HEALTH MAINTENANCE AND DISEASE PREVENTION
IN GERIATRICS
RICHARD E. FREEMAN MD MPH
2012
PREVENTIVE MEDICINE IN PRACTICE
• The aim of medicine is to prevent disease
and prolong life, the ideal of medicine is to
eliminate the need of a physician.
»William J. Mayo, M.D.
PREVENTION----What is what???
• PRIMARY PREVENTION –
– the prevention of disease from occurring at all - its total
avoidance.
• SECONDARY PREVENTION –
– the interruption of the disease process by slowing or
stopping its progression at any point in its course after
onset.
• TERTIARY PREVENTION– the rehabilitation and return of a diseased or injured patient
to a status of maximum usefulness with a minimum risk of
recurrence of a physical or mental disorder.
SCREENING
• –tests or procedures that can be
performed economically and rapidly
intended to identify unrecognized disease
or risk thereof.
Common Chronic Conditions
(ages 75 and older)
Men
•
•
•
•
•
Hearing Impairment
Heart Condition
Arthritis
Hypertension
Cataracts
Women
•
•
•
•
•
Arthritis
Hypertension
Heart Condition
Hearing Impairment
Cataracts
Deaths by Age and Leading
Cause
– Ages 45- 64
•
•
•
•
•
Cancer
Heart Disease
Stroke
Accidents
COPD
Ages 65 and Older
•
•
•
•
•
Heart Disease
Cancer
Stroke
COPD
Pneumonia/influenza
The Numbers
• In 2005 - persons 65
and older
• In 2005 - a person
reaching the age of 65
had an average life
– numbered 37 million or 12
% of the U.S. population
expectancy of an
– since 1900 this
additional 18.7 years
percentage has more
than triple
– www.livingto100.com
• A child born in 2005
could expect to live
77.8 years (30.5 years
longer than a child
born in 1900)
PRIMARY PREVENTION
IMMUNIZATIONS
INFLUENZA
• Trivalent inactivated influenza vaccine (TIV)
– Give IM or ID (intradermally)
• Live attenuated influenza vaccine (LAIV)
– Give intranasally
INFLUENZA- WHO
• • Vaccination is recommended for all adults.
– (This includes healthy adults ages 19–49yrs without risk factors.)
– • LAIV is approved only for healthy nonpregnant people
• 2–49yrs. • Adults age 18 through 64yrs may be given any
intramuscular TIVproduct or, alternatively, the intradermal TIV
product (FluzoneIntradermal).
• Adults ages 65yrs and older may be given standard-dose TIV or,
• alternatively, the high-dose TIV (Fluzone High-Dose).
– Note: LAIV may not be given to some adults; see contraindications and
precautions
www.immunize.org/catg.d/ p2010.pdf
INFLUENZA-WHEN
• • Give 1 dose every year in the fall or winter.
Begin vaccination services as soon as
• vaccine is available and continue until the
• supply is depleted.
• Continue to give vaccine to unvaccinated
• adults throughout the influenza season (including when
influenza activity is present in the community) and at
other times when the risk of influenza exists.
INFLUENZA• CONTRAINDICATIONS
• •Previous anaphylactic reaction to this vaccine, to any of its
components, including egg protein.
• For LAIV only: pregnancy; chronic pulmonary (including asthma),
cardiovascular (except hypertension), renal, hepatic,
neurological/neuromuscular, hematologic, or metabolic (including
diabetes) disorders; immunosuppression (including that caused by
medications or HIV).
• PRECAUTIONS
• Moderate or severe acute illness.
• History of Guillain-Barré syndrome (GBS) within 6wks following
previous influenza vaccination.
• For LAIV only: receipt of specific antivirals (i.e., amantadine,
• rimantadine, zanamivir, or oseltamivir) 48hrs before vaccination.
Avoid use of these antiviral drugs for 14d after vaccination.
PNEUMOCCOCAL
(PNEUMOVAX)- WHO
•
•
•
• People age 65yrs and older.
• People younger than age 65yrs who have chronic illness or other risk
factors:
– including chronic cardiac or pulmonary disease (including asthma),
chronic liver disease, alcoholism, diabetes, CSF leaks, cigarette
smoking, as well as candidates for or recipients of cochlear implants
and people living in special environments or social settings (including
American Indian/Alaska Natives age 50 through 64yrs if recommended
by local public health authorities).
Those at highest risk of fatal pneumococcal infection, including people who:
– Have anatomic or functional asplenia, including sickle cell disease.
– Have an immunocompromising condition, including HIV infection,
leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized
malignancy, chronic renal failure, or nephrotic syndrome.
– Are receiving immunosuppressive chemotherapy (including
corticosteroids).
– Have received an organ or bone marrow transplant.
PNEUMOCCOCAL
(PNEUMOVAX)-HOW
• Give 1 dose if unvaccinated or if previous vaccination
history is unknown.
• Give a 1-time revaccination to people - Age 65yrs and
older if 1st dose was given prior to age 65yrs and 5yrs
have elapsed since dose #1.
•
• Age 19 through 64yrs who are at highest risk of fatal
pneumococcal infection or rapid antibody loss and 5yrs
have elapsed since dose #1
PNEUMOCCOCAL
(PNEUMOVAX)• Contraindication
• Previous anaphylactic reaction to this
vaccine or to any of its components.
•
• Precaution
• Moderate or severe acute illness
HERPES VARICELLAZOSTER (ZOS)
GIVEN SC
•People age 60yrs and older.
•Give 1-time dose if unvaccinated,
regardless of previous history of herpes
zoster (shingles) or chickenpox.
•• If 2 or more of the following live virus vaccines are to be given
•—MMR, Zos, and/or yellow fever—they should be given on the same day.
•If they are not, space them by at least 28
HERPES VARICELLAZOSTER (ZOS)
• Contraindications
• • Previous anaphylactic reaction to any component of zoster
vaccine.
• • Primary cellular or acquired immunodeficiency.
• • Pregnancy.
• Precautions
• • Moderate or severe acute illness.
• • Receipt of specific antivirals (i.e., acyclovir, famciclovir, or
• valacyclovir) 24hrs before vaccination, if possible:
–
delay resumption of these antiviral drugs for 14d after vaccination
.
TD, TDAP
• (Tetanus, diphtheria, pertussis)
• Give IM
• Using tetanus toxoid (TT) instead
of Tdap or Td is not recommended
TD, TDAP---WHO
• All people who lack written documentation of a primary series
• consisting of at least 3 doses of tetanus- and diphtheria-toxoid• containing vaccine.
• A booster dose of Td or Tdap may be needed for wound
management, so consult ACIP recommendations.*
•
•
• In pregnancy, when indicated, give Td or Tdap in late 2nd or 3rd
trimester. Tdap is preferred because protective antibodies to per- tussis are provided to the fetus. If not
administered during preg- nancy, give Tdap in immediate postpartum period.
• For Tdap only:
• Adults younger than age 65yrs who have not already received Tdap.
• Adults of any age, including adults age 65yrs and older, in contact
with infants younger than age 12m (e.g., parents, grandparents,
childcare providers) who have not received a dose of Tdap should
be prioritized for vaccination.
Healthcare personnel of all ages.
• • Adults age 65yrs and older without a risk indicator (e.g., not in
contact with an infant) may also be vaccinated with Tdap.
TD, TDAP• For people who are unvaccinated or
behind:
– complete the primary Td series (spaced at 0,
1–2m, 6–12m intervals); substitute a one-time
dose of Tdap for one of the doses in the
series, preferably the first.
• Give Td booster every 10yrs after the
primary series has been completed.
• Tdap should be given regardless of
interval since previous Td
TD, TDAP
• Contraindications
•
•
• Previous anaphylactic reaction to this vaccine or to any of its components.
• For Tdap only, history of encephalopathy not attributable to an identifiable
cause, within 7d following DTP/DTaP.
• Precautions
•
• Moderate or severe acute illness. • Guillain-Barré syndrome within 6wks
following previous dose of tetanus-toxoid-containing vaccine.
• For Tdap only, progressive or unstable neurologic disorder, uncontrolled
seizures, or progressive neuropathy until a treatment regimen has
been established and the condition has stabilized.
• • History of arthus reaction following a prior dose of tetanus- or diphtheria
toxoid-containing vaccine;
• defer vaccination until at least 10yrs have elapsed since the last tetanus
toxoid-containing vaccine
HEPATITIS B
• All adults who want to be protected from
hepatitis B virus infection and lack a specific risk
factor.
•
•
•
•
•
•
•
•
•
Household contacts and sex partners of HBsAg-positive people;
injecting drug users;
sexually active people not in a long-term, mutually monogamous relationship;
men who have sex with men;
people with HIV;
people seeking STD evaluation or treatment;
hemodialysis patients and those with renal disease that may result in dialysis;
diabetics younger than age 60yrs (diabetics age 60yrs and older may be vaccinated
at the clinician’s discretion [see ACIP recommendations*]); healthcare personnel and
public safety workers who are exposed to blood; clients and staff of institutions for the
developmentally disabled;
inmates of long-term correctional facilities; certain international travelers; and people
with chronic liver disease
HEPATITIS B
• Give 3 doses on a 0, 1, 6m schedule.
• • Alternative timing options for vaccination include:
• 0, 2, 4m; 0, 1, 4m; and 0,1, 2, 12m (Engerix brand only). •
– There must be at least 4wks betweendoses #1 and #2, and at least
8wks between doses #2 and #3.
– Overall, there must be at least 16wks between doses #1 and #3.
• •
• Schedule for those who have fallen behind:
–
If the series is delayed between doses, DO NOT start the series over. Continue
from where you left off.
HEPATITIS B
• Contraindication
• Previous anaphylactic reaction to this
vaccine or to any of its components.
• Precaution
• Moderate or severe acute illness
PREVENTATIVE CARE
HEART
PREVENTIVE CARE: CARDIOVASCULAR DISEASE
• the leading cause of death in the US is
coronary heart disease
• every year 2.5% of men and 1.9% of
women age 65 and older die from CHD
• hypertension in the single greatest risk
factor for CHD, particularly in older
women
• screening
– blood pressure annually
– cholesterol
HEART DISEASE SCREENING
• USPSTF:
• recommends AGAINST routine screening with resting
electrocardiography (ECG), exercise treadmill test (ETT), or
electron-beam computerized tomography (EBCT) scanning for
coronary calcium for either the presence of severe coronary
artery stenosis (CAS) or the prediction of coronary heart
disease (CHD) events in adults at low risk for CHD
events. Grade: D Recommendation.
• USPSTF:
• found INSUFFICIENT EVIDENCE to recommend for or against
routine screening with ECG, ETT, or EBCT scanning for
coronary calcium for either the presence of severe CAS or the
prediction of CHD events in adults at increased risk for CHD
events. Grade: I Statement.
HEART RISK FACTORSNONTRADITIONAL
•
•
•
•
USPSTF:
concludes that the evidence is insufficient to assess the balance of
benefits and harms of using the nontraditional risk factors discussed
in this statement to screen asymptomatic men and women with no
history of CHD to prevent CHD events
Grade: I Statement.
The nontraditional risk factors included in this recommendation are
high-sensitivity C-reactive protein (hs-CRP),
–
–
–
–
–
–
–
•
ankle-brachial index (ABI),
leukocyte count,
fasting blood glucose level,
periodontal disease,
carotid intima-media thickness (carotid IMT),
coronary artery calcification (CAC) score on electron-beam computed tomography
Homocystein level
.
and lipoprotein(a) level
Screening for Abdominal Aortic
Aneurysm
• USPSTF:
• recommends one-time screening for abdominal aortic
aneurysm (AAA) by ultrasonography in men aged 65 to
75 who have ever smoked. Grade: B Recommendation.
• USPSTF :
• no recommendation for or against screening for AAA in
men aged 65 to 75 who have never smoked.
• USPTSF:
• recommends against routine screening for AAA in
women
• Grade: C Recommendation.
ASPIRIN FOR THE PREVENTION OF
CARDIOVASCULAR DISEASE
• USPSTF:
•
recommends the use of aspirin for men age 45 to 79
years when the potential benefit due to a reduction in
myocardial infarctions outweighs the potential harm due
to an increase in gastrointestinal hemorrhage. Grade: A
Recommendation.
• USPSTF:
• recommends the use of aspirin for women age 55 to 79
years when the potential benefit of a reduction in
ischemic strokes outweighs the potential harm due to an
increase in gastrointestinal hemorrhage. Grade: A
Recommendation.
ASPIRIN FOR THE PREVENTION OF
CARDIOVASCULAR DISEASE
• USPSTF:
• concludes that the current evidence is insufficient to
assess the balance of benefits and harms of aspirin for
cardiovascular disease prevention in men and women 80
years or older. Grade: I Statement.
• USPSTF:
• recommends against the use of aspirin for stroke
prevention in women younger than 55 years and for
myocardial infarction prevention in men younger than 45
years. Grade: D Recommendation.
ASPIRIN FOR THE PREVENTION OF
CARDIOVASCULAR DISEASE
• USPSTF:
• concludes that the current evidence is insufficient to
assess the balance of benefits and harms of aspirin for
cardiovascular disease prevention in men and women 80
years or older. Grade: I Statement.
• USPSTF:
• recommends against the use of aspirin for stroke
prevention in women younger than 55 years and for
myocardial infarction prevention in men younger than 45
years. Grade: D Recommendation.
LIPID SCREENING
• SCREENING MEN
• The U.S. Preventive Services Task Force (USPSTF)
strongly recommends screening men aged 35 and
older for lipid disorders. Grade: A Recommendation.
• The USPSTF recommends screening men aged 20 to
35 for lipid disorders if they are at increased risk for
coronary heart disease. Grade: B Recommendation.
LIPID SCREENING- WOMEN
SCREENING WOMEN AT INCREASED RISK
USPSTF
strongly recommends screening women aged
45 and older for lipid disorders if they are at
increased risk for coronary heart
disease. Grade: A Recommendation.
USPSTF:
recommends screening women aged 20 to 45
for lipid disorders if they are at increased risk
for coronary heart disease. Grade: B
Recommendation.
HYPERTENSION
• USPSTF:
•
recommends screening for high blood pressure in adults aged 18
and older.
• Office measurement of blood pressure is most commonly done with
a sphygmomanometer.
•
• Defined in adults as a systolic blood pressure of 140 mmHg or
higher, or a diastolic blood pressure of 90 mmHg or higher.
• Because of the variability in individual blood pressure
measurements,
– it is recommended that hypertension be diagnosed only after 2
or more elevated readings are obtained on at least 2 visits over a
period of 1 to several weeks
– http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm
VASCULAR DISEASE SCREENING
• Cerebrovascular disease is the 3rd leading cause of
deaths in the US
• at least 87% of stroke related mortality occurs in
persons 65 and older
• peripheral vascular disease affects 12-15% of
patients over 50
CAROTID ARTERY STENOSIS
• USPSTF:
• recommends against screening for
asymptomatic carotid artery stenosis
(CAS) in the general adult population
– This recommendation applies to adults without neurological
signs or symptoms, including a history of transient ischemic
attacks or stroke. If otherwise eligible, an individual who has a
carotid-area transient ischemic attack should be evaluated
promptly for consideration of carotid endarterectomy.
– may benefit patients who have a very high
risk for stroke;
• major risk factors for CAS include older age, male
sex, hypertension, smoking, hypercholesterolemia,
and heart disease
PERIPHERAL VASCULAR DISEASE
• USPSTF
• recommends against routine screening for
peripheral arterial disease (PAD).
•
The ankle brachial index, a ratio of Doppler-recorded systolic pressures in the lower
and upper extremities, is a simple and accurate noninvasive test for the screening
and diagnosis of PAD. The ankle brachial index has demonstrated better accuracy
than other methods of screening, including history-taking, questionnaires, and
palpation of peripheral pulses. An ankle-brachial index value of less than 0.90 (95%
sensitive and specific for angiographic PAD) is strongly associated with limitations in
lower extremity functioning and physical activity tolerance
• STRONGLY encourage:
• Lipid lowering, smoking cessation, HTN
control, Exercise
PREVENTATIVE CARE
MISCELLANEOUS
VISION SCREENING
USPSTF
concludes that the current evidence is insufficient to
assess the balance of benefits and harms of screening for visual
acuity for the elderly
The American Academy of Ophthalmology
–
recommends comprehensive eye examinations every 1 to 2 years for persons 65 years or older who have
no risk factors. This recommendation is based on descriptive studies, case reports, and expert consensus.
The American Optometric Association Consensus
Panel on Comprehensive Adult Eye and Vision
Examination:
– recommends annual eye examinations for adults 61 years or
older.
•
The American Academy of Family Physicians'
recommendation is currently under reconsideration.
The American College of Obstetricians and
Gynecologists
– recommends evaluation and counseling about visual acuity
HEARING SCREENING
• RATIONAL:
– An objective hearing loss can be identified in over 33% of persons aged 65 years
and older and in up to half of patients ages 85 years and older.
•
Older persons with hearing impairment are particularly prone to
suffering the associated social and emotional disabilities
USPSTF:
– As usual can not make up their mind
• Institute of Medicine:
– recommended audiometric testing once each during
ages 40-59, 60-74, and 75 and over
• AAFP:
– recommends evaluation of hearing in
persons aged 65 years and older, and hearing
aids for patients found to have hearing deficits
SCREENING for SENSORY IMPAIRMENT
• visual acuity and tonometry annually
• otoscopic examination and hearing
test annually
HRT IN WOMEN
• USPSTF:
• recommends against the routine use of
combined estrogen and progestin for the
prevention of chronic conditions in
postmenopausal women. Grade: D
Recommendation.
• USPSTF:
• recommends against the routine use of
unopposed estrogen for the prevention of
chronic conditions in postmenopausal
women who have had a hysterectomy.
Grade: D Recommendation.
OSTEOPOROSIS
Risk Factors
• LOWER BODY WEIGHT (WEIGHT < 70
KG ) IS THE SINGLE BEST PREDICTOR
OF FUTURE OSTEOPOROSIS
• smoking, weight loss, family history,
decreased physical activity, alcohol or
caffeine use, or low calcium and vitamin D
intake)
OSTEOPOROSIS
• USPSTF
– recommends that women aged 65 and older be screened
routinely for osteoporosis.
– bone density measured at the femoral neck by dual-energy x-ray
absorptiometry (DXA) is the best predictor of hip fracture
• USPSTF
– recommends that routine screening begin at age 60 for women
at increased risk for osteoporotic fractures Grade: B
Recommendation.
– makes no recommendation for or against routine osteoporosis
screening in postmenopausal women who are younger than 60
or in women aged 60-64 who are not at increased risk for
osteoporotic fractures.
•
–
COPD SCREENING
• USPSTF:
• recommends against screening adults for
chronic obstructive pulmonary disease
(COPD) using spirometry. Grade: D
Recommendation.
PREVENTATIVE CARE
CANCER
PREVENTIVE CARE: CANCER
• Aging is generally associated with an
increase in the risk of cancer and
reduction in the frequency of routine
screening.
• Late stage diagnosis and the presence of
metastatic disease at presentation have
been associated with advanced age
COLORECTAL CANCER SCREENING – Risk Factors
• Age older than 50 years; Each year higher
• Personal history of CRC or of ovarian,
breast, or endometrial cancers;
• IBD:ulcerative colitis or Crohn's disease;
• first-degree family member with CRC; and
• certain hereditary conditions (eg, familial
adenomatous polyposis or hereditary
nonpolyposis colon cancer)
COLORECTAL CANCER SCREENING – Prevention
• high doses of folic acid;
• increased physical activity;
• colon polyp removal;
• possibly, a high-fiber diet (that contains generous
amounts of fruits and vegetables and is rich in calcium
and vitamins D and E
• possibly, the use of nonsteroidal antiinflammatory drugs. (high risk only)
– (USPSTF) recommends against the routine use of aspirin and
nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent
colorectal cancer in individuals at average risk for colorectal
cancer.
COLORECTAL CANCER SCREENING
• home fecal occult blood testing (FOBT) &
DIGITAL RECTAL EXAM
• PLUS
• Colonoscopy OR
• Double-contrast barium enema. & flexible
sigmoidoscopy
COLON RECTAL SCREENING
•
•
•
•
•
•
•
•
USPSTF
recommends screening for colorectal cancer using fecal occult blood
testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years
and continuing until age 75 years. The risks and benefits of these screening
methods may vary. Grade: A Recommendation.
USPSTF:
recommends against routine screening for colorectal cancer in adults 76 to
85 years of age. There may be considerations that support colorectal
cancer screening in an individual patient. Grade: C Recommendation.
USPSTF:
recommends against screening for colorectal cancer in adults older than
age 85 years. Grade: D Recommendation.
USPSTF:
concludes that the evidence is insufficient to assess the benefits and harms
of computed tomographic colonography and fecal DNA testing as screening
modalities of colorectal cancer.
COLON RECTAL CANCER
SCREENING
• Sensitivity:
• Hemoccult II < fecal immunochemical
tests ≤ Hemoccult SENSA ≈ flexible
sigmoidoscopy < colonoscopy
• Specificity:
• Hemoccult SENSA < fecal
immunochemical tests ≈ Hemoccult II <
flexible sigmoidoscopy = colonoscopy
Colonoscopy
BREAST CANCER SCREENING- Risk Factors
• COMBINATION HORMONE (ESTROGEN/PROGESTIN)
REPLACEMENT THERAPY;
• BREAST EXPOSURE TO IONIZING RADIATION (HIGHEST
RISK OCCURS BEFORE PUBERTY);
• OBESITY AFTER MENOPAUSE;
• ALCOHOL INGESTION (DOSE-DEPENDENT);
• OLDER AGE;
• EARLY MENARCHE;
• IN MEN, HIGH LEVELS OF ESTROGEN EXPOSURE (EG,
WITH CIRRHOSIS OR KLINEFELTER'S SYNDROME);
• FAMILY HISTORY OF BREAST CANCER;
• GENETIC BREAST CANCER SUSCEPTIBILITY (HAVING
BRCA1 OR BRCA2 MUTATIONS);
• PERSONAL HISTORY OF BREAST CANCER OR BENIGN
BREAST DISEASE; AND
• WHITE RACE.
BREAST CANCER SCREENING- Prevention
• prophylactic bilateral mastectomy for women with a
strong family history of breast cancer;
• prophylactic oophorectomy for women with BRCA gene
mutations;
• participating in strenuous exercise for >4 hours/week;
•
• postmenopausal therapy with selective estrogen
receptor modulators (eg, tamoxifen or raloxifene) for
women at increased risk of breast cancer
(recommendation varies by degree of risk, age, and
comorbid conditions);
• postmenopausal therapy with aromatase inhibitors (eg,
anastrozole) for women with a history of breast cancer
(recommendation varies by age and comorbid
conditions).
BREAST CANCER SCREENING• USPSTF
• recommends biennial screening mammography for women
aged 50 to 74 years. Grade: B Recommendation.
– The decision to start regular, biennial screening mammography
before the age of 50 years should be an individual one and take
patient context into account, including the patient's values regarding
specific benefits and harms. Grade: C Recommendation.
• USPSTF:
• concludes that the current evidence is insufficient to
assess the additional benefits and harms of screening
mammography in women 75 years or older. Grade: I
Statement.
•
BREAST CANCER
SCREENING
• USPSTF:
• recommends against teaching breast self-examination
(BSE). Grade: D Recommendation.
• USPSTF:
– concludes that the current evidence is insufficient to assess the
additional benefits and harms of clinical breast examination
(CBE) beyond screening mammography in women 40 years or
older. Grade: I Statement.
• USPSTF
– concludes that the current evidence is insufficient to assess the
additional benefits and harms of either digital mammography or
magnetic resonance imaging (MRI) instead of film
mammography as screening modalities for breast cancer
Breast Cancer
CERVICAL CANCER SCREENING
• approximately 40% of new cases of invasive cervical
cancer occur in women over the age of 65
• reportedly 17% of women and 32% of poor women in
this age group have never had a PAP Smear
• Screening
– At least once every 3 years.
– Age 65-70 – had 3 normal PAPS and no
abnormal in past 10 years may decide to
stop with provider approval
– S/P TAH, not required unless done for pre-cancer or cancer
CERVICAL CANCER SCREENING
CERVICAL CANCER SCREENING
PROSTATE CANCER SCREENING – Risk Factors
• older age
• black race
• first-degree relative with prostate
cancer
• increased cumulative exposure of
the prostate to androgens;
• and
• possibly, a diet high in fats, dairy
products, and calcium.
Screening Guidelines for the Early Detection of
Prostate Cancer, American Cancer Society
•
The prostate-specific antigen (PSA) test and the digital rectal examination
(DRE) should be offered annually, beginning at age 50, to men who have a
life expectancy of at least 10 years.
•
Men at high risk (African-American men and men with a strong family history
of one or more first-degree relatives diagnosed with prostate cancer at an
early age) should begin testing at age 45.
•
For men at average risk and high risk, information should be provided about
what is known and what is uncertain about the benefits and limitations of
early detection and treatment of prostate cancer so that they can make an
informed decision about testing.
PROSTATE CANCER SCREENING
PROSTATE CANCER SCREENING- Prevention
• possibly, chemoprevention
• (eg, with difluoromethylornithine,
isoflavonoids, finasteride, selenium,
vitamins D and E, and lycopene)
• possibly, a diet lower in fat and calcium.
PROSTATE CANCER SCREENING- Screening
• USPSTF;
• evidence is insufficient to recommend for or against routine
screening for prostate cancer with prostate specific antigen (PSA)
testing or digital rectal examination. Furthermore, the task force
advises clinicians to refrain from ordering the PSA test without first
discussing the potential but uncertain benefits and the possible
harms of prostate cancer screening. They recommend that men be
informed of the gaps in the evidence, and they should be assisted in
considering their personal preferences and risk profile before
deciding whether to undergo testing.
USPSTF
• if early detection improves health outcomes, the population most
likely to benefit from screening will be men aged 50 to 70 years who
are at average risk and men older than 45 years who are at
increased risk (ie, black men and men with a family history of a firstdegree relative with prostate cancer).
ORAL CANCER SCREENING
• about half of the new cases and the majority
of deaths from oropharyngeal cancer occurs
in persons over the age of 65
• screening - annual dental examination
SKIN CANCER SCREENING
• Half of all newly diagnosed cancers are either
melanoma, basal cell or squamous cell
cancer. Dx over the age of 50
• screening
SCREENING FOR GERIATRIC SYNDROME
• annual body mass index
(malnutrition/obesity)
• review safety concerns - falls etc.
• polypharmacy - periodic medicine
reviews
• Self-neglect and self-care
COMMON GERIATRIC CONDITION SCREENING
• Remain aware of the common illnesses that
come with the aging process.
– Diabetes: sustained BP greater than 135/80
– Depression: in clinical practices with systems to
assure accurate diagnosis and effective treatment
• There are no recommended screenings for these
diseases other than good clinical judgment
– Dementia
– hypo/hyperthyroidism
Injury Prevention
• Falls
– Environmental hazards
– Gait and balance disturbances
– Sedative and hypnotic drugs
– Poly-pharmacy
WHAT DOES THE FUTURE HOLD??
• MORE STUDIES TO DETERMINE
EFFICACY
• Predictive medicine – RISK
STRATIFICATION
• the concept based on the detection of
genetic markers for disease
The aging population will
benefit from the care of
compassionate clinicians
comfortable with the concept of
preventive care.
If we can do this well
- we may assist our patients in
having more life in their
remaining years rather than
more years in their remaining
life.
USPSTF
•QUESTIONS???????