Exam 2 Geriatrics: Prevention & Health Maintenance
• An 83-year-old man with mild dementia lives alone in an area not served by public transportation. His nearest relative lives more than 40 minutes away. He has had 1 moving violation and 1 minor accident in the past year. • The patient scores 27 on the MMSE. • He says he is a good driver and that forcing him to stop would be like "cutting off my legs." He limits driving to local stores and does not drive at night or on the highway. His family agrees he is a safe driver. • Corrected visual acuity > 20/40, no physical limitations. The patient does not drink alcohol or use medications that might affect his alertness. Which of the following is the most appropriate next step in assessing this patient's safety as a driver? (A) No further assessment is necessary. (B) He should stop driving. (C) He should have formal neuropsychologic testing. (D) He should have a formal driving evaluation.
(A) No further assessment is necessary. (B) He should stop driving. (C) He should have formal neuropsychologic testing. *(D) He should have a formal driving evaluation.*
Which of the following is erroneously considered part of normal aging and is therefore often underreported by patients and their family members? • A. Gait disturbance • B. Decreased strength • C. Vaginal dryness • D. Decreased appetite
*• A. Gait disturbance* • B. Decreased strength • C. Vaginal dryness • D. Decreased appetite • Answer: A: Gait disturbance. Other symptoms, such as dyspnea, hearing or vision deficits, memory problems, incontinence, constipation, dizziness, and falls, may also be attributed to normal aging and thus be underreported. However, no symptom should be attributed to normal aging unless a thorough evaluation is done and other possible causes have been eliminated. Choices B, C, and D are associated with aging.
Which of the following is most likely to effectively stabilize the elderly patient with multiple disorders? • A. Make sure that treatments are well-integrated. • B. Decrease the number of drugs used. • C. Refer patients to appropriate specialists. • D. Call patients on a regular basis.
*• A. Make sure that treatments are well-integrated.* • B. Decrease the number of drugs used. • C. Refer patients to appropriate specialists. • D. Call patients on a regular basis. • Answer: A: Make sure that treatments are well-integrated. Treating one disorder without treating associated disorders may accelerate decline. Choices B, C, and D are also important, but integrating treatments (eg, bed rest, surgery, drugs), along with careful monitoring, is the best way to provide stability and the best possible outcomes and to avoid iatrogenic consequences.
Calcium and vitamin D maintain or increase bone density in postmenopausal women & help prevent hip and nonvertebral fractures in all older adults. What are the dosages for this?
- 1200 mg/day of calcium: men 65 years and older & postmenopausal women - 400-800 IU/day of vitamin D: regardless of sunlight exposure, to offset skin changes that ↓ efficient use of UV light to synthesize vitamin D precursors
ASSESS PSYCHOLOGICAL STATUS • Although prevalence of major depression among older adults is low (1%-2%), "subclinical" depression is common what should you ask?
- Ask, "Do you often feel sad or depressed?" - If patient responds affirmatively do further evaluation, - eg, Geriatric Depression Scale - Watch for signs of anxiety, bereavement
• Osteoporosis is?
- BMD measurement at any site >2.5 standard deviations below the young-adult standard, with or without previous fracture - T-score < -2.5
• Osteopenia is?
- Bone mineral density (BMD) measurement at any site >1 but ≤2.5 standard deviations below the young-adult standard - T-score < -1 but ≥ -2.5
Risk Factors for Postmenopausal Women for osteoporosis?
- Early menopause - White or Asian race - Sedentary lifestyle - Smoking - Low body weight - Alcohol abuse - Primary hyperparathyroidism - Hyperthyroidism - Glucocorticoid use
Modifying Risk Factors for osteoporosis?
- Encourage regular, weight-bearing exercise - Encourage adequate calcium and vitamin D intake - Encourage lower animal protein intake - Encourage smoking cessation - Use medications that may ↑ osteoporosis risk with caution (eg, anticonvulsants, cyclosporine, glucocorticoids, long-term heparin, methotrexate, thyroid hormone replacement)
COGNITIVE ASSESSMENT: PERFORMANCE MEASURES include?
- Folstein's Recall 3 items - Mini-Mental State Examination (MMSE) ➢ Widely used ➢ Tests orientation, registration, recall, attention, calculation, language, visuospatial skills - Tests of executive function ➢ Clock-drawing test ➢ Listing animals test
Exercise
- Marked decrease in physical activity or immobilization decline in bone mass - Walking, a weight-bearing exercise, can be recommended for all adults - Start slowly and gradually increase the number of days and time spent walking each day
RISK FACTORS FOR OLDER DRIVERS?
- Poor visual acuity and contrast sensitivity - Dementia - Impaired neck and trunk rotation - Limitations of shoulders, hips, ankles - Foot abnormalities - Poor motor coordination and speed of movement - Medications that affect alertness
WHEN is DRIVING CESSATION UNAVOIDABLE?
- Remember that driving cessation may result in Reduced activity level Depressive symptoms - Learn and follow individual state laws on reporting impaired drivers (contact local office of Department of Motor Vehicles)
Preventing and Treating Osteoporosis includes?
- Weight-bearing exercise - Calcium and vitamin D - Bisphosphonates - Selective Estrogen Receptor Modulators - Calcitonin - Estrogen replacement - Smoking cessation - Investigational agents
WHY do we SCREEN FOR COGNITIVE LOSS?
-Most people with dementia do not complain of memory loss -Cognitively impaired older persons are at ↑ risk for accidents, delirium, medical nonadherence, and disability
What is The Beers Criteria?
A list of over 50 medications that should: • Always be avoided in older adults. e.g. barbiturates, chlorpropamide. • Are potentially inappropriate in older adults with particular conditions: e.g. NSAIDS. • Be used with caution: e.g. diphenhydramine (sedative and anticholinergic properties), long-term PPI (risk of C. diff infection and bone loss).
What is Primary Prevention?
Aims to avert the development of disease.
Risk factors for alcohol abuse among older adults include?
Bereavement, depression, anxiety, pain, disability, and a prior history of alcohol use. • Screen for Frequency and Quantity of alcohol use, then askthe CAGE questions
What are Examples of Tertiary Prevention?
Identification of cognitive problems, disorders of gait and balance, malnutrition, and urinary incontinence are examples.
Tertiary Prevention for osteoporosis?
Identifies established conditions to prevent further morbidity or functional decline. • Identification of cognitive problems, disorders of gait and balance, malnutrition, and urinary incontinence are examples.
What are Examples of Primary Prevention?
Immunizations, life style modifications (smoking cessation, promoting physical activity), and chemoprophylaxis (ASA for primary prevention of heart disease).
For older adults the benefits of increasing physical activity include what?
Improved conditioning, strength, flexibility and overall physical fitness. Reduced risk of cardiovascular disease, thromboembolic stroke, HTN, type 2 DM, osteoporosis, obesity, colon cancer, breast cancer, anxiety, depression and cognitive decline. Reduced likelihood of falls and fall-related injuries. • Also may help in many chronic conditions • Benefits are immediate and extend at least through age 75-85 • Inquiry about physical activity should be part of routine assessment at each medical visit.
• Smoking is estimated to cause 6 million deaths worldwide each year. Half of those who smoke regularly will die from a tobacco-related illness. • A patient is never to old to benefit from smoking cessation • Smoking cessation significantly reduces the risk for CHD, various cancers and COPD. • Smoking is associated with what?
Increased risk of DM II, Osteoporosis, Reproductive disorders, PUD, Periodontal Dz, postoperative complications and several types of infection. • One study addressed smoking cessation in older community dwelling adults and found that, within five years of stopping smoking, the relative risk for all cause mortality fell below that for current smokers.
Screening is indicated in men with clinical manifestations of?
Low bone mass: • radiographic osteopenia, history of low trauma fractures, and loss of more than 1.5 inches in height. As well as in those with risk factors for fracture: • long-term glucocorticoid therapy, androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, hyperthyroidism, and intestinal disorders.
What tends to be the trend with elderly screening tests?
Many older patients in the US, and women in particular, both receive screening tests that are inappropriate for their age or health status, and do not receive other screening tests and preventive interventions (eg, immunizations and counseling) that are recommended for health maintenance.
What are Examples of Secondary Prevention?
Screening for cancer, hearing or vision impairment, osteoporosis, hypertension, and abdominal aortic aneurysm (AAA).
ASA- USPSTF Recs: include?
• + 50-59 yo w/ ≥10% 10y CVD risk (& no ⇧bleed risk). • +/- 60-69yo " " • <50yo: insufficient evidence to make recommendation • >70yo: " " UpToDate Recommends low-dose daily ASA for any pt ≥50yo w/o excess bleeding risk (PPI should be considered in Pts w/ Hx of GI bleed)
Secondary Prevention BP screening are done why?
• 60-80% of older adults have HTN • HTN is the leading risk factor for ischemic heart disease and stroke and is a significant risk factor for renal failure • Isolated systolic hypertension (ISH) is found in 2/3 of elderly with HTN, and should be treated • Treatment of HTN reduces stroke mortality by up to 60% and CAD mortality by 50% since 1972
Risks and Benefits of low-dose daily ASA?
• A possible reduction in the relative risk of overall mortality (6-8%) over 10y • ~20% relative risk reduction in non-fatal MI over 10y • ~50% increase in the relative risk of major non-fatal extracranial bleeding over 10y • ~24% decrease on colon CA incidence over long-term f/u (20y) • ~35% decrease in colorectal CA mortality over long-term f/u (20y)
Epidemiology of Osteoporotic Fractures includes what?
• High prevalence - 1.25 million female & 500,000 male hip fractures worldwide (1990) - 250,000 hip & 500,000 vertebral fractures in US annually • Serious consequences - ↓ quality of life, function, independence - ↑ morbidity & mortality (50% of women do not recover prior function after hip fracture; 20% excess mortality in year after hip fracture) • Cost: >$14 billion in US
Guidelines for pharmacologic intervention in postmenopausal women and men ≥50 years of age includes what?
• History of hip or vertebral fracture. • T-score ≤-2.5 (DXA) at the femoral neck or spine, after appropriate evaluation to exclude secondary causes. • T-score between -1 and -2.5 at the femoral neck or spine, and a 10-year probability of hip fracture ≥3 percent or a 10-year probability of any major osteoporosis-related fracture ≥20 percent based upon the United States-adapted WHO algorithm.
Conditions and deficits that predict MVCs and adverse driving events are what?
• Hx of falls in the past 1-2 years • Presence of visual and cognitive deficits • A prior Hx of MVCs • Current use of meds such as Benzos and Tricyclic Antidepressants
Exceptions to Standard Recommendations for Screening include?
• Life Expectancy: Most CA screening is not recommended if life expectancy is < 5-10 y (or if pt would be too frail for tx). • Functional Status: SF-36: assesses physical function, role limitations due to physical and emotional health, bodily pain, social functioning, mental health, vitality, and general health perceptions • Patient Preference: Ask about patient preferences regarding medical care and goal of care
Assessment of the Older Driver includes?
• Medical history (including medications, use of alcohol and other substances, social support, and driving experience. • P.E.: Assess mobility, vision, hearing, and cognitive function. • AMA Physician's Guide to Assessing and Counseling Older Drivers: www.ama-assn.org/ama/pub/category/ 10791.html • Community resources for driving refresher courses and evaluation to supplement the primary care evaluation and provide support.
What are risks of Smoking Cessation?
• Nicotine Withdrawal Syndrome: Wt gain, depression, etc. Sx's peak in the 1st 3 days and subside over the next month. • Cough and Aphthous Ulcers: usually resolves in a few weeks. • Symptoms are temporary and can be treated with Rx and behavioral tx.
What is secondary prevention?
focuses on early detection and treatment of asymptomatic disease.
Colorectal Screening options for the elderly include?
gFOBT, iFOBT/FIT (all annual), Stool DNA (q 3y), CT colonography (q5y), Flexible Sigmoidoscopy (q 5y), Colonoscopy (q 10y) • USPSTF recommends routine screening for those aged 50-75. • Decision to screen adults aged 76-85 should take into consideration pts overall health and prior screening hx.
What is tertiary prevention?
identifies established conditions to prevent further morbidity or functional decline.
Decline in function and loss of independence are NOT an inevitable consequence of aging. Given the high prevalence and impact of chronic health problems among older adults, evidence-based interventions to address these problems become increasingly important to maximize both what?
the quantity and quality of life for the elderly.
Which of the following should the clinician evaluate to ensure accurate results when testing mental status in an elderly patient? • A. Ability to walk • B. Ability to rise from a chair • C. Ability to hear • D. Ability to see
• A. Ability to walk • B. Ability to rise from a chair *• C. Ability to hear* • D. Ability to see • Answer: C: Ability to hear. The examiner must make sure that patients can hear; hearing deficits that prevent patients from hearing and understanding questions may be mistaken for cognitive dysfunction. Choices A, B, and D are part of the evaluation, but they are not required for accurate mental status evaluation.
What are some tools to assess functional status?
• Activities of Daily Living (ADLs) Bathing, dressing, transferring, toileting, grooming, • Instrumental Activities of Daily Living (IADLs) feeding, mobility Using telephone, preparing meals, managing finances, taking medications, doing laundry, doing housework, shopping, managing transportation • "Get Up and Go" test Qualitative; timed; assesses gait, balance, and transfers
There are 4 categories of focus recommended by the AHA and ACSM for exercise in elderly?
• Aerobic Exercise: Moderate intensity 30 min 5d/wk or vigorous activity 3d/wk. • Muscle Strengthening: 2 days/wk. • Flexibility: twice a week for 10 min (preferably after activity) • Balance Exercise: improves stability and helps prevent falls.
What is THE OLDER DRIVER: THE PROBLEM talk like?
• Although the number of crashes among older drivers is low . . . • The number of crashes per mile driven and the likelihood of serious injury and death are higher than for any other age group except young adults 16 to 24 years old
How many patients over 65 experience problems with alcohol?
• Approximately 15 percent of adults over age 65 years experience health problems related to complications of alcohol consumption in combination with medication or chronic conditions. • 2-4 % meet Criteria for Alcoholism: • >65yo: >7 drinks/wk or >3 drinks/occasion (for pts <65: Males: >14 drinks/wk or >4 drinks/occasion, Females: >7 drinks/wk or >3 drinks/occasion)
WHEN AN ACCIDENT OR DRIVING VIOLATION OCCURS what needs to be done?
• Assess Risks or family member, if possible • Discuss safety concerns with the older driver and with spouse • Urge consideration of other modes of transportation • Refer for formal driving evaluation • Encourage the Driver to Reduce Risks • Avoid rush hour, congested traffic • Avoid night driving • Avoid driving in poor weather
When should Hypertension screening be done?
• BP should be screened at least every 1-2 years. Most practices check BP at every visit. • Benefits of treatment outweigh risks • Unless BP is extremely high, trial of non-drug measures such as low salt diet, weight loss and discontinuing meds that increase BP such as NSAID's • Start BP meds at low doses, increase gradually • Monitor electrolytes, renal function, pulse, orthostasis, gait/unsteadiness at each visit
Bone mass density Measurements include?
• Best predictor of fracture - Relative risk of fracture is 10× greater in women in the lowest quartile than in those in highest quartile • Dual-energy x-ray absorptiometry (DEXA) - Preferred method of measurement - Can measure hip, anterior-posterior spine, lateral spine, and wrist - Cost = $200 to $300 - Covered by Medicare and Medicaid if indications for use are met
What do we need to know about COPD?
• COPD includes subtypes emphysema, chronic bronchitis, and chronic obstructive asthma. • The 3rd ranked cause of death in the US. • SMOKING is the primary culprit.
MCCs (multiple chronic conditions) of Hospitalization among Geriatric Patients include?
• Cardiac Arrhythmias • CHF • COPD • Coronary Atherosclerosis • Diabetes • Medication Problems • Infection (esp PNA & UTI) • Stroke
What do we need to know about Diabetes Mellitus?
• Common reasons for hospitalization due to diabetes include strokes, heart attacks, ulcers and dehydration from elevated blood sugar levels. • Being overweight, inactive and age 45 and older are three prominent risk factors for type 2, or adult-onset, diabetes.
What do we need to know about medication problems?
• Drug reactions of some sort led to 1.9 million hospital stays in 2008. • Medications most commonly involved: corticosteroids, blood thinners, sedatives and sleep aids. • Compliance to lists of meds to be avoided is sub-optimal. • Clinicians may be better at avoiding overprescribing inappropriate drugs than at prescribing indicated drugs (e.g. statins) that could benefit older adults. • Be alert to use of herbal and dietary supplements as many can cause drug interactions.
Pharmacologic Therapy of Osteoporosis
• Drug therapy must be individualized • Each treatment has its own risks and side effects - Bisphosponates: esophagitis/esophageal ulcers - SERMs: [e.g raloxifene (Evista)] increased risk of DVT, decreased risk of breast cancer - HRT: increased risk of uterine & breast cancer - Calcitonin: less effective in building bone density but relieves pain of vertebral compression fx, nasal spray or injection
Secondary Prevention in the elderly include Screenings like what?
• Early detection of cancer may lead to better outcomes • Must consider life expectancy and quality of life issues • Comorbid illnesses and frailty alter the risk-benefit ratio • Screening for colorectal, breast and cervical cancer are most likely to be effective in reducing cancer-specific mortality
Secondary Prevention for Abdominal Aortic Aneurysm (AAA) Screening include what?
• One-time u/s screening for AAA is recommended by the USPSTF and the American Heart Association for men ages 65 to 75 who have ever smoked. • Screening should be selectively offered to men aged 65-75 who have never smoked (1st degree relative who died from AAA rupture or had one repaired or other risk factors). • Recommends against screening women who have never smoked. • Insufficient evidence to make recommendations for women aged 65-75 who have ever smoked.
Secondary Prevention Osteoporosis Screenings are common in who?
• Osteopenia and Osteoporosis are very common in older women • Osteoporotic fractures result in major morbidity and mortality • Women over age 65 should be screened regularly with DEXA scan (Every 3-5 years) • Women under age 65, and men, with risk factors should also be screened
What is included in the summary?
• Primary and secondary prevention measures can result in marked improvement in both quantity and quality of an older person's life • Efficacy of preventive measures has already increased average life spans and often reduces disability burden in old age
Breast Cancer Screenings include?
• Screening mammography reduces breast CA mortality by 30% • USPSTF recommends biennial screening mamography every 2 years in women aged 50-74 years. • Decision to screen women aged 40-49 or >74yo is individualized and should only be offered if life expectancy is at least 10 years. (10 years from when relative was diagnosed)
Primary Prevention: Immunizations for the elderly include what?
• Tetanus (Td): every 10 years for adults who have completed a primary series in childhood. • Influenza: yearly • Pneumonia: single dose age ≥65 • Herpes Zoster: single dose for immunocompetent patients age ≥60
Secondary Prevention: Prostate Cancer Screening start when?
• The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms and recommends against routine screening.* • The American Urological Association recommends that PSA screening, in conjunction with a digital rectal examination, should be offered to asymptomatic men aged 40 years or older who wish to be screened, if estimated life expectancy is greater than 10 years. • When prostate cancer screening is initiated, stopping screening by age 75 is appropriate.
What is recommended for Secondary Prevention: Lipid Screening?
• The USPSTF strongly recommends screening men aged 35 and older for lipid disorders. • Worthwhile to offer non-drug therapy with diet and weight loss first • Lipid lowering drug therapy decreases the incidence of coronary heart disease in people with abnormal lipids and causes few major harms • Watch for liver dysfunction and muscle pain
What are State Laws for elderly licenses?
• The most restrictive states, New Hampshire and Illinois, require residents who are 75 years and older to take vision and on-the-road tests each year to renew their license. Restrictions can also be placed on the license, such as "daylight only" or "local area only." Some states require a physician certification each renewal period. • Utah drivers ≥65yo at the time their license expires are generally required to renew their license in person at a DMV office. In addition to a vision test every renewal after 5 years they may in certain situations be asked to take a written knowledge test as well.
When should Cervical Cancer Screening be done?
• While the incidence of cervical cancer declines dramatically as women age, the morbidity and mortality of cervical cancer is higher in older women. • Pap smears may be discontinued in women ages 65 - 70 who have had 3 normal Pap tests over the past 10 years and no abnormals, are not at high risk for cervical CA, or who have had a hysterectomy and no Hx of high-grade pre-CA lesion. • Those with persistent or recurring risk factors should continue screening.
• A 78-year-old woman who lives alone comes for an office visit as a new patient. • She has osteoarthritis, macular degeneration, hypertension, and mild hearing loss, but no symptoms except knee pain when she walks. • She is thin (BMI 19.2), and crepitus is present in both knees. The rest of the examination is within normal limits. • Hemoglobin and hematocrit are normal, as was a colonoscopy approximately 10 years ago. •What is the most appropriate next step in evaluating the patient's nutritional status? •(A) Check serum cholesterol. •(B) Check serum albumin. •(C) Check lymphocyte count. •(D) Inquire about recent weight loss. •(E) Perform anergy skin testing.
•(A) Check serum cholesterol. •(B) Check serum albumin. •(C) Check lymphocyte count. *•(D) Inquire about recent weight loss. * •(E) Perform anergy skin testing.
CASE 3 (1 of 2) •In an office setting, which of the following is the most appropriate screening strategy for hearing loss in older adults? •(A) Rubbing fingers next to the ears •(B) Hand-held AudioScope test •(C) Holding a vibrating tuning fork next to the ears •(D) Whisper test •(E) Weber test
•(A) Rubbing fingers next to the ears *•(B) Hand-held AudioScope test* •(C) Holding a vibrating tuning fork next to the ears •(D) Whisper test •(E) Weber test