To Treat or Torture?
Preventative Care
in the Elderly
Christi Stewart, MD
March 31, 20101
Objectives
1.
Know the primary physician’s role in
counseling for prevention.
2.
Have a basic understanding of
prognosis and life expectancy and how it relates to
screening recommendations.
3.
Learn the current screening guidelines for common
conditions.
4.
Determine cost-effectiveness of screening specifically in
the geriatric population.
5.
Come up with a screening guideline for patients at
various “stages” of the aging process.
2
Topics of Review



Counseling Recommendations:
– Diet
– Tobacco cessation
– Alcohol consumption
Screening Recommendations:
– Breast cancer
– Cervical cancer
– Prostate cancer
– Colon cancer
– Osteoporosis
– Abdominal aortic aneurysm
– Diabetes
– Hypercholesterolemia
Immunizations
3
Leading Causes of Death
in the US - 2006










Heart disease - 631,636
Cancer - 559,888
Stroke - 137,119
Chronic respiratory illness - 124,583
Accidents - 121,599
Diabetes - 72,449
Dementia - 72,432
Influenza or Pneumonia - 56,326
Renal disease - 45,344
Septicemia - 34,234
4
Counseling


Given leading causes of death,
changes in lifestyle behaviors will
influence mortality, even in older
adults.
Why we don’t do it?
– Lack of time
– Lack of perceived benefit
– Lack of patient cooperation
5
Tobacco Cessation
Level A Recommendation

USPSTF recommends asking all adults
about tobacco use (2009).
– Recommends providing tobacco cessation
interventions for those who use tobacco
products.


Average recommended length of
counseling session - 3 minutes
Survival benefit for individuals >65yo:
– 1.4 - 2 years for men
– 2.7 - 3.7 years for women
6
Alcohol Counseling
Level B Recommendation




USPSTF recommends screening and behavioral
counseling interventions to reduce alcohol misuse
in primary care settings (B recommendation).
There is evidence that brief counseling
interventions and follow-up show small to moderate
reductions in alcohol consumption that are
sustained over 6-12 months.
Interventions lead to positive health outcomes 4+
years post-intervention.
Little evidence to show that counseling reduces
alcohol related morbidity.
7
Nutrition Counseling
Level I & B Recommendation


USPSTF notes evidence is insufficient to
recommend for or against routine
behavioral counseling to promote healthy
diet in the general population.
Does recommend dietary counseling in
patients with diet-related illnesses:
–
–
–
–
Diabetes
HTN
Hyperlipidemia
Those at high risk for CAD
8
No Evidence to Support
Counseling For:










Exercise
Prevention of low back pain
Benefits of ASA for primary prevention of CAD/CVA
in adults >80yo.
Self breast exams
Dental services
Illicit drug use
Domestic abuse/ Elder abuse
Seat belt use
Driving while under the influence
Use of multi-vitamins
9
Definition of Screening
Examination of a group of
asymptomatic individuals to
detect those with a high
probability of having a given
disease, typically by means of an
inexpensive diagnostic test.
10
Cancer Screening


Cancer is the second leading cause of
death in individuals >65 yo.
Survival benefit (in general) from
cancer screening is not seen unless
the life expectancy exceeds 5 years.
11
Life Expectancy

Predictors:
– Functional status
– Comorbid medical conditions

Four-year mortality index
– See handout
– Incorporates age, sex, self-reported
behaviors, comorbid conditions and
functional status

Jumping point for discussion of benefits
v risks of screening tests
12
Life Expectancy in
Older Women
Life Expectancy
in Older Men
13
Breast Cancer


#1 female non-dermatologic cancer
#2 cause of cancer deaths in females
– 66% of deaths occur in women >65yo.


10% of women older than 70 will have
breast cancer.
8.6% lifetime risk for general population
14
How to screen

Mammogram is
accepted route
of screening for
breast cancer.
– Digital imaging
v MRI no better
than plain film.
Yes, I did have my mammogram
today... Why do you15 ask?
USPSTF Recommendations
2009



Recommends biennial screening
mammography for all women aged 50-74
years old.
Concludes that the current evidence is
insufficient to assess the additional benefits
v harms of screening women older than 75.
Concludes that the current evidence is
insufficient to assess the benefits v harms of
clinical breast exams beyond screening
mammography.
16
Evidence



Screening biennially from ages 50 to 69 years
achieved a median 16.5% (range, 15% to 23%)
reduction in breast cancer deaths versus no
screening.
Biennial screening after age 69 years yielded some
additional mortality reduction in all models, but overdiagnosis increased most substantially at older ages.
There is a lack of primary data on the natural history
of breast cancer and an absence of screening trial
data for patients after age 74 years.
17
Evidence
Pooled RRs for Breast Cancer Mortality From
Mammography Screening Trials for All Ages
Age
#Trials RR for Breast
Cancer Mortality
(95% Crl)
NNI to Prevent 1
Breast Cancer
Related Death
39-49y 8
0.85 (0.75-0.96)
1904
50-59y 6
0.86 (0.75-0.99)
1339
60-69y 2
0.68 (0.54-0.87)
377
70-74y 1
1.12 (0.73-1.72)
Not available
18
Cost


Cost of mammogram:
$11.00
Cost of radiology read of mammogram:
$70.00
19
Bottom Line-Breast Cancer
Biennial breast cancer screening in
women between ages 50-74 reduces
mortality at reasonable costs for
women without clinically significant
comorbid conditions and with a life
expectancy of at least 5 years.
20
Cervical Cancer


16,000 new cases/year
Incidence of invasive cervical cancer in
US 2006-2008
– 14.2 per 100,000 Hispanic women
– 7.3 per 100,000 non-Hispanic women

Abnormal Pap smear rates
– 10.3% at age 18-28 years
– 0.8% at age > 65 years
21
Geriatric Considerations


25% of newly diagnosed cervical cancers
are in women >64yo who have never had
previous screening.
40% of cervical cancer deaths will occur in
women >64 years old.
22
How to screen
Pap (Papanicolaou) smear is the accepted
route of screening for cervical cancer.
Traditional
Thin Prep
23
USPSTF Recommendations
2003


Recommends against routinely screening
women older than age 65 for cervical
cancer if they have had adequate recent
screening with normal Pap smears and are
not otherwise at high risk for cervical
cancer.
Recommends against routine Pap smear
screening in women who have had a total
hysterectomy for benign disease.
24
What factors make a
woman high risk?

HIV infection

Immunosuppression

Diethylstilbestrol in utero exposure

History of cervical cancer

Onset of sexual activity before age 16

> 4 sexual partners in lifetime

History of sexually transmitted disease

< 3 normal Pap smears

No Pap smears within previous 7 years
25
Other Recommendations

American Geriatrics Society
– Regular Pap smear screening at 1 to 3 year
intervals should continue to age 70.

American Cancer Society
– Women age 70 or older may elect to stop
cervical cancer screening if they have had 3
consecutive satisfactory normal test results and
no abnormal pap smears in the prior 10 years.

American College of OB-GYN
– Recommends individualization based upon
annual assessment of risk factors and
26
examination.
Evidence

Systematic review of 12 cohort studies
– Risk of CIN III or cancer per 1,000 women
screened



2.3/1000 for first screen at age 50-64
1.7/1000 for first screen at age 65
<1/1000 for women >60yo with no prior abnormal
Pap smears
27
Cultural variability



Incidence rates for cervical cancer in
Vietnamese women are more than two
and a half times those for any other
racial or ethnic group.
The next highest rates occurred
among Hispanic women.
Cervical cancer mortality is 2.5 times
higher for African American women
than for Caucasian women.
28
Cost



Cost of Pap smear (Thin Prep):
$67.00
Cost of office visit to perform Pap smear:
$77.00
Extra cost if pathology read is necessary:
$60.00
29
Cost Effective?


In elderly women who were never
screened, annual Pap smear screening
would cost less than $6500 per year
of life saved.
In elderly women who have received
regular screening, annual Pap smear
screening would cost $33,572 per year
of life saved.
30
JAMA Vol. 259 No. 16, April 22, 1988
Medicare Reimbursement



Covers high risk women once every
12 months.
Covers low risk women once every
24 months.
20% copayment is required for test
collection, but no copay required for
lab fees.
31
Bottom Line-Cervical cancer
Women older than 65 years old who
have never had a Pap smear, should
be screened with annual Pap smears
for at least three consecutive years.
Women older than 65 who are at low
risk and have at least three previously
normal Pap smears may
stop screening.
32
Prostate Cancer




#1 non-dermatologic cancer in men
#2 in cancer deaths in men
30% of men > 50 have occult cancer
at autopsy.
18% of all new cancer in US
33
How to screen

Digital rectal exam
– May identify prostatic
nodules or occult
blood

Prostate specific
antigen (PSA)
– A glycoprotein that is
expressed by both
normal and neoplastic
prostate tissue
Are you ready for your prostate exam?
34
USPSTF Recommendations
2008


Recommends against routine
screening for prostate cancer in men
>75 years old.
Concludes that the current evidence is
insufficient to recommend for or
against routine screening in men
younger than 75 years old.
35
Other Recommendations

American College of Preventive Medicine
– Recommend against routine screening

International Union for Cancer Control
– Does not endorse universal screening

American Cancer Society
– PSA and DRE should be offered annually at age 50 and
older for men with a life expectancy at least 10 years.

American Urological Association
– “All men over 40 should speak with their doctors at the the time of
their annual physicals and develop a proactive prostate health
plan that is right for them based on their lifestyles and family
history.”
– Recommends getting a baseline PSA along with a DRE at age 40.
36
Evidence-DRE


DRE during previous 10 years
associated with reduced risk of prostate
cancer mortality (observational study).
If a prostate nodule was found in an
asymptomatic 65yo man, biopsy might
give an average patient 1.1 extra
months of life expectancy.
37
PSA Information

Recommendations are that PSA levels be
adjusted for age and race.
– PSA cutoff levels of normal for black men


Age 60-69 – PSA>4.5
Age 70-79 – PSA>5.5
– PSA cutoff levels of normal for white men


Age 50-79 – PSA>3.5
Also, PSA velocity >0.75/year suggests need
for prostate biopsy, but requires at least 3 PSA
tests 12-18 months apart all performed under
similar circumstances.
38
Overall evidence
Observational study comparing fixed cohorts from WA v
CT aged 65-79
Connecticut
Washington
 2.2% received PSA
 11.8% received PSA
 0.84% received biopsy
 1.85% received biopsy
 0.5% received radical
 2.7% received radical
prostatectomy
prostatectomy
 3.1% received radiation
 3.9% received
radiation
No differences between two groups in prostate specific mortality.
39
BMJ 2002;325:740
Why not to screen

Overdiagnosis of prostate cancer
– Computer simulated study showed significant
overdiagnosis rates:



29% in white men
44% in black men
Pain from diagnostic procedures
– 55% of men surveyed after prostate biopsy
found the procedure caused discomfort.
– 2% had pain persisting longer than 1 week.
40
Risks of Therapy

Radical prostatectomy
– Operative mortality in men >75yo = 1%
– Complications include urinary incontinence, sexual
dysfunction, and bowel problems.



20-70% have decreased sexual function
15-50% have urinary problems
External beam radiation
– 20-45% of men experience erectile dysfunction
– 2-16% of men experience urinary incontinence
– 6-25% of men experience bowel dysfunction
41

“The USPSTF found convincing
evidence that treatment for
prostate cancer detected by
screening causes moderate-tosubstantial harms, such as erectile
dysfunction, urinary incontinence,
bowel dysfunction, and death.”
42
Cost


Digital rectal exam
$30.00
PSA
$92.00
43
Medicare Reimbursement



Medicare will reimburse for annual
prostate screening for all men >50
years old, with both PSA and DRE.
Copay (20%) will apply for DRE.
Copay will not apply for PSA.
44
Bottom Line-Prostate Cancer
There is no evidence supporting that
screening men >65 years old with
either a PSA or a DRE decreases
mortality due to prostate cancer.
Screening should be discussed with men
with a life expectancy of 10 years or
more after careful education regarding
risks of treatment for prostate cancer
are explained.
45
Colorectal Cancer




#2 cause of non-dermatologic cancer
in US
#3 cause of cancer death in men and
women
Average age at diagnosis is 63.
5% lifetime risk of diagnosis.
46
How to Screen

Fecal occult blood test
yearly
– Set of 3 fecal occult
blood cards


Sigmoidoscopy every
5 years
Colonoscopy every 10 years
47
USPSTF Recommendation
2008


Recommends screening for individuals
between the ages of 50-75 yo.
Recommends against routine screening for
individuals between the ages of 75-85y.
– “There may be clinical considerations that
support colorectal screening in individuals in
this age group.”

Recommends against screening individuals
older than 85.
48
Evidence-FOBT

50 positive tests are obtained for every case of
colorectal cancer identified.

4 positive tests are obtained for every polyp found.

Cochrane review:
– 1,237 patients need to be screened with FOBT to prevent
1 colon cancer death.

NEJM trial using yearly or biyearly screening:
– 14.1 deaths per 1,000 in unscreened group
– 9.5 deaths per 1,000 in yearly screened group (NNT 217)
– 11.2 deaths per 1,000 in biyearly screened group (NNT 345)
49
Evidence-Sigmoidoscopy

65mm scope can reach 50% of colon cancers

Stats:
– 78% sensitivity (reports as low as 35% in women)
– 66%-82% specificity (reports as high as 95% in women)
– 19%-38% positive predictive value
– 96%-98.5% negative predictive value

In persons older than 80:
– 22% of men could only be examined to 50cm
– 32% of women could only be examined to 50cm

Persons older than 70 are at increased risk for
incomplete screening with sigmoidoscopy.
50
Evidence-Colonoscopy



No direct evidence that colonoscopy
prevents deaths from colorectal cancer.
Indirect evidence given that all screening
methods are compared to gold standard of
colonoscopy, and screening decreases risk.
Sensitivity and specificity difficult to
ascertain as colonoscopy is its own
reference standard.
51
Comparing colonoscopy
to sigmoidoscopy


Random controlled study screening first
with sigmoidoscopy, then colonoscopy
showed 1.6% of patients who had a
negative sigmoidoscopy had a proximal
advanced neoplasm.
It would be necessary to screen 64 patients
with colonoscopy rather than sigmoidoscopy
to find one additional person with an
advanced neoplasm.
52
Risks of screening

Perforation rate of colonoscopy:
– 0.03%-0.19%

Perforation rate of sigmoidoscopy:
– 0.004%-0.088%
53
Cost



Stool cards:
$21.00
Flexible sigmoidoscopy:
$176.00
Colonoscopy:
$950.00 physician’s fee
$750.00 facility fee
54
Medicare reimbursement


FOBT is fully reimbursed without copay.
Flexible sigmoidoscopy
– Covered once every four years

Colonoscopy
– Covered once every 10 years, but not within
48 months of a screening flexible
sigmoidoscopy.
55
Bottom Line-Colorectal Cancer
All persons between 50-75 years old
with a life expectancy of 5 years
should undergo routine screening for
colorectal cancer.
No clear evidence exists as to which
screening method is superior, so the
choice should be an individualized to
each patient, with his/her input.
56
Osteoporosis



Affects about 25 million in US
7% ambulatory postmenopausal women
> 50 years old have osteoporosis
The presence of osteoporosis was
associated with a four-fold increase in
fracture rate.
– vertebral fractures occur in 1/3 women >65
– hip fractures occur in 1/3 women >90

(10-15% mortality)
57
How to screen

Sahara scan
– Calcaneal ultrasound

DEXA scan
– dual energy
x-ray
absorbimetry
58
USPSTF Recommendations
2002

Women aged 65 and older should be
screened routinely for osteoporosis.
59
National Osteoporosis
Foundation Recommendations


Women >65 years old
Men >70 years old
– Regardless of clinical risk factors
60
Evidence

Comparison study with >3,000 women
who did or did not receive screening
DEXA scans and risk of hip fractures
– 4.8/1,000 fractures in those screened
– 8.2/1,000 fractures in those not screened
– NNT 56
61
Cost


Sahara screen
Free
DEXA scan
$150
62
Medicare Reimbursement


Medicare will pay for a screening
DEXA scan once every two years for
patients at risk of losing bone mass
(postmenopausal females).
Will not pay for DEXA scans for men
for routine screening.
– Will pay with other risk factors.
63
Bottom Line-Osteoporosis
While few studies exist showing direct benefits
of screening for osteoporosis, fracture cost is
an enormous source of financial burden and
mortality among the elderly.
All women over 65 should be screened at least
once every five years for osteoporosis.
Screening should not be stopped based on
patient age, as lifetime risk of fractures
increases with age.
64
Abdominal Aortic Aneurysm


Prevalence rates vary from 2-9%
Annual death rates from ruptured AAA
– 1.2% males > 65
– 0.6% females > 65


80-94% overall mortality rate from rupture
It has been estimated that the excess
prevalence associated with smoking accounts
for 75% of all aneurysms that are >4.0 cm
in diameter.
65
How to screen


Retroperitoneal
ultrasound
Palpation
66
USPSTF Recommendation
2005



Recommends one time screening for
AAA by ultrasound in men aged 65-75
who have ever smoked.
Makes no recommendation for or
against screening for AAA in men 65-75
who have never smoked.
Recommends against routine screening
for AAA in women.
67
Evidence re: palpation

Using ultrasound as the gold standard
– sensitivity – 50%
– specificity – 91%
– positive predictive value – 35%

Sensitivity varies with patient’s BMI:
– AAA were missed in 50% of patients <70yo
with a BMI greater than 24.
68
More Evidence




Prevalence of population with risk factors
(tobacco use) was 9%.
Expected gain in life expectancy from
screening using a combination of abdominal
palpation + ultrasound was 5.4 years.
Four randomized trials of one-time screening
using rupture as an end point noted
reductions in aneurysm-related mortality of
21%-68% with screening.
Re-screening men with negative initial screen
not useful at 4 years.
69
Why screen?


Mortality rates of elective surgical
repair of AAA are 4%-6%.
Mortality rates of emergency surgical
repair after rupture are 37%.
70
Cost


Retroperitoneal ultrasound:
$270
Radiology read of retroperitoneal U/S:
$146
71
Medicare Reimbursement

Medicare will pay for one time
screening U/S for those at risk
– Family history of AAA
– Men aged 65-75 yo with a history of
tobacco use


>100 cigarettes in a life-time
Must be ordered as part of the
Welcome to Medicare physical
– Order must be obtained within 12 months
of enrollment in Medicare Part B.
72
Bottom Line-AAA
Screening has been shown to be cost effective
in men aged 65-75 with risk factors
(HTN, CAD, history of tobacco use),
there is good evidence to support long term
(10 year) cost-effectiveness of screening
all men older than 65.
73
Diabetes





Estimated 6-8% US adults have diabetes.
Estimated lifetime risk of diabetes for persons
born in US in 2000 is 32.8% for males and
38.5% for females.
Incidence of diabetes declines with old age.
Diabetes is fourth most common diagnosis made
during family physician visits.
DMII caused 69,301 deaths in United States
in 2000
– death rate 25.2 per 100,000 population
74
How to screen



Fasting blood glucose
2 hour post-prandial glucose
Glycosylated
hemoglobin
75
USPTSF Recommendation
2008


Recommends screening individuals
who have a sustained BP (treated or
untreated) >135/80.
Current evidence is insufficient to
assess the risks v benefits in screening
those with BP less than 135/80.
76
Evidence-FBS


The sensitivity and specificity of the
fasting blood glucose as a screening test
vary according to the population tested
and the threshold used to define
diabetes.
Among people ages 40 to 74:
– Specificity of a FBS >140 = 91%
– Sensitivity of a FBS >126 = 50%
– Sensitivity and specificity decrease for
persons >65yo.
77
Evidence-HgbA1C

Of patients with HgbA1C>7%
– 89.1% had diabetes
– 7.1% had impaired glucose tolerance


More convenient and cost-effective
than oral glucose challenge testing.
No studies comparing to FBS.
78
Evidence-Post-prandial glucose

Post-prandial glucose >200 correlates
with increased risk of diabetic
retinopathy.
– 15% v 2%

More sensitive than fasting glucose for
early diabetes mellitus.
79
Evidence




No evidence exists that supports universal
screening.
Prevalence of diabetes in otherwise low-risk
population was 0.2%.
Research on cost-effect suggests targeted
screening to those with hypertension between
55-75yo.
Early detection of diabetes has not been
shown in any study to improve long-term
outcomes.
80
Cost

Fasting blood glucose:
$22.00

Glycosylated hemoglobin:
$66.00
81
Medicare Reimbursement


No Medicare reimbursement for
screening general population over 65
for diabetes.
Does pay for screening in those with
HTN, hyperlipidemia, obesity, history
of high blood sugar.
– Up to twice yearly

Reimbursement does exist for
diabetes self-management training.
82
Bottom Line-Diabetes
No evidence exists for screening the general
population over 65 years old for diabetes.
It has been found minimally cost-effective to
screen patients with hypertension between
65-75yo.
Early detection of diabetes does not seem to
decrease future risk of diabetic complications.
83
Hyperlipidemia



Prevalence of dyslipidemia is approximately
40-48% in the general population.
Progressive elevation in total cholesterol
levels with aging.
It has been estimated that 40% or more of
those above age 65 meet the National
Cholesterol Education Program guidelines
for treating hypercholesterolemia.
84
How to screen


Fasting lipid profile
Total
cholesterol
85
USPSTF Recommendation

Recommends that clinicians routinely
screen men aged 35 years and older
and women aged 45 years and older for
lipid disorders and treat abnormal lipids
in people who are at increased risk of
coronary heart disease.
– Screening should include measurement of
total cholesterol and high-density
lipoprotein cholesterol (HDL).
86
Evidence

Relationship between lipid levels and CAD
is weak and controversial in older adults.
– Relative risk between lipids and CAD declines
with age.

LOW cholesterol associated with
increased mortality in elderly.
– Sign of poor nutritional status.
87
Evidence from AGS

American Geriatrics Society study (2004)
– Enrolled 5,000 patients >65yo (men and women)
– None of lipid measures were associated with
total mortality.
– Total and LDL levels were very weakly related to
stroke and MI risk.
– Total and LDL levels do not improve risk prediction
in older adults.
– Low HDL associated with greater risk of
CAD mortality.
– High HDL associated with lower risk of
88
ischemic stroke.
Cost

Total cholesterol:
$17.00

Fasting lipid profile:
$72.00
– If TG >200, automatic direct LDL is run =
$53 more
89
Medicare Reimbursement

Medicare will pay for screening q5years.
– Total cholesterol
– HDL
– Triglyceride level

No copay exists for patients.
90
Bottom Line-Cholesterol
No evidence exists supporting general
screening for hypercholesterolemia in
persons >65yo with no known history
of CAD.
Treating low-risk patients who qualify
for hypercholesterolemia therapy has
not been shown to have effects on
morbidity or mortality.
91
Immunizations

Centers for Disease Control (CDC)
comparing vaccinations in elderly
adults in 1989 and 2003:
– pneumococcal vaccine:
15% to 64%
– annual influenza:
33% to 70%
92
What to give (per CDC)

Influenza vaccine:
– One dose annually to all those >65yo

Pneumococcal vaccine:
– One dose over lifetime
– Dose should be 5 years from administration of last dose if
patient received vaccination at <64yo.

Tetanus booster:
– One dose booster every 10 years.

Tetanus immunization series:

– Once to all patients >65yo who have never been immunized.
Zoster vaccine:
– One dose to all those >60yo
93
Evidence-Flu vaccine


90% of influenza related deaths are in patients >60yo
2005 cohort study: Among residents of long term care facilities,
vaccines well-matched for the circulating influenza viruses were
not effective against influenza (relative risk [RR] 1.04).
– Vaccines were associated with significant 54 to 58 percent
reductions in pneumonia, hospital admission, and death from
influenza or pneumonia

A similar conclusion was reached for elderly patients living in the
community
– Vaccine did not reduce the rate of pneumonia in this population

A separate pooled cohort study demonstrated a small but
significant reduction in mortality in vaccinated elderly individuals
(1.0 versus 1.6 percent in unvaccinated individuals)
94
Evidence-Pneumovax

2008 Cochrane meta-analysis of randomized control
trials vaccinating elderly in developed countries
– Strong evidence of efficacy against invasive pneumococal
disease

Bacteremia or meningitis
– Inconclusive evidence regarding prevention of PNA
– No reductions in all-cause mortality

In a subsequent study of 3415 patients with CAP
requiring hospitalization:
– Individuals who received pneumococcal vaccine had a 40
percent lower rate of mortality or ICU admission compared
with those who had not been vaccinated.
95
Evidence-Tetanus booster

In USA, tetanus primarily affects the
elderly.
– 35% of 127 cases of tetanus in 1995-1997
occurred in patients >60yo.
– Chronic wounds were noted in 15% of
cases of tetanus reported to CDC (decub
ulcers, leg ulcers).

Only 27.8% of those >70yo have
antibodies to tetanus.
96
Evidence-Zostavax

Shingles Prevention Study
– Double-blind randomized, placebo-controlled
study involving 38,546 participants

Zoster vaccine reduced:
–
–
–
–
–
Incidence of zoster by 51.3%
Incidence of post-herpetic neuralgia by 66.5%
Shortened course of PHN
Reduced severity of zoster by 57%
Reduced the degree of interference with ADLs
97
Efficacy of Zostavax

Efficacy decreases with increasing age.
– Efficacy highest among patients 60-69yo
– Efficacy of vaccine reduced to 18% in those
>80yo.


Vaccine retains efficacy against the severity of
zoster better than zoster itself in all age
groups.
CDC recommends one-time administration in all
those >60yo
– Regardless of age
98
– Regardless of prior history of zoster or varicella
Cost

Cost to administer any vaccine:
$13.00

Flu vaccine:
$25.50

Pneumococcal pneumonia vaccine:
$56.60


Tetanus booster:
$28.25
Zoster vaccine:
$193
99
Medicare Reimbursement



Flu shots: one per year
Pneumococcal pneumonia: once per
lifetime.
Tetanus: no reimbursement as primary
prevention
– There must be an acute injury.

Zostavax: reimbursed under Medicare
D (prescription drug plan) - varies
with individual plans
100
What Not to Screen For:










Alzheimer’s disease
Asymptomatic bacteriuria
Bladder cancer
Carotid artery stenosis
Coronary artery disease
Depression (when staff-assisted depression care
supports are not in place)
Lung cancer
Ovarian cancer
Skin cancer
101
Visual acuity
102
References










US Preventative Services Task Force. Recommendations for Screening. Available at
http://www.ahrq.gov/clinic
Van Dijck, Holland, et al. Efficacy of Mammographic Screening of the Elderly: a Case-Referent Study in the
Nijmegen Program in The Netherlands. Journal of the National Cancer Institute. 1994. 86(12):934-938.
Lucus FL, Cauley JA, et al. Bone Mineral Density and Risk of Breast Cancer. American Journal of
Epidemiology 1998. 148 (1): 22-29.
Ostbye T, Greenburg GN, et al. Screening Mammography and Pap Tests Among Older American Women
1996–2000: Results from the Health and Retirement Study (HRS) and Asset and Health Dynamics Among
the Oldest Old (AHEAD). Annals of Fam Med 2003. 1:209-17.
Fahs MC, Mandelblatt J, et al. Cost Effectiveness of Cervical Cancer Screening in the Elderly. Ann of Int
Med 1992. 117(6): 520-7.
Screening for Cervical Cancer. AHRQ Systematic Evidence Review 2002 Jan:25.
Mandelblatt JS, Fahs MC. The cost-effectiveness of cervical cancer screening fro low-income elderly
women. JAMA 1988. Vol. 259 No. 16.
Dynamed. Prostate Cancer Screening. Available at
https://access.lancastergeneral.org/Detail.aspx,DanaInfo=dynamed102.epnet.com.
Lu-Yao G, Albertsen PC, Stanford JL, et al. Natural experiment examining impact of aggressive screening
and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut. BMJ
103
2002;325:740.
J Am Geriatr Soc 2001 May;49(5):655
References Continued

AHRQ Systematic Evidence Review 2002 Jan:25

Dynamed. Osteoporosis Screening.

Dynamed. Colorectal Cancer Screening.

Dynamed. Abdominal Aortic Aneurysm Screening.



Ortqvist A, Hedlund J, et al. Randomised trial of 23-valent pneumococcal capsular polysaccharide
vaccine in prevention of pneumonia in middle-aged and elderly people. Lancet. 1998 Feb
7;351(9100):399-403.
Arun S. Karlamangla, PhD, MD; Burton H. Singer, PhD; David B. Reuben, MD; Teresa E. Seeman, PhD.
Increases in Serum Non-High-Density Lipoprotein Cholesterol May Be Beneficial in Some HighFunctioning Older Adults. J Am Geri Soc 2004. 52 (9), 1442–1448.
Center for Disease Control. Recommendations for Vaccination. Available at http://www.cdc.gov/nip/.
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