HESC 450 Midterm Study Guide (CH 1-7 /Not Ch 6)
HBP Causes/Consequences
(Some) Causes of HBP Smoking Obesity/being overweight Diabetes Sedentary lifestyle Lack of physical activity High levels of salt intake Insufficient calcium, potassium, & magnesium consumption High levels of alcohol consumption Stress Aging (Some) Consequences of HBP Heart disease, heart attack Stroke Kidney damage/failure Increased vascular & vision damage, esp in diabetics Possible cognitive decline/dementia
Wilson's Classic Screening Program Criteria
- Condition should be an important health problem. - There should be an accepted treatment for patients with recognized disease. - Facilities for diagnosis and treatment should be available. - Recognizable latent or early symptomatic stage. Suitable test or examination. Screening test should be acceptable to the population. - Understanding of natural history of the condition, including development from latent to declared disease. - Agreed policy on whom to treat as patients. - Cost of case-finding (including diagnosis and treatment of those diagnosed) should be economically balanced in relation to possible expenditure on medical care overall. - Case-finding should be continuing process, not a "once and for all" project. (Wilson and Jungner, 1968)
Healthy People 2020
- Launched in 1979 via a US Surgeon General's Report: Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention - Renewed every 10 years - More than 1200 objectives with 42 topic areas tracked - Objectives Specific to Older Adults (new area) - Chronic Disease Management (including diabetes self-management programs) - Clinical Preventive Services (including "Welcome to - Medicare" preventive visit) - Functional Limitations - Leisure-time Physical Activities - Geriatric Education among Healthcare Professionals - Long-Term Services and Supports - Elder Abuse, Neglect, and Exploitation - Falls Prevention - Objective Selection Criteria
Other Health Promotion Benefits of Older Adults
- Proper exercise reduces risk for falls - Proper nutrition prevents malnutrition - Adequate social support decreases mortality - Some other health promotion examples that benefit older adults are: 1. Exercise programs have shown to reduce risk for falls 2. Proper nutrition courses aid in preventing malnutrition 3. Opportunities to increase or maintain social support and social ties decreases one's mortality
Updated Screening Program Criteria
- Screening program should respond to a recognized need. - Objectives of screening should be defined at the outset. - Defined target population. - Scientific evidence of screening program effectiveness. - Program should integrate education, testing, clinical services and program management. - Quality assurance, with mechanisms to minimize potential risks of screening. - Program should ensure informed choice, confidentiality and respect for autonomy. - Program should promote equity and access to screening for the entire target population. - Program evaluation should be planned from the outset. - Overall benefits of screening should outweigh the harms.
Healthy Aging Determinants
- mental health -gender -health behaviors -SES and social status -stress, coping, and resitience -health and social services -physical enviroment -sulture -empowerment ageism -engagement -disease and disability state -spirituality -urbanization and migration -family and social relationships -stability -medication use
Health Status
-Activities of Daily Living (ADLs) -Instrumental Activities of Daily Living (IADLs) -Disability / Functional Ability -Utilization Rates for Medical, Social / Home and Community Based Services, and Long Term Care -Chronic Disease Burden -Life Expectancy and Mortality
Why study health promotion in aging populations?
-Globally, older adults will more than double by 2050. The United States will experience a similar trend. When considering the 65 plus age group in the United States only, this age cohort will represent 20% of the population in 2030. Yes, 1 in 5 people will be over the age of 65. While, people under 65 years old are experiencing a slower growth rate at 17%. -Fastest Growing Segment of the Population Globally
The Rise of the Baby Boomers
-Largest age cohort (76 million births with 70 million reaching "older adult status" by 2030) -Longest-lived cohort -Healthiest cohort -Best educated cohort -Most engaged cohort -Largest diverse cohort Baby Boomers will be a force to reckon with. As the largest cohort, reaching 70 million by 2030, they will continue to redefine aging and force us to rethink the role of an older adult. As the cohort that will have the most years lived in retirement, they will find ways to re-engage in society, as social entrepreneurs, community volunteers, business consultants or venture capitalists. As the best educated cohort of older adults, research shows this may actually have benefits for their cognitive health. A good deal of research shows that more education throughout the life-course has positive implications for long term brain health. However that same research shows that the quality of education may matter. We can expect to continue to see disparities. Baby Boomers will also be the healthiest cohort, due to improvements in medical diagnosis and treatment, in addition to prevention efforts, like the pneumococcal or shingles vaccinations. Public health information and campaigns have further provided enhancements in this area. Such as the increases we have seen in exercise and reductions in smoking. I would add that the Baby Boomers will be the most diverse, which will present unique opportunities and challenges for health care providers.
Healthy People Objectives Met
-Leisure-time Physical Activity -Obesity -Smoking -Hypertension Medications -Preventive Screenings: Mammograms and Colorectal
Counseling for Prevention
-Objectives: to change health behaviors in order to improve health status -May be conducted by physician, nurse, dietician, health educator, or other health professional -Good evidence for changing some important health-related behaviors Small changes may add up on a population level -Risk-benefit and Cost-effectiveness Considerations: No intervention, including counseling, is ever risk-free, or cost-free!
Other Unhealthy Behaviors
-Persistent Physical Inactivity -Unhealthy Weight -Poor Diet and Malnutrition -Clinical Preventive Services
HBP in America: Issues
65% of people 60+ have HBP CDC estimates 65 million have it, but only half are treated; large % of older adults inadequately treated with HBP not controlled Medicare supports screening, drugs, but less emphasis on lifestyle changes Some data show less mortality from HBP in the older old Worth screening after age 85? New research: lower not always better?
Barriers to Delivering Preventive Services
Clinician time Sometimes inadequate reimbursement Uncertainty about which services should be offered -Multiple recommendations coming from multiple sources, some with vested interests, e.g. specialty societies, advocacy organizations, industry -Variable evidence regarding effectiveness -A surprising % of medical care not evidence-based! We have a tendency in our US healthcare system and culture to want "to do everything" for everyone. However, we saw in Chapter 1 that many objectives for preventive services aren't being met for older adults in the US: Why?
Socio-Economic Status among Older Adults Labor Force Participation
According a report by the Administration on Aging, 18.6 % of older adults aged 65 and over were in the labor force in 2014, representing 5% of the total labor force. Current estimates predict that older adults will remain in the workforce and steadily increase over the next 15 years, particularly in the younger cohort, those between the ages of 65 and 74. Many older adults wish to remain in the work force, because they feel connected to the broader community, they enjoy the financial independence it affords them, and provides them a sense of fulfillment. However, there are seniors who wish to retire but cannot retire due to financial reasons: lack of sufficient retirement savings (or extreme monetary losses from the recession) or pensions. Social Security was never envisioned to be the only retirement account for older adults. In fact, President Franklin D. Roosevelt proposed a three-tiered system: 1. company pensions; 2. personal savings; and 3. social security. Unfortunately, the prevalence of the first and second items have been dramatically reduced for several reasons, such as: rising cost of living, increases in consumption, corporate cutbacks, and rising out-of-pocket medical costs, to name only a few.
Tech Adoption Climbs Among Older Adults Report by the Pew Research Center, 2017
According to a recent report released in May of 2017, more than two-thirds of older adults, 65+, use the internet, up from 12% in 2010. 80% of older adults own a cellphone, including flip phones and smartphones. Taking into consideration education and wealth, some groups of older adults use more advanced technology (e.g., smartphones, tablets, etc.) at similar rates to younger age cohorts. For the most part, though, the 75+ remain largely disconnected from technology. Therefore, health educators must have several different mediums to communicate messages: print, video, internet-based/website, app, etc.
Screening
Accuracy of Test: -Sensitivity: % of those with the condition (really) who test positive -Specificity: % of those without the condition (really) who test negative -Reliability: test-retest Effectiveness: -Now you have a test result, so what? What happens next? Does screening lead to appropriate, effective intervention, leading to improved outcomes, e.g. -Years of life saved, preserved or improved function, quality of life?
Colorectal Cancer (CRC)cont.
Age is a major risk factor, with the risk of disease increasing with age. Males and African Americans generally have the highest risk of being diagnosed and have a higher risk of mortality - it is not fully understood why. With early detection of precancerous polyps can lead to polyp removal and lower risk that they will develop into invasive cancer, so this is a special case of cancer screening similar to Pap smear, where screening can actually lead not just to catching cancer in an early stage but even to prevention of cancer developing in the first place!
USPSTF Aims
Another important thing to bear in mind is that all interventions - all things we do to patients and clients even as public health professionals - everything we do has risks. Whether you are doing something invasive to someone or just giving advice and counsel, you are potentially having an effect in someone's life, and doing so has risks of harm. To reiterate, everything we do to people has risks, even counseling. So it makes sense that we only want to do things to people when the likelihood of benefit outweighs the risks of harm. Therefore, given this, and given the fact that we have limited resources, we need to set priorities, and it makes sense to prioritize those things with the best chance of benefit outweighing the chance of harm. So, in order to cut through some of the noise out there, the US Preventive Services Task Force was formed by the federal government in the 1980s to assess and summarize the best available evidence on clinical preventive services for a long list of health conditions. The task force is an independent panel made up of volunteer physicians and epidemiologists, and the ideas was that this way recommendations would not be biased by the kinds of interests that might influence recommendations from, say, healthcare provider specialty societies that think their specialty should get to do all services possible, or payers such as insurance companies that might have an incentive to recommend as little as possible, or recommendations from drug companies that involve using their company's drug. The task force is NOT allowed to consider cost-effectiveness - just the evidence on benefits and risks of the interventions they look at. USPSTF recommendations are not legally binding on anyone - this is a misconception that some people have - but their recommendations do get a lot of attention and do often influence what Medicare and large private insurance companies decide to cover and not cover.
Chronic Disease
As Haber notes, and is illustrated in this slide, heart disease is the number one cause of death among older adults, with cancer close behind in the number two slot. Despite health promotion efforts and vaccinations, older adults continue to die from influenza and pneumonia although to a much lessor extent. According to the CDC, only 48.5% of at risk older adults have ever received a pneumococcal vaccine. As a side note, many states including California are now reporting that total cancer deaths have surpassed heart disease, primarily due to medical advances in heart disease and greater health promotion efforts. However, data comprises all ages, not just older adults. Yet, I am fairly positive that data will demonstrate a similar trend for persons 65 years and older. A vast majority of chronic conditions can be prevented or delayed. As health professionals, our goal is promote health behaviors, encouraging people to make healthy choices, like eating a proper diet, exercising regularly, and not using tobacco.
CRC Screening
Colonoscopy examines entire colon, 5 feet allows removal of suspicious polyps Fecal Occult Blood Testing Sigmoidoscopy examines 2 feet of colon "Virtual" colonoscopy Stool DNA test Education and informed choice are key!
How does Health Promotion support each of these segments?
As Haber states in the book, primary prevention's main purpose is to target asymptomatic older adults who potentially have a risk factor. For instance, older adults are at a high risk of contracting pneumonia, as seen in the previous slide on chronic conditions. Therefore, promotion of the pneumococcal vaccination among older persons is vital. Or, an exercise program to lessen one's probability of acquiring a disease or disability. Secondary prevention aims to address a disease or condition for which an older adult has an actual risk factor (such as older adults with hypertension for heart attacks) or may be asymptomatic (such as some early stage cancers). Health Educators are important ambassadors and advocates to inform seniors of the need to get screenings regularly. Once the disease or condition has developed, tertiary prevention attempts to reduce the burden of the disease and/or disability through methods that decrease complications or providing rehabilitation. For older adults with Type 2 diabetes, regular eye examinations should be a standard practice to identify early stage retinopathy in order to slow progression into blindness. Diabetes health educators, therefore, create and share promotional materials about eye examinations for their Type 2 diabetic clients. Or, for older adults who have had a major stroke, rehabilitation to help improve physical functioning.
Health care expenditures are more closely aligned with dying than with age. That is, the US spends more as individuals get closer to dying. Children receive more aggressive treatment (with higher costs) than older adults.
As a positive outcome of health promotion actions and behaviors, we are living longer, which then delays end-of-life care costs to our later years, generally when older adults are receiving Medicare or Medicaid (Medi-Cal in California).
HRT: Current Thinking
As a result of these findings, HRT use declined substantially Yet many women still need help managing severe symptoms, and HRT remains an option Safer when started closer to actual time of menopause Use for shortest duration possible Lower doses should be considered Best risk: benefit ratio when used for severe sxs Need to consult with physician
Types of Preventive Services
As mentioned above, preventive services may be thought of in three broad categories or types: -Screening -Counseling -Immunizations and Chemoprophylaxis (aka, Chemoprevention, preventive medications) -We will take a brief look at each of these types, with some examples
HRT: Current Thinking cont.
At this time there is no final "one-size-fits-all answer. In 10 years' time, from 2002 to 2012, prevalence of HRT use went from 40% to 20% of postmenopausal women! So what's a woman to do? Over the counter - herbal treatments have not been found to be terribly effective. So, HRT remains one of the better options for women who experience severe menopausal symptoms, but it is generally thought to be best for women actively going through menopause (generally 50-59 years of age or within 10 years of menopause), for healthy women with severe symptoms, and for limited duration of use, not something to stay on long-term. HRT still increases the risk of blood clots but these are fairly rare in 50-59 year-olds, especially non-smokers. Breast cancer risk also increases slightly if taken for >5 years but the risk declines once the HRT is discontinued. Current recommendations are against using it in healthy women for purposes of preventing heart disease, stroke, or fractures. As with many clinical preventive services for older adults it is best to make individualized decisions together with a physician.
Generational Conflict created by the US Media
Be wary of the generational conflict created by the media. In fact, older adults are the strongest advocates of younger generations. In return, are you a strong advocate for older adults? In this slide, I've referenced a couple headlines that portray older adults as parasitic and greedy. In reality, employers who hire older adults are similarly likely to hire young adults, rather than adults in their 40s and 50s. In addition, we often hear that older adults consume a large portion of the federal budget, which is true when only considering health programs or only considering entitlement program spending. Yet, the federal budget encompasses much more. How about defense? Energy and environment? Housing and community? Education? Transportation? To name just a few. Rather, we should be having a discussion about our collective national priorities. For example: is health care a right or a purchased service?
Prostate Cancer
Benign prostate enlargement common with age 2nd leading cause of cancer death in men Present in 70% of men at age 80, but many do not die from it Slow growing (indolent) cancer; many times causes no serious problems Risk factors Older age Race More common, and may occur at younger ages in African-American men Family History
High Blood Pressure cont.
Blood pressure naturally tends to rise to some degree as we age. However, thresholds, or cutoffs for how we define HBP - numbers that we should worry about -- have been falling as evidence of the harms of HBP mounts. Current guidelines for HBP are Systolic higher than 140; diastolic higher than 90, regardless of age. (This is the simplified version -- guidelines can get a lot more complicated depending on risk factors a person may have). It turns out, those with "High normal" BP (130/85) are still at increased risk for heart disease & stroke, and other evidence also links such slightly elevated blood pressure to cognitive function and dementia. The A high profile NIH panel recommended that the definition of pre-hypertensive should be: 120-139 systolic; 80-90 diastolic, and some argue that the criteria for a diagnosis of high blood pressure should be lowered to 135/85.
Osteoporosis
Bones become thin, brittle & susceptible to fracture Affects more than 28 million Americans Primarily women Causes 1.5 million fractures; risk of fracture as much as 4x higher following diagnosis Osteopenia Weakening of bones Warning sign; risk of fracture as much as 2x higher
Cervical cancer cont.
Cervical cancer is still the fourth most common cancer worldwide, and earlier in the 20th century it was s one of the most common cause of cancer death among women. The Pap test has reduced the US death rate due to cervical cancer by 70%. The Pap test is so effective at reducing mortality because it can not only detect cancer early, it can detect precancerous changes in cells. Treatments can then target the affected areas before they even become cancerous. Pap smears are recommended to start at the onset of intercourse. After 2 normal screens, screening may continue once every three years. The USPSTF recommends that in women with a regular screening history with normal findings, screening may be discontinued after age 65. However, it is important to recognize that many older women have either never had a Pap smear, and as many as 75% of older women have not had Pap smears as regularly as recommended, and in fact about 15% of all cervical cancers occur in women over age 65! Sometimes this is due to their generation, financial factors, cultural factors, having immigrated as an older adult from a country where screening is not readily available, or a combination of factors. In recognition of their continuing needs, and the effectiveness of Pap screening for catching cervical cancer in its early or even precancerous stages, Medicare now covers Pap smears every 3 years for low risk, and more frequently for high risk older women.
Cholesterol cont.
Cholesterol is a lipid: a waxy, fat-like substance found in the body: it is an essential structural component of all animal cell membranes. It is needed to make hormones, Vitamin D & other substances, linked to brain health. However, excess cholesterol can stick to the interior walls of arteries and restrict the flow of blood. Over time, it can restrict these vessels so much that blood cells bump into and start to stick to each other, which can lead to a clot. This is why high cholesterol, also known as "hypercholesterolemia", is a major risk factor for heart disease and stroke. Abnormal levels of LDL cholesterol or HDL cholesterol can be treated with a low-fat diet, exercise, and medications such as statins.
Aspirin for the Prevention of Heart Attack
Routinely used in those with history of a heart attack to prevent a 2nd attack Baby aspirin sometimes used as primary prevention of heart attack (ie in those with no history) - controversial USPSTF has changed recommendation to use in high risk older adults even if no prior heart attack
Healthy People 2020
DHHS has defined healthy older adults as a set of healthy indicators about our population ranging from diet, to falls and accidents, conditions such as heart disease, and ultimately reductions in mortality brought on by chronic disease. Health People 2020, launched in 1979 via a US Surgeon General's Report: Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention is renewed every 10 years. More than 1200 objectives within 42 topic areas are tracked. Objectives Specific to Older Adults, which is a new area, include: Chronic Disease Management (including diabetes self-management programs) Clinical Preventive Services (including "Welcome to Medicare" preventive visit) Functional Limitations Leisure-time Physical Activities Geriatric Education among Healthcare Professionals Long-Term Services and Supports Elder Abuse, Neglect, and Exploitation Falls Prevention Objectives are selected and determined by a core set of guidelines; objectives must be: 1. Measurable and Actionable 2. Prevention-oriented 3. Have National significance 4. Reduce Population Disparities 5. Improve health 6. Evidence-based 7. Comparability and Reliable
Guidelines for cholesterol
Decades ago MDs used simple target thresholds as in high blood pressure However, no more simple one-size-fits-all cutoff NCEP Guidelines consider: Lipid profile Numerous risk factors
Guidelines for cholesterol cont.
Decades ago physicians used a simple target threshold, with one number measuring total cholesterol, as they often do in high blood pressure. However, since about the turn of the 21rst Century there is no longer any one simple one-size-fits-all cutoff. Now, we tend to examine the levels of the three types of cholesterol: LDL, HDL, and triglycerides. Similar to high blood pressure, guidelines for the target levels of each type of cholesterol and when and how aggressively to treat it can get quite complex depending on someone's risk factors. To follow current national guidelines (American College of Cardiology/American Heart Association/National Cholesterol Education Program), health care providers need to consider the entire lipid profile: levels of HDL, level of LDL, and triglycerides, combined with information regarding numerous risk factors related to cardio-vascular disease and diabetes.
Hearing
Decreases with age: Decline begins about age 40 In those 60+, 1/3 have some hearing loss In those 80+, 80% have some hearing loss Cohort Effects: Prevalence of problems may increase with new cohorts Headphones... BUT, on the other hand, fewer noisy jobs, less smoking, better medical care generally Consequences of hearing impairment depression, worry, anxiety, paranoia, social withdrawal, problems with memory, balance Hearing aids can help, BUT...many older adults don't use Cost (no Medicare coverage), vanity
Population Shift
For the first time in history, older adults will out pace young kids. We are beginning to witness a significant transition. It is a fantastic time to be working in health care and health promotion! As the US makes this shift, what will this mean for health care and health promotion? Will infectious diseases still be a priority in the US or other industrialized nations? Or will we, as health care professionals, need to focus more on chronic diseases? What does this mean for hospitals who typically perform better with acute conditions? We will further discuss this and other aspects later in this course.
HPV Prevention & Screening cont
HPV's are now recognized as the primary cause of cervical cancer, and DNA testing for it is now widely available and is recommended along with Pap smear. There are many strains, some of which cause genital warts, and some of which cause cervical, as well as some anal and vaginal cancers. The vaccine Gardisil prevents infection from as many as 70% of the HPV strains that cause cervical cancer. For maximum effectiveness it is given to girls in their preteen years to ensure immunity before girls are exposed via sexual intercourse. This aspect of the vaccine has given it something of a stigma among some parents who worry that being vaccinated will give young women license to be sexually active. Studies are also underway to determine whether vaccination of boys prevents the spread of the virus. Other studies are examining whether fewer than 3 shots can be as effective or nearly as effective as 3, since if there were fewer shots in the series this would likely be more acceptable to many parents. Vaccine cost is a factor for uninsured families: even with the passage of the Affordable Care Act, families who do not qualify for subsidized insurance or for Medicaid may find the vaccine unaffordable. Again, as we think of older women, we must remember that they will have "come of age" and become sexually active prior to the availability of the vaccine. However, future cohorts of women will likely have different risk profiles due to the availability of the vaccine, particularly if it gains greater acceptability.
Health Status
Health status measurements are collected by a slew of different agencies at the international, national, state, and local levels. You can find data from the Centers for Disease Control, World Health Organization, US Census Bureau, even large data sets like the Farmingham Heart Study, Health and Retirement Study, and the National Health & Aging Trends Study. At the State level, the California Department of Aging and Department of Health collect several types of aging, health, and utilization data, as well as non-governmental entities, such as the California Healthcare Foundation and California Health Interview Survey (or CHIS) housed at the UCLA Center for Health Policy Research. At the local level, counties frequently collect data on aging and health. For example, local Area Agencies on Aging are mandated to conduct community assessments every four years. Of course, hospitals, clinics and other medical facilities are amassing utilization data everyday on patients, although this data is highly protected by HIPAA. Can you think of others? Specific health status measurements include: Activities of Daily Living, or ADLs Instrumental Activities of Daily Living, or IADLs Disability or Functional Ability Utilization Rates for Medical, Social / Home and Community Based Services, and Long Term Care Chronic Disease Burden Life Expectancy and Mortality Activities of Daily Living (or ADLs) and Instrumental Activities of Daily Living are frequently used to assess functional capacity, either physical or mental. ADLs are those items that measure whether an older adult can bathe, dress, toilet, walk, and eat on their own. IADLs determine whether an individual can perform more complex tasks independently, such as balancing bank accounts, grocery shopping, managing medications, and driving. According to a fairly recent report by the US Administration of Aging, one-third of Medicare beneficiaries, so adults 65 years and older, living in the community were found to have at least one ADL that they could not perform. The Institute on Aging reports that 13% of men in the young-old segment, that is those between the ages of 65 and 74, have at least one limiting ADL. Of the women within the same age group, 19% had at least 1 ADL that required assistance. Furthermore, the Administration on Aging reported that 12% of Medicare recipients could not perform at least one IADL. As one would expect, the super agers, remember those 85 years and older who, have the most difficulty performing ADLs and IADLs. In 2011, 57.4% of these super agers reported a functional limitation. Among persons 65 years and older, the US Census Bureau, found 36% had a disability, which included limitations in hearing, vision, cognition, ambulatory, independent living or general self-care. In fact, the greatest disability reported was ambulatory, or getting around / lack of mobility, at 23% followed by hearing problems at 15%. On the positive side, we can say that nearly two-thirds of older adults don't have a disability. Media often portrays that older adults have severe functional limitations, so it's important to examine the data and form your own conclusions. In fact, the US Dept of Health and Human Services predicts a continued slowing of disability among older adults, that is, until the younger generation begins to enter their later years. With the significant increases in obesity and large decreases in physical activity, researchers predict that disability rates will rise in addition to chronic diseases. In the US, chronic disease continues to increase, and approximately 80% of older adults have been found to have at least one chronic condition and 68% report at least two chronic diseases. Hypertension is the top chronic disease at 71% (down from 94% in 2009); arthritis at 49%; heart disease at 31%; cancer at 25%; and diabetes at 25%.
High Cholesterol Risk Factors
Heredity Age Sex Diet % from Saturated fats, trans-fats Physical Inactivity Activity raises HDL Comorbidities CVD, especially prior heart attack, carotid or peripheral artery disease; Diabetes Smoking history
HBP Causes/Consequences cont.
High blood pressure is referred to as both hypertension & high blood pressure (HBP). Blood pressure that is too high is associated with damage to blood vessels which can affect organs such as the kidneys, eyes, brain, and others, and it is associated with long-term damage to the heart. In the past 30 or so years, general awareness of the health risks of high blood pressure has increased a great deal. However, the CDC estimates that between 2000 and 2015, deaths associated with HBP increased by 23%. The natural history of HBP in untreated patients shows the higher the blood pressure, the higher the rate the adverse events, which led to the general conclusion in past years that when it comes to blood pressure, "the lower the better"
CRC Screening cont.
However, we should understand that there are several screening modalities. USPSTF strongly recommends some form of CRC screening begin at age 50 and continue to age 75. The gold standard is colonoscopy, which examines the entire 5 feet of colon, and can allow the physician to remove suspicious polyps during the procedure. 20 years of data indicate that individuals who received colonoscopy experienced a 53% reduction in mortality rate compared with those who did not! At one time, the USPSTF recommended colonoscopy as the gold standard for this reason. However, newer recommendations are just for some form of screening to begin at age 50. Why the change? Well, even despite big improvements in rates of people getting colonoscopy (rates have in fact tripled in recent years!), we still fall far short of the recommendations. Over one third of eligible older adults have never been screened at all. Colonoscopy is quite invasive, uncomfortable, and the preparatory purge prior to the procedure is a big hassle. Life expectancy and comorbid conditions must also be considered prior to colonoscopy due to the risks of the procedure: there are small risks of electrolyte imbalances due to the preparatory purge, as well as bleeding and even perforation of the colon (important especially in older adults who may be on blood thinners for stroke risk or other conditions). Complications are reduced when the procedure is performed by a high volume, experienced gastroenterologist who does many of the procedures per day. Additionally, it is a long procedure and many facilities require a driver who will take the patient home remain at the facility during the procedure (Apparently they got stuck with too many patients with no ride home). You can imagine how this would cut down on customers for this test! Due to these factors and anatomical variations, there are just some individuals who will not or cannot undergo colonoscopy. Other options are Fecal Occult Blood Test (FOBT), which is not the greatest test due to its high false positive rate. However, it has been shown to be effective in reducing mortality. Patients with a positive test need to get a confirmation via colonoscopy. There is also flexible sigmoidoscopy (flex sig), which is somewhat easier on the patient, but only examines about 40% of the colon, so cases can be missed. Virtual colonoscopy 3-D imaging of the colon. The drawbacks of this are that the same burdensome prep is required as for regular colonoscopy is still required, and abnormal findings must still be followed up with a colonoscopy in order to examine and remove any suspicious lesions. New technology allows DNA testing of stool samples to detect DNA changes associated with cancer - you may have even seen ads for this recently! How much more user-friendly is it to provide a little stool sample as compared with undergoing a fairly burdensome procedure in a specialist's office? Again, there is a risk of a false positive, and a positive result requires follow-up with colonoscopy. On the other hand, the test can also miss cancers as well if errors are made such as not providing enough sample or errors in the lab. Despite its drawbacks DNA testing gets the highest level of recommendation from the USPSTF for benefits outweighing these risks. So, as mentioned above, the current thinking is just to get SOME form of screening as recommended between ages 50 and 75. Over age 75, the decision should be individualized depending on the health status and preferences of the person. The USPSTF states that the decision to continue screening in the older old probably makes the most sense (ie, benefits would most outweigh the risks) in healthy adults who would be healthy enough and willing to undergo treatment if a cancer were found, and without other life-limiting health conditions.
HPV Prevention & Screening
Human Papillomavirus: -Primary cause of cervical cancer -Common: > 50% of sexually active individuals -Causes cellular changes that can lead to cancer Vaccine (Gardisil): -Blocks 70% of HPVs that cause cervical cancer -Ideally given to girls before start having sex -Studies also examining effects of vaccinating boys and of using fewer shots HPV Screening: -Can get HPV DNA test at same time as Pap smear
Millennial Retirement Outlook
I thought it would be interesting to share with you a study of millennials and when they expect to retire. When examining North America, which represents both the US and Canada, many millennials expect to retire at 65 years or younger. For the most part, this seems to be in direct contrast to the current aging cohort in the US, who plan to remain in the workforce well into their late '60s and early-mid '70s.
Skin Cancer cont.
If we consider all types of skin cancer together, skin is the most common cancer site in the US, affecting 1 in 7 Americans. Like most cancers the risk tends to increase with increasing age: more than half of all skin cancer deaths occur in adults 65+. This is because of an age effect -- more total years of exposure and accumulation of damage - and a "cohort" effect: the current older generation is a generation with a history of little to no sun protection. And I include myself in this: we used to have a serious culture of tanning, with people laying out to tan and using artificial tanning beds. My kids don't believe me that we used to use either SPF 2 lotion or plain old baby OIL when going out in the sun. So, we have three major types of skin cancer: the most common, but highly treatable are Basal cell and Squamous cell carcinomas. Basal cell makes up 65-85% of cases, while squamous cell makes up 15-30%. The least prevalent (3% of cases) but most lethal is melanoma. Melanoma however is becoming somewhat more treatable than it once was, and survival has increased substantially. Immunotherapies and targeted therapies (ie, targeted at specific mutations) have had a significant impact.
Population Pyramids to Population Rectangles
In essence, the US population shows less like a traditional population pyramid and is starting to resemble a population rectangle with the Baby Boomers leading the way. Basically, we are living longer. But are older adults experiencing a high quality of life? On a different note, there is some speculation that longevity in the US has peaked, and the average life expectancy will begin to decline as people die prematurely due to the obesity epidemic in our country. As a result, the US population pyramid will resemble an hourglass-shaped population pyramid, with large populations of older people from the Baby Boomer cohort and current cohort of children at the ends, while significantly less numbers are seen in the Gen X and Millennials cohorts due to these obesity-related premature deaths.
A Public Health Framework for Healthy Aging An opportunity for public health action across the life span
In light of the collection of heathy aging goals and determinants, health care programs, services, and systems need to move away from the one encounter (such as a visit to the physician's office), one disease approach. Rather, the delivery of care needs to focus on the capacity of older adults, which can shift. For instance, an older adult may have stable capacity, then is diagnosed with breast cancer, resulting in diminished or significant loss of capacity. Once the senior is in remission, the older adult may shift back to high-functioning or stable capacity. Therefore, these programs, services, and systems must become more sophisticated in providing multiple entry points for seniors, and allow for movement from one group to another. The WHO proposes the following guide, addressing 3 subpopulations of older persons based on their intrinsic capacity: older adults with relatively high and stable capacity, those with decreasing capacity, and older people with substantial losses of capacity. In addressing each of these subpopulations, service delivery systems for older adults can develop methods to maintain or improve capacity, or provide dignified support. In the next couple sides, you can review some viable actions that will support this new structure. You may even begin considering primary, secondary, and tertiary health promotion activities that could complement this framework. Furthermore, we cannot rebuild systems in the current siloed (or fragmented) structure. Rather, this framework is only successful when delivery systems (i.e., medical, social, and public health) operate in an integrated manner that don't pose financial burdens on older adults. Aligning health systems to the needs of the older populations they serve Develop systems to provide long term care Ensure everyone can grow old in an age-friendly environment Improve measurement, monitoring, and understanding
What is Prevention?
Intervention to alter the negative consequences of disease or health-related events 3 levels of prevention Primary prevention - risk factors but no disease or condition present yet Secondary prevention - early pathologic changes present but signs or symptoms may not be evident yet Tertiary prevention - signs and/or symptoms noted, morbidity and mortality possible outcomes to be prevented
Extending the Health-span
Intriguing research areas: Genetic bases for deterioration of the body Lessons learned from studies of caloric restriction New discoveries regarding gene loci for Alzheimer's Disease But we already know a good deal: Positive effects of physical activity, nutrition, and maintaining healthy weight Weighing the risk-benefit ratios of various clinical preventive services Lifestyle and wellness interventions remain key
Skin Cancer: Prevention, Screening
Prevention Sunscreen Protective clothing Avoid sun at midday hours Screening Identify and have MD examine suspicious mole Dermatology society recommends melanoma screening for those 50+ USPSTF found insufficient evidence Studies show weak effect of counseling for prevention Studies raise questions about association between melanoma and sun exposure/sun protection Sun exposure and sun protection difficult to measure accurately
Prevention Classifications
Primary Prevention Secondary Prevention Tertiary Prevention
Hearing cont.
It is estimated that about a third of americans 60 and over have hearing loss - rising to 80% in those 80 and over. In the Baby boomer cohort, some professionals believe loud rock concerts and the rise of using headphones has contributed to this, but on the other hand, this same cohort had less exposure to noisy jobs and to damaging cigarette smoke, as well as better medical care generally. It typically becomes harder to hear higher tones, and consonants with higher tones start to blend together. Female health care professionals (and wives of older men!) sometimes find they must speak in lower tones to be heard. Often it becomes more difficult to decipher sounds of interest from background noise, so that understanding conversational speech becomes difficult, especially in public settings. This can lead to depression, anxiety, social withdrawal, and emotional insecurity...also, the increased cognitive work of distinguishing sounds is thought to contribute to memory impairment. Loss of hearing function is also associated with impaired balance. An evaluation by and Ear Nose and Throat (ENT) specialist with audiology testing can help target the most appropriate device, and many options are available these days that are much improved over basic devices available in the past. However, it is estimated that only 14% of older adults who need a hearing aids actually ever get them: based on the reading, why do you think this is?
Prostate Cancer cont.
Lest you think we are too hard on screening tests for breast cancer, let's take a look at a major screening test directed towards men - it turns out prostate cancer screening has been just as controversial as mammogram screening. So what is the problem? It is very common for men to experience benign or non-cancerous prostate enlargement as they age - this occurs in over 50% of men. However, the prostate can also be a site of cancer, and is in fact the second-most common cancer in men, and the 2nd leading cause of cancer death after lung cancer. 242,000 men were diagnosed in 2014, and that year there were 27,500 deaths in the US. However, these figures refer to medical diagnoses - where the cancer was discovered. This is a cancer that is rather "indolent" or slow-growing. Because of this and because it occurs so commonly, autopsy studies have found that it is actually present in many men at death without being their actually cause of death. So what can and should be done?
Extending the Health-span
Lifestyle interventions remain key. In The Diabetes Prevention Trial published in The Lancet, lifestyle interventions were actually more effective in people aged 60+ than in the younger population. The SPRINT trial raises the question of whether older adults live longer with less morbidity when we try to lower their systolic BP to 120 instead of just to 140. We continue to see in study after study the positive effects of exercise in delaying mortality and/or preventing morbidity and disability. A study published in JAMA reiterated the importance of a combination of walking, resistance training, balance, and stretching. Additionally, research needs to include a greater number of older adults, and move beyond disease, disabilities, or other weaknesses. Studies on resilience in late life is one area that's beginning to explore, and build upon, the strengths of older adults.
Lung cancer cont.
Lung cancer is the leading cause of cancer death overall, with 71,000 deaths in women and 86,000 in men in 2015. Partly this was due to the prevalence of smoking in the cohort of adults who are now older, since smoking has been and remains the most common risk factor for lung cancer. Moreover, it was often diagnosed in late stage, with more than half of all cases diagnosed at Stage IV. The main symptom tends to be persistent cough or shortness of breath which smokers might think is normal, and doctors sometimes would attribute to COPD or emphysema if the patient is a smoker. People would tend to suspect cancer only when they started coughing blood and/or losing a lot of weight. Why weren't we screening for it? People tried screening with chest x-ray but it wasn't generally able to detect tumors early enough to make much of a difference. Research was done on CT scans to determine if they could be useful, and eventually the technology was high enough quality and sufficiently standardized, and researchers amassed evidence that in the correctly defined target population CT scan screening for lung cancer could be an effective tool. Based on this newer evidence, screening began to be recommended by the USPSTF in ages 55-80, in high risk adults (ie 30 pack year history and current smoker or quit within past 15 years. Discontinue after 15 years post-quitting or age 80 or if other health problems would preclude undergoing curative surgery. So this is an important concept as we continue to think about screening programs for older adults and at what point screening might be best discontinued - the principle is one that people not trained in healthcare sometimes don't understand, and that is the general principle that you don't test for something if the results are not going to change your course of action. So why get a test for something if the information is not going to make any difference in what you are going to do, especially if the test itself comes with health risks. In the case of cancer screening and geriatric populations, we start to think about the fact that individuals may have other health problems that prevent them from being able to tolerate treatment, which in the case of cancer may be surgery or chemotherapy. However, one big challenge is that, as they say, age is just a number. It is very difficult to pick a universal age cutoff and say after this age or that age people in general are not going to benefit. Yet, when making policies (and funding decisions) for populations, that is often what many people want - guidelines with simple clear-cut numbers. In reality, decision-making is more complex and can depend on the individual's own health status, life expectancy and preferences. I remember in the days before these scans were approved, people used to ask me, why can't we all just go every year and get some kind of a full body CT scan? Well, first of all, what would the sensitivity and specificity be for that scan in detecting of all the possible things you might be worried about? Another way of thinking about this is, the human body is not 100% uniform like a Gray's anatomy textbook - we all have natural variations. So a random scan of your whole body is likely going to pick up a lot of odd variations. Which one of those "abnormalities" is something to worry about and which is a "false positive"? Well, you're really not going to know without going in there and taking a closer look. That would mean needle or surgical biopsy of every abnormal finding, which would likely mean subjecting patients to risks of surgery when they are at very little risk of truly having a problem. Kind of hard on the consumer, lol. Furthermore CT scans themselves expose us to a lot of radiation. So, we see in lung cancer screening some of these concepts at work as the USPSTF was very careful to define the population that they thought would get the most benefit with the lowest associated risks - those at higher risk for lung cancer in the first place (so more likely that positives would be real), and those in the age range and with good enough health status to be able to withstand the treatment if they are diagnosed with cancer.
Life Span
Maximum number of years that a person will live
Polypharmacy
Medication use, and particularly polypharmacy, has presented its own problems. As a group, older adults are being prescribed more medications today than any other previous older adult cohort. 91% of adults 65 years and older were taking at least one prescription drug, and of those, 41% were taking 5 or more prescription drugs. What should we also be considering? How about the sometimes lethal combination of over the counter medications and prescribed drugs? Hospitals and clinics often see first hand the adverse effects of older adults taking prescribed medications and over the counter medications. Additionally, older adults who take herbal remedies with their prescription medications may also experience serious side effects. Compounding this, based on an analysis completed by Moore, Cohen, and Furberg, 20% of prescribed medications are contraindicated. As the Baby Boomers age, health professionals and policy leaders are concerned about potential impacts of long term illegal drug use (seen in the rise of addiction) and prescription drugs. In fact, the Riverside County Office on Aging had a series of conferences to tackle this issue, and as a result the County earmarked additional funds for health promotion and treatment of addiction among older adults, including a specialized medication management program for this unique population. Another study by Olfson, King, and Schoenbaum found that more than 75% of older adults receiving a prescribed antipsychotic medication didn't have a clinical psychiatric diagnosis and 50% did not receive the medication from a psychiatrist, concluding that physicians are overprescribing this classification of drugs. Many antipsychotic medications have dangerous side effects, including: strokes, fractures, kidney injuries, and death. Moreover, these risks are elevated when combined with other drugs.
Menopause and Hormone Replacement Therapy (HRT)
Menopause Body goes through changes so pregnancy no longer possible Symptoms Irregular menstrual cycles, hot flashes, changes in mood & cognition, insomnia, headache, fatigue HRT: Relives symptoms of menopause Early studies Supportive of HRT as having numerous benefits Later studies Big problems identified with the earlier research and it conclusions!
Super Agers (oldest old)
Moreover, the Super Agers (or often times referred to as the oldest old, those over the age of 85) are growing even faster at over 200%. Even more, the Centenarians are growing at an escalating rate in the US. Those 100 years and older will rise by 452.5% between 2011 and 2050.
Skin Cancer
Most common cancer site in U.S. More than half of all skin cancer deaths occur in adults 65+ Age effect: More total years of exposure Cohort effect: a generation with little to no sun protection Three types Most common, but highly treatable Basal cell Squamous cell Least prevalent (3% of cases) but most lethal Melanoma
What are Clinical Preventive Services?
Refers to services that may be offered, often in the primary care setting, by MDs, PA's, RN's, and other professionals involved in health education. Generally grouped into 3 categories or types: -Screening -Counseling -Immunization and preventive medication More on this to follow!
High Cholesterol Risk Factors cont.
NCEP guidelines take into account lipid levels and profile in combination with family history, age, sex, comorbidities (ESPECIALLY HEART DISEASE, VASCULAR DISEASE, AND DIABETES), as well as smoking history. Essentially the higher the risk, the lower the target for LDL, or bad cholesterol. You can refer to the table in your text for the specifics, but essentially a low risk patients might have an LDL target of 130-159, while a high risk patient might have a target for LDL of < 100, and very high risk patients would be pushed to achieve an LDL < 70. Along these same lines, the USPSTF recommended that routine screening for HCH begin younger and continue into older ages than ever before.
Screening Example: Breast Cancer
Need, Objectives: Target population Tests: Breast self-examination Clinical breast examination Screening mammogram Accuracy, reliability Sensitivity 75-88%; increases with age Specificity as low as 75% Inter-rater reliability can vary
Wilson's Classic Screening Program Criteria
Now let's think about screening tests on a slightly different level - on a public health level, with the health of a population in mind. The population might be your county, or the service area of your program, the patients of your healthcare organization, or the covered lives served by a health insurance company. What if we don't just want to screen one person, but we want to implement a screening program for our population? Wilson and Jungner considered the criteria listed here "especially important when screening for a cindition is carried out by a public health program, where the pitfalls may be more numerous than when screening is performed by a personal physician" on a case by case basis.
Types of Preventive Service
Now you will note that your text organizes this discussion by disease or condition, but I would like to start off our discussion here by asking you to think about preventive services another way, the way the US Preventive Services Task Force organizes its reports. Preventive services can be conceptualized as falling into one of three categories: Screening, Counseling, and Chemoprevention (essentially immunizations and preventive medications). I believe it may be helpful to you whether you become a health educator, a clinician treating patients, a program planner or manager or administrator - when you are in a position to read preventive health care literature and to plan and/or evaluate a program to have this framework in mind. We will then proceed to think through issues important to older adults, condition by condition.
Life Expectancy
Number of years a person is expected to live based on several socio-demographic facts (e.g., gender, SES, birth year, etc.)
Health Expectancy
Number of years a person is expected to live in excellent/good health
Screening Example: Breast Cancer
OK, now let's walk through an example of a very notable and controversial screening, screening for breast cancer. Remember, the goal here is early detection of a cancer, or secondary prevention Need/Significance: Breast cancer control is important because it is the 2nd leading cause of death among women in US, with 40,000 deaths in 2015. Who is the population we would be most concerned about? Risk of breast cancer diagnosis increases with age. In fact, age is the single most important risk factor for developing breast cancer. The median age of diagnosis is 61, and it is most often diagnosed from age 55-64. 57% of breast cancer deaths occur in women over age 65. There are three commonly used methods of screening for breast cancer: breast self-examination, clinical breast examination, and screening mammography. There is actually no good evidence that breast self exam reduces mortality. Clinical breast exam is conducted by a trained professional such as a nurse, PA or doctor. Because it is usually performed in conjunction with screening mammography it is hard to tell if it has its own effect separate from screening mammography. For the rest of this example on screening tests we focus on screening mammography. (Also note that screening mammography is used to detect lesions in asymptomatic women. This is distinct from diagnostic mammography, which is used to aid in the diagnosis of a woman who is already known to have a suspicious breast lesion or lump). Now, as we examine screening mammogram as a screening test, we would like to know something about its accuracy - which is based on its sensitivity - how well it correctly identifies a true positive, and specificity - how well it correctly identifies a true negative. Sensitivity has been found in trials to range from as low as 68% to 75-88%, with specificity of as low as 75% to 83-99%. Reliability can vary a good deal, so that different radiologists reading the same film often disagree on the result. This is improved with training and continuing education and there has been a big push in the country for quality control in this area in recent years. So what does this all mean? We have a test that catches a fairly large percentage of cases, but also results in a fair amount of false positives: women who are told they have may have a cancerous breast lesion who really do not. Current evidence indicates that for women who undergo screenings for the recommended 10-20 years, as many as 50% will have at least one false positive. The screening mammogram test is more sensitive the older you get, so that mammogram does a better job detecting breast cancer as you age.
Osteoporosis cont.
Osteoporosis is a condition in which the bones become thinner, more brittle and susceptible to fracture. This affects more than 28 million Americans, primarily women, and causes 1.5 million fracture annually. This means that about half of all women over 50 will have an osteoporosis-related fracture in their lifetime. About half of these fractures are to vertebrae, with the rest predominantly to the hip and wrist. Osteoporosis is technically defined as bone density 2.5 standard deviations below the average, young adult peak bone density. "Osteopenia" (or thinning bone that does not meet the definition of osteoporosis) is defined as bone density of 1.0-2.5 standard deviations below young adult peak bone density.
Vision Changes in later adulthood
Presbyopia: age-related changes impair eye's ability to focus & maintain image on retina Worsens with age Largest declines from 40-59 Harder to see close objects Correctable in most healthy older adults Decreased blood supply to eye 50's and 60's smaller visual field, increased blind spot Although visual impairment is less common than hearing problems, visual impairment is perhaps more feared.
Cervical cancer
Prevalence, Screening: -Was a leading cause of cancer death until 1940s; less common in U.S. following introduction of Pap smears -Pap smear: collection of cells from cervix Pap smears allows early detection of cancer & of precancerous cells, leading to early treatment Older Women: -Pap recommended from age 21 to age 65 -Every 3-5 years age 30-65 depending on hx of screens -Many women >65 have never had Pap; 75% have not had regular screening -Medicare now covers every 2 years (annual if high risk) -USPSTF recommends against in those >65 if regular, normal Paps prior
Colorectal Cancer (CRC)
Prevalence: 3rd leading cause of cancer death (after lung and sex-specific cancers) in US 144,000 new cases and 50,000 deaths in 2015 Risk increases with age Early detection of polyps can lead to polyp removal and lower risk of cancer Risk Factors: Age History of polyps Family history of colon cancer Diet (low fruit/veggies; low fiber; high fat) Physical inactivity Obesity Tobacco Use Genetic diseases
Generational Conflict created by the US Media
Scare tactics used: - "Young and Old Are Facing Off for Jobs" (New York Times) - "Will Surge of Older Workers Take Jobs From Young?" (Associated Press) - "The Case Against Parasitic Baby Boomers." (National Journal) - "The War Against Youth. The recession didn't gut the prospects of American young people. The Baby Boomers took care of that." (Esquire) Studies reveal: - Intergenerational cooperation remains a high value - Older adults generally advocate strongest for younger workers - Unemployment for younger workers has more to do with the growth of the economy and less to do with older workers - Positive correlation between employment rates of the younger and older population for both men and women
Osteoporosis Screening, Treatment
Screening Bone density scan - "densitometry" using a type of x-ray technology USPSTF recommends routine screening >65 Unclear for women 50-64; depends on risk factors Treatments: Calcium, Vit D Exercise, especially weight-bearing Medications such as bisphosphonates
Prostate Cancer Screening
Screening Prostate-specific antigen screening (PSA): Measures elevated protein levels made by prostate that might be indicative of cancer Increases are more significant than absolute level Accuracy not great: much over-diagnosis; also misses cases Treatment Surgical removal of prostate gland, radiation Mounting research indicates treatment associated with more risks of harm than benefits on average, esp for men 65+ USPSTF: In 2012, changed recommendation from neutral to recommending against routine PSA screening ACS still recommends for high risk groups
Osteoporosis Screening, Treatment cont.
Screening is generally recommended routine screening for women ages 65 and above, but the optimal frequency is not really known. For women ages 50-64, it is unclear when to screen, and this decision depends on the individual's risk factors (there are assessment tools such as the FRAX mentioned in your text to help assess risk). So, USPSTF doesn't recommend routine screening in this younger group even though we know osteoporosis is not uncommon in this age group. But think back to what we discussed previously about criteria for the effectiveness of screening: one consideration is that screening lead to effective treatment. Effective interventions do exist. Helpful interventions include weight-bearing exercise, calcium and Vitamin D, and newer medications such as the bisphosphonates such as Fosomax, Boniva, and Actonel. This class of medications has been found to reverse bone loss and to have a significant impact on reducing the risk of fracture by as much as half. However, in recent years some studies point to the need for caution in long term use of these drugs, finding that after 3-5 years of use there is little additional benefit in as many as 2/3 of women. The exception to this is that benefits do seem to be worth it in women who have a current fracture or a history of spinal fracture. Furthermore, after 3-5 years of use these medications can lead to a renewed increase in the risk of weakened bone and fracture, especially in the femur and jaw.
Lung cancer
Significance: -Leading cause of cancer death in men and women -Leading cause: smoking - also occupational and environmental risks exist -Historically diagnosed late -Screening - potential to lead to early treatment -Began to be recommended once quality was standardized and population defined Screening -Recommendations: -USPSTF recommends for ages 55-80 -Thought to be most effective (ie, most worth the time, bother, potential problems) in high risk individuals (ie, 30 pack year history and current or recent smokers) -ACA currently requires insurance to cover; Medicare covers up to age 77
Socio-Economic Status among Older Adults Education
Similar to employment, education attainment among older adults is rising. Since 1970, the percentage of older adults who completed high school increased from 28% to 84% with 26% of seniors today receiving a bachelor's degree or higher. Needless to say, older adults today are highly educated compared to seniors of yesterday. Yet, we cannot forget there still exists significant disparities. For example, only 47% of older Hispanics have completed high school, considerably lower than other races and ethnicities: 74% of older Asians and 65% of older African-Americans have completed high school. In 2013, personal median income for seniors was $21,225. During this same year, 90% of older Americans 65 years and older received Social Security benefits, with 86% of older adults relying mainly on this income stream. Older adults reported other sources of personal income, which included: income from assets (e.g., rental properties) by 51% of seniors; private and government pensions by 41% of older adults; and earnings at 28%. During this same time period, 9.5% of older adults lived at or below the federal poverty line, and when employing the Supplemental Poverty Measure, the number of impoverished older adults increases to 16%. While 7.4% of White / Anglo older adults live in poverty, 17.6% of older African Americans, 13.6% of older Asians, and 19.8% of older Hispanics live in poverty. Significant disparities remain.
Skin Cancer: Prevention, Screening cont.
So what can we do in terms of PRIMARY prevention? Reduce our exposure to the sun's harmful rays by avoiding the sun at midday, and using protective clothing and sunscreen (though the evidence is somewhat weak that sunscreen prevents melanoma). In terms of screening for early detection (secondary prevention) dermatologists recommend having primary care physicians examine the skin to identify and refer suspicious moles to dermatology. However, the USPSTF finds insufficient evidence that this is very effective overall. One issue with conducting high quality research into the impact of sun protection is that it can be difficult to measure accurately. You need to follow people for years and basically rely on their reports of their own behaviors. People may not remember accurately, may use sunscreen the wrong way (eg, not enough, or not reapplied often enough, etc) and may also try to make their behaviors sound better than they really are (social desirability can affect how people report their behaviors).
Benefit vs harms - how do we think about this? Do the benefits outweigh harms, and for whom? Why all the controversy?
So what is the big deal about false positives? What are the potential harms of screening mammography? What are the burdens? It is inconvenient, uncomfortable, and some women need to pay co-pays for the test and for follow-up visits. What about psychological well-being? It causes a good deal of anxiety in some women. What about that false positive rate? Increased sensitivity tends to go hand in hand with increased false positives. False positives lead to additional, more invasive tests such as biopsies. Some false positives lead to biopsies with a needle while some lead to surgery. Some of these women have no problem at all. Some will turn out to have a condition called DCIS, which in a minority of patients can lead to cancer, but in most patients it does not. Some women diagnosed with DCIS elect to undergo surgery and radiation, when the majority of cases of DCIS would have remained harmless even with no treatment. WHY THE CONTROVERSEY? Back in the late 1980s, use of mammogram was low overall, and it was especially low for African American and Latina women, who got mammograms at only a little more than half the rate of white women. Many women would have their cancers diagnosed at late stages when symptoms were obvious, such as very large tumors that were sometimes even eroding through the skin. Great efforts were being made to raise awareness about breast cancer, remove its stigma, and to encourage women to seek testing so that if they had breast cancer they could be treated early. Advocates also fought to remove financial barriers by fighting for insurance and Medicare coverage for mammogram, and offering free mammogram programs for women without insurance. All these efforts were very successful in encouraging women to adopt mammograms. By 2013, the percentage of eligible older women getting mammograms as recommended had tripled to 72%. The controversies began as early as the 1980s as well. Given the evidence regarding risk of disease and sensitivity and specificity at different ages, many entities disagreed over whether mammography should begin at age 40 or 50. This was really an argument over what is the right target population for our screening recommendations. Considering the prevalence of the disease in those 50 and older and the harms of false positives, the USPSTF has recommended starting at age 50. There have also been ongoing arguments about frequency, with disagreements about every year vs every 2 years. Some, usually advocacy organizations such as ACS, argue that with more frequent mammograms we have more chance of catching more cancers early. Others such as the USPSTF have argued that greater frequency of screening again results in more false positives, and so they have recommend every other year. This led the ACS to revise its recommendation and split the difference, with annual screening starting at 45 and screening every 2 years starting at age 55! Some doctors probably rightly point out that with an every other year schedule or these other variable schedules it is harder for women to remember whether they are up to date or not! Meanwhile there have also been prominent research papers arguing that mammogram is not a good enough test to recommend at all. In 2001 a pair of Danish researchers famously published a review of many of the original studies that were used to support mammogram. These researchers declared that most of these studies were not designed well enough to be credible. The remaining studies, they argued, did not show enough of a positive effect on mortality to make mammogram worthwhile. One of the researchers later wrote that the higher quality studies did show a benefit from mammogram, but the benefit was small, and that for every woman who would have her life prolonged as a result of mammogram screening, there would be 200 healthy women who would go through the negative experience of a false positive, and 10 of those women would actually receive unnecessary cancer treatment. This caused a great deal of uproar in the clinical and advocacy communities. Some argued that even a flawed test was better than no test at all. Others argued that this was a simplistic view and that we should be taking the risks of harms more seriously. Even the ACS came out with a statement that American medicine has been overstating the benefits of screening mammography. As you can see, there have been many conflicting studies and conflicting interpretations of the data, but the evidence does seem to point to a small but statistically significant improvement in lives saved in women who undergo mammography. Why is it so difficult to make sense of all this evidence and reach a consensus? In part the arguments stem from differences in what risks do we feel more comfortable with - the risk of missing a cancer that might be present in a younger woman in whom the cancer risk is low, vs the risks of exposing a lot of women to the inconvenience, hassle, expense, discomfort of the procedure itself, especially when there is a higher chance that a positive mammogram result will be a false positive at earlier ages. Furthermore, we have a medical culture (and a culture in general) that likes to intervene - we like to feel as though we are doing something about a problem. It is very hard for most of us to say no to anything that we think might have the smallest chance of helping! Another issue that muddies the waters when it comes to early detection of breast cancer is the advances that have been made in treatment. We have seen use of mammogram screening increase, and we have seen improvements in breast cancer survival. So, early detection by mammogram must lead to better survival, right? Well, we have to be careful and remember that treatment of the disease has improved A LOT since the 1980s. Many new discoveries in terms of therapies have helped women live longer, and some oncologists argue that THAT is what has made the difference in survival. Last but not least (and perhaps scariest) is that some point to "overtreatment" as something that skews survival statistics. That is some women get treatment who never had invasive cancer in the first place, or who had lesions that never would have been life-threatening to the woman (like some cases of DCIS). So you have some women being screened, treated, and lo and behold, they survived! Well, in the case of overtreatment, the concept is that they would have been fine without enduring the burden surgery, radiation, etc.
Screening mammography: Effective or not? How do we think about effectiveness? The role for education, informed choice, quality assurance
So what shall we say about the effectiveness of screening mammography? Is screening mammography worth the time, cost, bother? Does it lead to improvement in health outcomes? As we mentioned, the evidence does seem to point to a small but statistically significant improvement in lives saved in women who undergo mammography. Thinking back to some of our screening program effectiveness criteria, does widespread use of screening mammography respond to a recognized need? It certainly seems to do that! Do the harms of follow-up tests and psychological distress outweigh the benefits of screening mammogram? Perhaps this is not a one-sized fits all decision, and this is part of the importance of defining the target population as best as we can. Can we come to a consensus over how best to define the population for whom the test gives us the most accurate results and will do the most good. Remember in women over 50, the test is more accurate, and this is the group most likely to be at risk for a cancer that needs treatment. (This does not mean that younger women can't get breast cancer: they certainly can - I personally know 2 women diagnosed in their 30s. However, we are thinking about the epidemiology in a population, not about individual cases). Quality improvement and assurance programs over the past couple of decades have also boosted mammogram accuracy since the 1980s. Once tested, are there subsequent interventions for women with a positive finding that are effective in improving health outcomes? In this case, there are well-established protocols for further diagnostic testing and then treatment of cancer if necessary. What about the possibility of finding something that leads to women undergoing unnecessary treatment? As we mentioned, the current thinking among cancer researchers is that there are lesions that will never cause a woman any problems if left alone. The problem is that we don't yet have the technology to identify the situations in which treatments are necessary or unnecessary! One of the other important screening program effectiveness criteria we mentioned is that a screening program should ensure informed choice and respect for autonomy. The American Cancer Society announcement that the scientific community has overpromised on mammogram was an important first step. At this point the key may lie in better patient education and informed decision-making so that women can make the decision that is right for them and fits their values and needs. I would also emphasize that if we want a better education campaign, it would be nice if we could create a coherent, consensus message from the major sources of information that are trusted by laypeople, including the American Cancer Society, the National Cancer Institute, and the USPSTF, so there there were clearer recommendations regarding when to start screening, how often to screen, and when to think about stopping. Good primary care physicians can and should do some of this education, but health educators and allied health personnel are key in helping inform women about these issues. What would you do, or advise a family member or client to do?
Counseling for Prevention
So, what is meant by counseling in this context? Counseling is an intervention involving talking to clients, providing education, support, and encouragement about a health behavior in order to encourage them to change to or maintain desirable health behavior (ie, behavior that we think will improve or maintain good health status) It is important to remember, no intervention, including counseling, is ever risk-free, or cost-free! When we intervene in people's lives, we have the responsibility to remember that there can be risks. What if we give the wrong advice? What if the information the client receives is controversial in their culture and affects their family relationships? Counseling also takes resources. Even though the USPSTF does not consider costs, it is a good practice to always be thinking about the effectiveness of an intervention in the context of its costs. Is there something more effective that could be done with the same resources?
Healthy aging
The World Health Organization (WHO) has publically defined healthy aging as the various pursuits inherent in healthy promotion and supportive environments, starting at birth and progressing through our later years, that allow individuals to remain engaged in activities that are important and they enjoy. The WHO found these to be the key determinants for healthy aging. I'm sure that many of these will be of no surprise. For instance, healthy behaviors will generally afford people longer life. We know that. Older adults without disease or disability typically live longer and have a higher quality of life. Women are living longer than men, but the gap is closing for the US but not necessarily across the globe. Access to quality health care and supportive services is another determinant of healthy aging. Universal health care coverage is one aspect, affordability is another key component, but if the older adult does not have access to the right care, in the right setting, at the right time, then older adults will have poorer health outcomes than their counterparts with universal, quality access to care. We will discuss this later in the course. Engagement. Older adults who feel engaged in their community and with their family and friends are found to have higher quality of health. On the contrary, seniors who are disengaged, withdrawn, isolated tend to be depressed, show signs of cognitive decline, and vulnerable to abuse. What about physical environment? Do older adults experience quality of health when they are active and mobile? Absolutely. Take the community in which you live, can older adults easily walk from place to place? Are street signs well lit so they may drive safely? Is public transportation easily accessible? What other physical environment characteristics may effect one's quality of life? How about in the home? Or even much broader, how about general air and water quality?
What are some of the issues with addressing high blood pressure currently?
There is now widespread awareness of the importance of blood pressure, and it is easy to screen for, given the easy process of taking blood pressure and the ease of remembering simple cut-offs. There are many effective medications, and in recent research has shown that some of the older, cheaper high blood pressure drugs are in fact some of the most effective. But when we think about older adults we must always think in terms of risk-benefit ratios. The research supporting very low, aggressive BP targets has been controversial. One 2014 expert panel actually recommended relaxing the standards for adults age 60+. However, the influential SPRINT study concluded the opposite, finding dramatic reductions in heart attack, heart failure, stroke and death when very low BP targets were achieved with a very aggressive approach using several medications. Others who specialize in caring for older adults question the risks of having patients on this aggressive medication regimen. They argue that the risk of poor circulation, weakness, dizziness and falls in not worthwhile, especially in the the older old. With older adults, we always have to be concerned with how many medications is the patient on (polypharmacy), and what are the risks of those drugs, and of drug interactions. For example blood pressure medicines can lead to dizziness, falls, and insufficient perfusion or blood flow to organs. Meanwhile some new research calls into question whether lower blood pressure is always better. One study has found more of a U shaped curve, with the lowest mortality in the mid-range and the highest mortality for patients with the highest AND with the lowest blood pressures! (Sim et al, 2014). This controversy continues, not just for BP as you will see but for high cholesterol as well! Medicare has done a great job supporting blood pressure monitoring and medications, and national quality metrics emphasize the importance of any patients meeting the definition of high blood pressure being on medication. But the same level of support is not always given to health education and lifestyle interventions. Medicare "managed care" programs( which tend to be more comprehensive and integrated in their service delivery) are often better than Medicare Fee for Service in terms of offering health education and lifestyle interventions. Lifestyle changes can be effective in lowering BP to some degree for those with mild HBP.
High Blood Pressure
Thresholds for HBP have been falling as evidence of harms mounts Current (simplified) guidelines for HBP Systolic higher than 140; diastolic higher than 90 High normal (130/85) still at increased risk for heart disease & stroke NIH panel stated that "pre-hypertensive" should be considered 120-139 systolic; 80-90 diastolic
What is the goal of health promotion?
To promote healthy behaviors and improve quality of life. Inversely, to prevent or reduce the onset of diseases and disabilities.
Compression of Morbidity
Today, health providers, particularly in the medical field, focus on extending life, even after the onset of a chronic disease, incorporating a variety of medical innovations at their disposal. Can you think of medical advancements that prolong life? How about dialysis? In essence, we seem to be adding years to life, at times with severe disability and illness, and not necessarily quality of life to years. We use to talk about this dilemma quite a bit while I was at the Office on Aging. How can we prolong quality of years within one's life? One answer, but not necessarily the correct one depending on who you talk to, is to compress morbidity through health promotion activities, such as information on prevention of disease or disability. For instance, through never smoking, better nutrition, more exercise, as well as proper vaccinations and screenings to name just a few. All in all, people prefer to live longer AND with less years spent with a chronic disease and/or disability. Take a few moments to review and digest this slide. You may even think, like me as the optimist, that we should add another scenario that has both life extension to 100 years and compression of morbidity to a few months.
Clinical Guidelines & Treatment
Treatment Lifestyle: diet and exercise Statins: Reduce levels of bad cholesterol Possible side effects: Elevated blood sugar; Muscle pain, damage; Liver damage Need to weigh risks/benefits! Guidelines increasingly aggressive New: Latest guidelines focus on risk factor profile and drug treatment
Clinical Guidelines & Treatment cont.
Treatments may include changes in diet and increased exercise, moving onto medications if lifestyle changes don't work, but increasingly treatment moves directly to using medications due since it has been observed that lifestyle changes do not often get very big results. Drug treatment with a class of drugs called "Statins" has been clearly shown to lower bad cholesterol and to reduce rates of coronary heart disease events. Over the years, the changes in thresholds needed to treat people have had the effect of increasing the number of adults eligible for treatment with lipid lowering medications such as statins. The American College of Cardiology and American Heart Association guidelines also explicitly recommend drug treatment, stating that lifestyle treatments are not sufficiently effective in reducing risk. Some critics see these increasingly aggressive drug trends in drug treatment as being the result of a lot of influence from the pharmaceutical industry. By some estimates, following these new guidelines means that as many as 80% of US adults should be on a cholesterol-lowering medication! Others argue that this approach is based on strong empirical evidence and expert opinion and will save the most lives in the long run. Either way, geriatricians are often concerned regarding the lack of data about how such recommendations apply to the elderly, especially since part of this trend has been expanded treatment of older adults. Also controversial is that there are no clear criteria for ever stopping drug treatment. In the past, treatment was more focused on adults under the age of 70. Treatment in those 70+ was not expected to have a significant impact on longevity, and there was concern that dietary restrictions put older adults at risk for malnutrition. Now, with the medications available and mounting evidence supporting their effectiveness, the USPSTF has eliminated upper age limits for routine cholesterol screening (unusual for them!), leading to more older adults aged 70+ being screened and treated. The most recent guidelines continue this trend, supporting aggressive treatment in high risk adults at least until age 75. However, in older adults it is always essential to consider risks as well as benefits of treatment. For example, poly-pharmacy is always a consideration in older adults, since being on multiple medications can result in cognitive problems, falls, and financial burden which sometimes leads older patients to avoid taking some or all of their medications as directed. Two new drugs in particular, which were developed to help individuals who could not tolerate statins or who didn't reach their LDL targets on statins alone, are very expensive indeed, at over $1000 per month retail. Even with Medicare Part D, which covers some of the cost of prescription drugs, the share of the cost the patient pays can certainly pose a financial burden.
USPSTF Aims
US Preventive Services Task Force (USPSTF) Conducts scientific evidence reviews of a broad range of clinical preventive health care services (e.g., screening, counseling, and preventive medications) Develops unbiased recommendations for primary care clinicians such as physicians, nurses, and other allied health professionals
Healthy People Objectives Met
Unfortunately, many of these objectives are unfunded. Nonetheless, a report, The State of Aging & Health in America, illustrates that the following Healthy People 2020 objectives are on track to being met among older adults 65 years and older: 1 Leisure-time Physical Activity - older adults with no leisure-time physical activity in the past month decreased to 31.4%, which is under the goal of 32.6%. 2 Obesity among older adults fell under the objective's threshold of 30.6% to 24.3%. 3 Similar to national trends, current smoking among older adults was 8.4%, well below the target of 12.0%. 4 Additionally, seniors who are compliant with taking medications for their high blood pressure rose to 94.0%, well beyond the goal of 77.4%. 5 Lastly, older adults acquiring colorectal cancer screenings is reported at 73.1% compared to a target of 70.5%. In addition, 82.9% of older women reported they received a mammogram within the past 2 years, again well above the goal of 70%. But improvements still remain, such as reducing the number of fall-related injuries, increasing the utilization of vaccinations, and motivating seniors to eat healthier.
Cholesterol
Waxy, fat-like substance found in all cells of body Needed to make hormones, Vitamin D & other substances, linked to brain health Our bodies make cholesterol Additional sources from food Types Low-Density Lipoproteins (LDL)("bad cholesterol") High-Density Lipoproteins (HDL)("good cholesterol") Triglycerides (worst!)
Menopause and Hormone Replacement Therapy (HRT) Cont.
We begin with menopause and Hormone Replacement Therapy for Older Women. In menopause, the female body goes through hormonal changes so that pregnancy is no longer possible. So what is the problem: menopause is not a disease after all! These changes sometimes bring on symptoms such as irregular menstrual cycles, hot flashes, changes in mood, memory, and ability to focus, headache, and also insomnia and fatigue. It can also be associated with loss of bone density and increased risk for cardiovascular disease. Some women and health care providers viewed this as a normal process to be endured, while at the other end of the spectrum some viewed menopause as a pathology of estrogen deficiency that should be treated. For many years it was common practice to offer women hormone "replacement" therapy, with either estrogen alone or in combination with progestin. Early studies seemed to support the notion that hormone replacement therapy or HRT could not only relieve acute symptoms, but could protect women against heart disease, strokes, and osteoporosis. Women began to be placed on HRT for years at a time. However, these studies tended to be observational studies with no randomization or control groups. It turned out that the women in those studies who took HRT were different from those who did not: for example, they were younger and more affluent, which may have accounted for their better health outcomes over time. When the more rigorous HERS and HERS II studies were conducted, they used randomized, controlled trial designs, and actually found that not only was HRT not protective against cardiovascular disease, it actually seemed to place women at higher risk of heart attacks, strokes, blood clots, and also breast cancer.
Osteoporosis risk factors cont.
We build a lot of bone until about age 30, then tend to maintain. Now, bone is a dynamic tissue that is constantly remodeling, but around menopause bone loss tends to outpace bone replacement, with about 5-10% bone loss in the first 2 years and as much as 20% in the 5 to 7 years post-menopause, and more gradual loss after that.
Osteoporosis risk factors
We build bone until approximately age 30, then maintain After menopause, we lose bone Why more prevalent among older adults? Risk factors Female Caucasian or Asian Slender build Early onset menstruation Smoking Alcohol abuse Physical inactivity Use of steroidal hormones Too little calcium Too much caffeine, protein, salt
Prostate Cancer Screening cont.
We do have a screening test, the Prostate-specific antibody test (PSA). This is a blood test developed in the 1980s that measures elevated protein levels made by the prostate that can be indicative of cancer. This is one of those tests that was developed at a time that we had no other good way method of early detection for this cancer, and a time when early detection and treatment was thought to pretty much always be the best option if possible. Well, the PSA test was put into widespread use, but meanwhile a good deal of research was being done both on how good treatments were and how effective PSA was as a screening test. Numerous research studies have since found that routine PSA screening saves few lives if any. One problem has been that the PSA is not very accurate in identifying cancer. Some have argued that absolute levels of PSA in the blood aren't that meaningful, and that sudden increases are more useful indicator than the absolute level. However, even this is disputed. Other issues though lie with treatment itself. One summary of research findings concluded that screening 1000 men results in saving one life, while another 43 men are seriously harmed by treatment itself. One man for every 3,000 tested will die of complications of treatment. Wait, what? What does treatment involve anyway? Most men diagnosed through screening were undergoing surgery to remove the prostate gland, followed by radiation to the area. Common side-effects of treatment include urinary incontinence, impotence, painful defecation, and diarrhea. Side-effects have improved to some degree with more targeted radiation technologies such as proton beam radiation, but the side effects of impotence and incontinence remain significant for patients undergoing surgery and radiation. With such side-effects, we would hope treatment would be effective at saving lives. However, research findings were showing that these aggressive treatments with all of their side-effects weren't even making that big of a difference in overall survival. "Watchful waiting" became an accepted alternative to aggressive treatment. Yet, PSA doesn't really help us identify which cancers are the ones that might really need treatment vs those that could do just as well with watchful waiting. So, as you can imagine, effectiveness of routine PSA screening as a program has been seriously challenged, and the USPSTF has actually changed its recommendation from simply "not recommending" to actually "recommending against" routine PSA screening. For those of you interested in pharmaceutical industry developments, the drug Provenge represented something of a breakthrough in that it is actually a cancer vaccine. It does not prevent the cancer, but mobilizes the body's own immune system to fight the cancer. Unfortunately its major claim to fame was a median survival benefit of about four months for the price of $93,000 for a course of treatment. Even with the change in USPSTF recommendations, the American Cancer Society still recommends for high risk groups, including those with a strong family history, and African Americans, and the test continues to be used widely in the US - more so than in other developed countries. Why do you think this is? One possibility is that we tend to have a medical culture (and culture in general) of intervention, of doctors and patients alike wanting to DO something - the more the better! Also, it is possible that the cancer awareness campaigns of the 1960s and 70s did a good job - the population has a heightened awareness of cancer and wants to avoid it and to fight it. We also tend to have oversimplified media messaging - things are often portrayed as always all good or always all bad, and more of a good thing is always better! These tendencies will tend to affect many of the conditions we will be examining in this course this semester.
Dimensions of Wellness
Wellness is often defined by 7 dimensions: physical, emotional, intellectual, vocational, social, environmental, and spiritual. The level to which we incorporate each dimension directly effects our quality of life. Haber talks about these dimensions in his book, so I won't spend much time on it here. A few health professionals believe that an eighth dimension should be added: financial wellness, to ensure people are saving and working toward a healthy financial future in their later years. However for purposes of this class, and the papers, we will use the 7 Dimensions of Wellness
