Preventative Health Care in the Geriatric Patient: What Are We Trying to Prevent? Jane Elizabeth Whiteman, MD

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1 Preventative Health Care in the Geriatric Patient: What Are We Trying to Prevent? Jane Elizabeth Whiteman, MD

2 Preventative Health Care in the Geriatric Patient What are we trying to prevent? Elizabeth Whiteman, MD Clinical Professor of Medicine UCLA Department of Medicine Geriatrics UCLA Intensive Course in Geriatric Medicine and Pharmacy September 7, 2016

3 Disclosures I have nothing to disclose 2

4 Learning Objectives Learn to identify which geriatric patients will benefit from cancer screening Understand how a patient s functional status, health status, and personal preferences play a role in preventative screening Understand that preserving function and improving quality of life are cornerstones of geriatric preventative care, as opposed to extending number of years lived Balance the risks of routine health screening against the potential benefits in the context of predicted life expectancy 3

5 Outline Cancer Screening: general Specific cancer screening guidance Other screening and vaccinations Primary prevention 4

6 Cancer Screening: general 5

7 Cancer Screening: geriatric guidelines When to start screening is clearly defined When to stop screening is unknown Clinical trials do not include older geriatric patients Professional society guidelines often conflict Different age cut-offs Professional society guidelines are often vague deflect responsibility to the primary physician 6

8 Overscreening Unnecessary screening Screening without a medical indication Screening without a perceived benefit Extra procedures False positives Anxiety Excessive costs to healthcare system 7

9 Overscreening for Cancer is Common National Health Interview Survey (NHIS: ) 27,404 participants > 65 years stratified by mortality risk low, intermediate, high, and very high Very High Mortality Risk Group (>75% mortality risk) 31-55% had recent screening (55% had PSA testing) California Survey (NHIS) 77% of women over age 70 had a recent PAP smear Women categorized as poor health and over age 80 >50% had recent PAP and/or mammogram Screening rates did not differ with health status in an age group 8

10 Why does overscreening happen? Defensive medicine Appease the patient Reassurance Patient refusal to accept limited life expectancy Poor physician communication regarding prognosis Difficulty predicting life expectancy Lack of an easy-to-use clinical tool 9

11 Cancer Screening: Risks vs. Benefits Benefits Finding treatable cancer Reassurance Extending life But what quality... Risks Find cancers that are not clinically significant Anxiety False Positives Unnecessary Procedures procedural risks in the elderly Unnecessary Treatment Treatment Side Effects Cost 10

12 Cancer Screening: General Guidelines Remember: Age is just a number Can this patient benefit from an intervention? Can we improve QOL or increase healthy years lived? What is this patient s risk of dying from this cancer? Individual approach 11

13 Cancer Screening: Individualized Approach Overall health Life expectancy Natural progression of comorbidities Risks and benefits of screening Personal preferences 12

14 Cancer Screening: Health & Life Expectancy Categorize patients into health groups Below Average Average Above Average Estimate life expectancy based on their overall health What is the number needed to screen to prevent one cancer death during that time frame? In general: if life expectancy is < 5years, there is no survival benefit to screening for any cancer 13

15 Estimating Life Expectancy US Census Bureau from the CDC United States Life Tables EPrognosis (eprognosis.org) Estimate by underlying comorbidities Many tools studied None without bias Only moderate accuracy 14

16 Life Expectancy by Age (CDC US Census Bureau Data from 2008) Age (years) White Male (years) White Female (years) Birth

17 Life Expectancy by Disease Alzheimer s Disease 4.2 yrs (men) 5.7 yrs (women) 8-10yrs after early diagnosis Hip Fracture (age 80) 5.4yrs CHF (>75yrs) 3.9 yrs (men) 4.5 yrs (women) Myocardial Infarction 11.3 yrs 16

18 Mortality at 4 years Prediction Tool Lee, JAMA 2006 Age Sex Points Comorbid Conditions DM, Cancer, Lung Dz, CHF, Current Smoker, BMI < 25 ADL Difficulty Bathing, Walking several blocks, managing money, pushing large objects Mortality Risk 0-5 points: <4% risk 6-9 points: 15% risk points: 42% risk 14 points: 64% risk 17

19 Life Expectancy by health status: women Walter, JAMA 2001 Age (years) Above Average Health (years) Average Health (years) Below Average Health (years)

20 Cancer Screening: Time Lag to Benefit Benefit of screening is not immediate Time from point of screening observed benefit Avoid screening: life expectancy < time lag to benefit Colon Cancer: ~10 years USPSTF: minimum 7 years 10.3 years to prevent one death from cancer for 1000 patients screened (meta-analysis by Lee, BMJ 2012) Breast Cancer: ~5 years 10.7 years to prevent one death from cancer for 1000 patients screened (meta-analysis by Lee, BMJ 2012); range yrs 19

21 Personal Choice Patient s opinion matters Shared decision making Establish goals of care 20

22 AGS Don t recommend screening for breast, colorectal, prostate or lung cancer without considering life expectancy and the risks of testing, overdiagnosis and overtreatment. 21

23 Cancer Screening: specific diseases 22

24 US Preventative Service Task Force (USPSTF) Assigns 1 of 5 letter grades to screening recommendations A-Benefit substantial B-Benefit moderate to substantial C-selective offering based on judgement D-recommends against risk outweighs benefit I-Evidence insufficient and patient should be aware of risk /benefit 23

25 Colon Cancer Screening: USPSTF (2016) Ages 50 75yrs (Grade A) Screen with stool/fit, sigmoidoscopy, or colonoscopy Fecal DNA-FIT(Cologuard) and CT Colonography Methylated Septin9 DNA -plasma(fda Approved April 2016) Ages (Grade C) Individual decision taking into account the patient s overall health and prior screening history Never been screened most likely to benefit > 85 yrs (Grade D) Recommends against screening No head-to-head studies prioritizing screening strategies 24

26 Colon Cancer Screening: Age 76-85???? Life expectancy > 10 years Most beneficial in those with fewer comorbidities Elderly people in good health have similar number needed to screen as younger patients Screening related complications often outweigh expected benefits Personal preference is important 25

27 Colonoscopy Complications Perforation Bleeding Sedation/Anesthesia Anxiety Bowel Preparation Overdiagnosis 26

28 New colon cancer screening test: Cologuard Fecal DNA testing (for average risk screening) Approved by FDA August 2014 Available by prescription only Frequency of screening not yet established (~3years) Stats 13% false positive (rate of false positive increase with age) Found 69% high-risk precancers and 92% colon cancers (10,000 patient clinical trial) Cost $649 out of pocket Medicare covers test (traditional Part B without co-pay) 27

29 Breast Cancer Screening: USPSTF (2016) Ages (Grade B) Biennial screening with mammograms Best balance of benefit to harm if done every 2 years Age 75yrs: ( I Statement) Clinical trials do not include women >75 yrs Many women >75 yrs will die from non-breast cancer related illnesses & be overdiagnosed Clinical Breast Exams & Digital Breast Tomosynthesis ( I Statement) Dense Breast I statement on whether to do additional screening 28

30 Breast Cancer Screening: other societies American Geriatric Society Screen if life expectancy >5 years up to age 85 > 85 years Excellent health/functional status in patients who feel strongly they will benefit American Cancer Society (2015 update) Ages 45-54: annual screening Age 55: biennial screening Continue screening if life expectancy is 10 years Does not recommend clinical breast exam 29

31 Breast Cancer in Older Woman Incidence increases with age < 2% of women over age 80 die of breast cancer Oldest-old less likely to die of breast cancer 73% of women age with breast cancer died of disease 29% of women age >85 with breast cancer died of disease More likely to die of non-cancer death Breast cancer biology changes with aging Less aggressive, more favorable biological characteristics Benefits of cancer therapy not well studied or tolerated 30

32 Breast Cancer Screening: > 75yrs???? Personal Preference Lag time to benefit: minimum 4-5 years Observational evidence of mortality benefit to age 85 Provided minimal comorbidities Cost-effective up to age 80 Only in those with greatest life expectancy 31

33 Harms of Mammogram Overdiagnosis False Positives Anxiety DCIS detection 13% of women >80yrs experience harms while only 0.3% were harmed from NOT being screened 32

34 Cervical Cancer Screening USPSTF (2012) Stop at age 65 provided normal recent screening & average risk Fewer then 1/1000 women > age 60 with normal baseline PAP will develop high-grade cervical lesion or cervical cancer Risk is almost double if woman has not had a prior PAP smear Routine screening should continue for 20 years after high-grade precancerous lesions (even if beyond age 65) ACS (2012) Stop age age 65 provided normal prior screening High Risk Group: HIV, Transplant patients, DES exposure AGS Stop at age 70 provided normal prior screening 33

35 Too many women are getting Pap Smears! California Survey Showed... Over age 70 77% reported recent Pap smear Over age 80 & poor health 50% reported recent Pap smear 34

36 Prostate Cancer: USPSTF (2012) Recommend against PSA-based screening Grade D recommendation 35

37 Prostate Cancer Screening: Other Societies ACS (2012) Discussion of screening at age 50 in those with at least 10 year life expectancy Shared Decision Making Screen every 2 yrs if PSA < 2.5ng/ml; yearly if > 2.5ng/ml American Urology Society (2013) Age weigh benefits and harms of screening Shared Decision Making PSA Q2yrs may reduce harms more then annual screening Recommend against PSA screening in men > age 70 or in those with < yrs life expectancy Some men > 70yrs & in excellent health may still benefit 36

38 Prostate Cancer and Overscreening 80% of men >70yrs autopsied have subclinical prostate cancer Number needed to screen to prevent one death in 11yrs 1055 men 37 cancers would be detected 1 prostate related death 37

39 Lung Cancer: USPSTF (2013) B recommendation Ages 55-80yrs Annual screening with low dose CT 30 year smoking history Current smoker Quit within 15 years Stop screening Once > 15 yrs smoking cessation Develops health problem that limits life expectancy or willingness or ability to have curative lung surgery 38

40 Other Screening 39

41 Vascular Screening: USPFTF Yearly blood pressure Lipids Every 5 years in men 35 and women 45 with risk factors Diabetes Every 3 years if BP > 135/80 Not Recommended Carotid stenosis screening EKG or stress test if low CHD risk 40

42 Abdominal Aortic Aneurysm: USPSTF (2014) B recommendation Ages One time ultrasound Men who have ever smoked (100 or more cigarettes) C recommendation Selectively offer screening in men ages who have never smoked I Statement Women ages who have smoked D recommendation Women who have never smoked 41

43 Vaccines Influenza Pneumococcal TDAP Zoster Hepatitis A and B Diabetics Liver Disease Dialysis Nursing Homes 42

44 Influenza Multiple Versions Trivalent: 2 influenza A strains, 1 influenza B strains Quadrivalent: 2 influenza A strains, 2 influenza B strains Egg Free Version Nasal (ages 2-49 only!) High Dose Vaccine 4 times typical antigen Triggers stronger immune response Recommended > age 65 Give whatever vaccine is available do not delay! 43

45 Pneumococcal Vaccine Pneumococcal Polysaccharide (PPSV 23): Pneumovax 23 Once after age 65 Do not need Q5yrs 38% of invasive pneumococcal disease caused by serotype unique to PPSV % effective in preventing invasive disease (not pneumonia) Complicated dosing schedule with Prevnar13 Pneumococcal Conjugate 12 (PCV 13): Prevnar13 Once after age % of invasive pneumococcal disease caused by PCV13 serotypes 10% of community acquired pneumonia cases in adults caused by PCV13 serotypes Newly recommended 8/

46 Zoster Recommended 60yrs Give if personal hx of zoster Live Vaccine Avoid in immunocompromised Reduces incidence of zoster 64% if given 60-69yrs 41% if given 70-79yrs 18% over age 80 Reduces postherpetic neuralgia 67% reduction 45

47 Screening for Hepatitis C 50% of people with Hep C in US are unaware New treatments are less toxic and more successful Screen those born between HCV Antibody is test of choice Screen high-risk patients IV Drug Use Blood Transfusion before 1992 Abnormal LFTs HIV Dialysis Incarceration 46

48 Osteoporosis: USPSTF (2011) B recommendation Screen women > 65 years No upper age limit specified Screen those who you think will benefit I statement Not enough evidence to screen men 47

49 Vitamin D Primary Prevention for Fractures Premenopausal: I statement Post-menopausal Vitamin D>400 IU/day + Ca >1000 mg/day: I statement Prevention of Falls Grade B recommendation 800IU/day ( 12mo) community dwelling elders Screening asymptomatic community elders I statement 48

50 Primary Prevention 49

51 Aspirin Chemoprophylaxis: USPSTF (2009) guidelines under current review USPSTF: Men age Recommends when potential benefit due to reduction in MI outweighs potential harm due to an increase in GI hemorrhage USPSTF: Women age Recommends when potential benefit of a reduction in ischemic strokes outweighs potential harm of an increase in GI hemorrhage USPSTF: Men and Women > age 80 I statement 50

52 Aspirin For Primary Prevention Data on primary prevention is lacking No reduction in cardiac mortality, nonfatal stroke or MI in Japanese patients over age 60 (Ikeda, JAMA 2014) POPADAD Trial: no benefit in CV risk reduction diabetics JPAD Trial: no benefit on CV risk reduction in diabetics FDA issued advisory on lack of evidence Overuse for primary prevention >10% of patients use aspirin inappropriately 51

53 Aspirin: Cardiac Risks vs. GI Bleeding Risks Bleeding risk increases with age No risk calculator for GI risk Aspirin clinical trials are ongoing 52

54 Cardiovascular Primary Prevention: Statins American College of Cardiology/American Heart Association (ACC/AHA) 2013 Guidelines Apply to ages 40-75yrs Recommend statin if > 7.5% risk 53

55 Cardiovascular Primary Prevention: Statins VA/DoD Clinical Practice Guidelines (Aug 2015) Recommend 12% risk before starting statin National Lipid Association (Oct 2014) Recommend 15% risk Choosing Wisely (American Medical Directors Association) Do not routinely use statins in adults age 70 or older given statin related adverse events 54

56 Statin concerns in the elderly Reversible Cognitive impairment (short term) No association found in developing dementia Falls, neuropathy, myalgia fatigue, reduce physical activity Diabetes association Cost Effective if using generics for primary prevention Small increases in frequency or severity of harms would negate the benefits What life expectancy to stop? For primary prevention? For secondary prevention? 55

57 Accordingly, a discussion of the potential ASCVD risk reduction benefits, risk of adverse effects, drug-drug interactions, and consideration of patient preferences should precede the initiation of statin therapy for primary prevention in older individuals 56

58 Additional Geriatric Preventative Healthcare Vision Comprehensive eye exam every 2 years Hearing Annual evaluation of hearing Cognitive Impairment Depression Falls and Mobility Alcohol Abuse and Smoking Cessation HIV (at least once if > 65 with risk factors) 57

59 Exercise Reduces all cause mortality 32% risk per SD increase in energy expenditure (287kcal/day) Reduces risk of CVD (events and mortality) Improved glycemic control & insulin sensitivity Cancer Prevention and increase cancer survival Bone Health Decreases gallstones Decreases risk of dementia and cognitive impairment Mental Health Decreases disability with mobility 58

60 Elder Abuse Contusions, Burns, Bite Marks Genital or Rectal Trauma Pressure Ulcers BMI <17.5 without clinical explanation 59

61 Geriatric Preventative Healthcare Minimize functional limitations Prevent functional decline from chronic conditions Increase number of healthy years lived 60

62 Geriatric Preventative Health Care Summary Cancer screening should be based on a patient s overall functional status, health, and personal preferences Geriatric preventative care should focus on preserving function and improving quality of life The risks of routine health screening need to be heavily weighed against the potential benefits in the context of predicted life expectancy 61

63 Remember There is often not a right answer in geriatric medicine 62

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