home safety checklist or formal environmental assessment by a physical or occupational therapist can facilitate injury prevention.
Medicare covers the costs of influenza, pneumococcal, and tetanus immunizations.
The current influenza vaccine is a killed virus that is moderately immunogenic, with estimated efficacy rates of 70% for illness and 90% for mortality. Multiple evaluations of the vaccine’s efficacy reveal that, although it incompletely protects against disease, it clearly reduces rates of respiratory illness, hospitalization, and mortality in the elderly age group. Annual vaccine administration must be provided because of antigenic drift and the short-lived (4 to 5 months) protection provided by the vaccine. Current recommendations are that all patients aged 65 or over or those under age 65 with underlying medical illnesses be immunized annually between October and mid-November, but any time from September to the end of influenza season is appropriate. Medical personnel and caregivers for high-risk patients should also be immunized. Potential adverse effects include fever, chills, myalgias, and malaise, but these are rare. Contraindications include anaphylactic egg hypersensitivity or allergic reactions following occupational exposure to egg protein. Live, attenuated influenza vaccines have been developed, appear to be more effective, and are likely to be approved for widespread use in the near future.
In outbreak situations, chemoprophylaxis can protect against influenza during the 2 weeks immediately after immunization until the antibody response is mounted, or in persons who cannot receive the vaccine. Amantadine, rimantadine, zanamivirOL, and oseltamivir are all effective for influenza A, but they differ greatly with regard to cost, adverse effects, mechanism of action, and mode of delivery. Only the neuraminidase inhibitors zanamivir and oseltamivir have activity against influenza B. Zanamivir is administered via a disk-inhaler system; the others are taken orally.
Treatment of influenza is also possible with any of the four drugs and reduces the duration of illness by about 1 to 1.5 days, if started within 24 hours of symptom onset. Again, only the neuraminidase inhibitors can be used for treatment of influenza B. Resistance to amantadine and rimantadine can develop rapidly in many persons during the course of treatment; resistance to the neuraminidase inhibitors is less well characterized at this time.
Pneumococcal vaccination is indicated for all persons aged 65 years or older and many persons under age 65 with comorbid conditions. If ≥ 5 years has elapsed since the first dose and the patient was vaccinated before the age of 65, repeat vaccination is indicated. Studies show that adverse events following revaccination are rare and mild. Thus, an unknown vaccination history should prompt administration of the pneumococcal vaccine. (When in doubt, vaccinate!) The vaccine does not prevent mucosal disease such as sinusitis and has unclear efficacy for preventing pneumonia. However, there is strong evidence that suggests that the vaccine reduces the risk of invasive disease (ie, bacteremia) and that it is cost-effective for older immune-competent adults.
Although the protective efficacy of the pneumococcal vaccine is estimated to be only 60% to 70% and studies have revealed mixed results regarding benefits in high-risk older adults, all patients aged 65 years and older should receive one dose of 0.5 mg IM. Studies suggest that people may benefit from revaccination every 7 to 10 years. Other than local soreness, adverse effects are usually minimal.
More than 60% of tetanus infections occur in persons aged 60 years of age and older. There is evidence that the absorbed tetanus and diphtheria toxoids provide long-term protection 35 years after the primary series or booster. Older adults who have never been vaccinated should receive two doses, 0.5 mg IM 1 to 2 months apart, followed by an additional dose 6 to 12 months later. The optimal interval for booster doses is not established; the USPSTF and Canadian Task Force recommend booster vaccinations every 10 years. Local pain and swelling or, rarely, hypersensitivity may accompany vaccination. A neurologic or hypersensitivity reaction to a previous dose is an absolute contraindication.
A number of other preventive activities are recommended by assorted specialty organizations even though the evidence for effectiveness is lacking. Some of these preventive measures are listed in Table 9.2. In the face of unproven effectiveness for each of these procedures, clinicians must weigh the potential benefits of the preventive procedure against the potential risks of unnecessary treatment. Procedures that are particularly pertinent and controversial in the older adult population are discussed below.
The USPSTF recommends neither for nor against annual skin examination to detect early skin cancers because of a lack of research-proven effectiveness. However, the relatively low cost associated with annual skin examinations and the low costs and morbidity associated with treatment (eg, excision, cryotherapy) of false positives makes the decision to screen considerably less weighty for skin cancer than for prostate cancer. The USPSTF does recommend counseling high-risk patients (those who are light-skinned or with a past history of skin cancer) to avoid sun exposure and to use protective clothing when outdoors. (See also Dermatologic Diseases and Disorders.)
Although routinely screening for dementia in the general older population is not recommended by the USPSTF, clinicians should be alert to detect new cases as early as possible since a combination of medications, education, and counseling can benefit patients and their families.
For primary prevention, aggressively controlling cardiovascular and cerebrovascular risk factors (eg, hypertension, hyperlipidemia) may be helpful for both vascular and Alzheimer’s dementias. There is some evidence that staying mentally active (eg, reading, pursuing new areas of learning, working crossword puzzles) may be beneficial in prevention as well. Estrogen and nonsteroidal anti-inflammatory agents are not efficacious in Alzheimer’s prevention. Statins are currently under investigation and cannot at this time be routinely recommended for prevention of Alzheimer’s disease. (See also Dementia.)
The increased prevalence of diabetes mellitus with age and the consequent morbidity burden warrants consideration for screening. Routine screening of asymptomatic adults for diabetes is not recommended by the USPSTF; however, the USPSTF does recommend screening for type 2 diabetes in those individuals with hyperlipidemia, as a method to improve an individual’s risk estimates for coronary heart disease. (See also Diabetes Mellitus.)
The prevalence of subclinical and clinical hyperthyroidism and hypothyroidism increase with advancing age. The USPSTF does not recommend routine screening but acknowledges that screening may be performed on the basis of the high prevalence of the disease and the likelihood that its symptoms will be overlooked in older adults. The preferred test is the immunometric assay that is sensitive to thyrotropin. (See also Endocrine and Metabolic Disorders.)
Randomized controlled trials of screening by prostate-specific antigen or digital rectal examination, currently in progress, should provide valuable information on the efficacy of these modalities. Until the results of those trials are known, however, patients should be counseled about the implications of an elevated prostate-specific antigen level or a mass detected by digital rectal examination and the potential adverse effects (surgery, incontinence, impotence) of treating false or even true positives. The American College of Physicians supports selective testing in 50- to 69-year-old men, provided that optimistic assumptions are used and the risks, benefits, and uncertainties are understood. With evidence currently available, it is difficult to justify screening in men aged of 70 and over. Medicare covers the cost of prostate cancer screening. (See also Prostate Disease.)
For a discussion of vitamin and mineral supplements and antioxidants, see Malnutrition.
Aspirin therapy up to 500 mg per day has not been consistently shown to reduce myocardial infarction or cardiovascular mortality. The adverse bleeding effects of aspirin increase with age, although the absolute serious adverse-effect rate of dosages ≤ 325 mg per day is low. Older adults with risk factors for myocardial infarction or stroke may be more appropriate for prophylaxis with aspirin. (See also Cardiovascular Diseases and Disorders.)
See also the section on infective endocarditis in Infectious Diseases for the use of antibiotics to prevent infective endocarditis and prosthetic device infections in at-risk patients.
Table 9.3 lists services that have been shown not to be effective in preventing certain conditions or their adverse outcomes. There is excellent evidence that the general screening modality of the annual complete history and physical examination is not any more effective for improving outcomes than a more targeted approach of individual screening, counseling, immunoprophylaxis, and chemoprophylaxis. Current evidence does not support specific screening for lung, pancreatic, ovarian, bladder, or hematologic malignancies for the general population. However, promising new screening modalities, such as helical low-density computed tomography of the chest for lung cancer and homocystinemia for heart disease, are being actively developed and investigated.
Recent evidence has demonstrated that the risks of estrogen-progestin combinations significantly outweigh any potential benefits and therefore should not be recommended. (See the section on estrogen replacement therapy in Endocrine and Metabolic Disorders.)
A well-organized systems-based approach using various personnel, sites, and communication methods may narrow the gap between the knowledge of age-appropriate practice recommendations and the implementation of preventive measures. Lack of time and inadequate reimbursement are only two of the barriers faced by clinicians. Overcoming these barriers commonly involves the assistance of paramedical personnel and the use of technology. A nurse or trained office assistant may be able to adequately explain a screening procedure such as FOBT and its implications in terms of follow-up diagnostic testing. Reminders can be used to prompt clinicians to offer selected screening tests and improve adherence to recommendations. Mailed or computer-generated reminders can be used to enhance screening rates for procedures such as mammography, colorectal cancer screening, and influenza vaccination. Automated telephone technology may be useful to deliver behavioral interventions for improving medication adherence, dietary modification, and physical activity among sedentary persons. Primary and secondary preventive services may be provided at a variety of sites, including ambulatory clinics, assisted-living and long-term-care facilities, mobile vans, and supermarket-based pharmacies.
The implementation and evaluation of novel approaches for preventive practice are clearly warranted if progress is to be made in this increasingly important field. The more the primary care physician is able to rely upon others to help explain and perform preventive maneuvers, the greater the likelihood that the patient adherence will improve as well.
■ Agency for Healthcare Research and Quality. Preventive Services. Available at http://www.ahrq.gov/clinic/prevenix.htm (accessed October 2005).
Routinely updated literature searches and critical reviews with revised recommendations continue to make this the best source for evidence-based guidelines. Recommendations of the USPSTF, however, are conservative and therefore can be justifiably modified depending upon the setting and population being addressed.
■ Bloom H. Prevention. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine: An Evidence-Based Approach. 4th ed. New York: Springer-Verlag; 2003:169–184.
This chapter presents a comprehensive overview of preventive approaches and practices in the care of the older population. Included are tables outlining the recommendations of key prevention-oriented organizations and specialist organizations regarding primary and secondary prevention for persons aged 65 and older.
■ Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750–2756.
This article delineates the complexity of decision making regarding cancer screening in older persons. The authors argue credibly that many factors need to be taken into account when recommending for or against screening for various cancers. Such factors include estimated life expectancy, potential harmful as well as beneficial screening outcomes, and detecting cancers that would never have become clinically significant. Also emphasized is the importance of the patient’s own values and preferences in decision making.
Harrison G. Bloom, MD