Geriatric Preventive Care. Lee A. Jennings, MD, MSHS Reynolds Department of Geriatrics University of Oklahoma Health Sciences Center

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1 Geriatric Preventive Care Lee A. Jennings, MD, MSHS Reynolds Department of Geriatrics University of Oklahoma Health Sciences Center

2 Summary of Preventive Care Lifestyle Exercise Tobacco cessation Alcohol Use Immunizations Cancer Screening CV Health Blood pressure Lipids AAA screening DM screening Aspirin

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4 Who Recommends?

5 US Preventive Services Task Force (USPSTF) Volunteer independent task force Administered by AHRQ Letter grade (A, B, C, or D grade or I) based on the strength of the evidence and the balance of benefits and harms Because evidence based, may only apply to subpopulations, and for many important questions, USPSTF is unable to comment

6 Other Organizations Institute of Medicine Professional societies Disease-specific organizations AHRQ Guideline clearinghouse

7 Limitations Lack of data for older persons Many guidelines don t consider life expectancy Conflicting guidelines/recommendations

8 Lifestyle USPSTF counseling recommended for Alcohol 15% of older adults drink more than rec d amount (>7 drinks/week or >3 drinks/day) CARET (alcohol consumption, comorbidities, and medications), AUDIT, CAGE Smoking cessation Exercise 30mins moderate-intensity aerobic exercise 5days/week (minimum) Muscle strengthening, flexibility, balance (fall prevention)

9 Benefits of Exercise risk of all-cause mortality 32% lower risk per SD increase in energy expenditure (287kcal/d) risk of CVD improves lipids & BP; decreases CRP glycemic control & insulin sensitivity, may prevent type 2 diabetes cancer prevention (breast, prostate, colon) BMD, mobility disability, hip fractures risk of cognitive decline anxiety and depression

10 Immunizations Influenza vaccination yearly Zoster vaccination once after age if immunocompetent Tetanus and Pertussis One-time substitution of Tdap for Td then Td every 10 yrs Pneumococcal vaccination PCV13 (Prevnar 13) once at age 65 Followed 12 mos later by PPSV23 (Pneumovax) If already received Pneumovax, wait 12 mos before giving Prevnar If Pneumovax given before 65, re-administer once after 65 (5 years after initial dose)

11 Screening Tests Consider life expectancy (~10 years), risk vs. benefit of screening, treatment options, time to benefit, and patient goals (not just age) Eprognosis.ucsf.edu Mortality risk calculators Cancer screening risk vs. benefit calculators Communicating prognosis Smart phone app

12 USPSTF Cancer Screening Breast cancer mammography every 2 yrs (women age 50-74) Colon cancer (age 50-75) Stool testing for blood yearly (high sensitivity guaiac or immunochemical) Sigmoidoscopy every 5 yrs with yearly FIT Colonoscopy every 10 yrs CT colonography every 5 yrs Lung cancer Low dose CT scanning yearly (age with 30 pack-yrs of smoking and currently smoke or have quit within the past 15 yrs)

13 USPSTF Don t Screen Cervical cancer screening after age 65 If not high risk and adequate prior screening 3 consecutive negative cytology tests or 2 consecutive negative HPV/Pap co-tests in last 10 yrs with most recent test in last 5 yrs Ovarian cancer screening Prostate cancer screening (PSA) Pancreatic cancer

14 USPSTF CVD Screening High blood pressure yearly Lipids every 5 yrs for men > 35 & women > 45 No recommendations on when to stop Over age 75, most reach treatment threshold, but risk may outweigh benefit Abdominal Aortic Aneurysm Ultrasound once in men who have ever smoked Diabetes (age 40-70) Every 3 years if BMI 25 (HTN, hyperlipidemia)

15 USPSTF Low Dose Aspirin for Primary Prevention of CVD Men MI risk; Women CVA risk Age with 10yr CV event rate >10% and life expectancy of at least 10 yrs Without increased risk of GI bleeding Consider taking with ppi (ACC/ACG/AHA) Over age 70, insufficient evidence

16 USPSTF Other Recommended Screening Depression PHQ-2 mood and anhedonia in last 2 weeks Frequency not specified Osteoporosis BMD (hip and spine DXA) at least once after age 65 for women No recommendations for men; Consider for men with risk factors, prior fx, height loss FRAX calculator HIV, HBV, HCV: At least once if 65+ with risk factors Screen for HCV if born in US between 1945 & 1965

17 Screenings: USPSTF Don t Do Carotid stenosis screening EKG or exercise stress test if low CHD risk COPD (incentive spirometry) Screening for asymptomatic bacteruria

18 USPSTF Screening no recommendations but still important for older adults Falls multifactorial risk assessment Cognitive screening Hearing loss screening Visual impairment (including glaucoma) Skin cancer screening Incontinence Medication review Elder mistreatment (routine, direct questioning recommended) Safety (including driving) Advance Care Planning

19 Gait, Balance, Falls and Vitamin D Ask about falls (50% of adults over age 80 fall) Gait speed (>1 meter/sec predicts better than average life expectancy) Gait and balance exam Get up and Go; Semi-tandem stance; Pick object off floor Foot exam Vitamin D and calcium supplementation No recommendation (USPSTF) 800 IU D3 if > 71; 1200 mg Ca if > 71 (IOM) Interventions: Exercise, PT, assistive device, home safety eval, orthostatic VS, vision eval, cognitive screen, medication review, osteoporosis screen

20 Screening for Dementia Required as part of Medicare Annual Wellness Visit PCPs detect cognitive impairment more often with structured screener (83% vs. 59%) Opportunity to prevent some consequences of cognitive impairment (safety); help families plan for future care; offer available community services Age to start? Prevalence of dementia in US by age 11% of people age 65 and older 14% of people age 71 and older 32% of people age 85 and older

21 Screening for Dementia Start with general screening question for patient and informant Cognition concern? During the past 12 months, have you experienced confusion or memory loss that is happening more often or getting worse? Functional impairment? During the last 7 days, did you need help from others to perform everyday activities such as bathing, grooming. (ADLs)? During the last 7 days, did you need help from others to take care of things such as laundry, shopping, transportation (IADLs)? If positive response use structured screening tool (Mini-Cog, MMSE, MoCA) If screening tool positive full evaluation for dementia Okay to bring back for a second visit

22 Vision and Hearing Impairment Common in older adults Ask about symptoms Snellen eye chart; referral for dilated exam Whisper test at 2 feet Part of work-up if patient has functional impairment, cognitive impairment or falls

23 Elder Mistreatment Short screener Do you feel safe where you live? Who prepares your meals? Who handles your checkbook?

24 Advance Directives and Health Care Proxy New CPT codes for discussions (30mins+) Identifying a proxy Understanding care preferences POLST in California Updating as health changes

25 Conclusions Geriatric health maintenance is complicated Data are sparse, particularly for those with limited life expectancy Guidelines may conflict Coverage decisions most closely follow USPSTF, but leaves out many common geriatric syndromes Consider life expectancy, risk vs. benefits of screening and treatments, patient goals and preferences

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27 Guideline Warfare Condition USPSTF ACS AUA Prostate Cancer screening* Recommends against Consider if 10 y life expectancy Consider if *All agree on, informed, shared decision-making USPSTF IOM NOF Vitamin D/Calcium Against < 400 D3 and 1000 Ca for women Insufficient for > 400 D3 and > 1000 Ca 800 IU D3 if > mg Ca if > if > if > 71

28 Advisory Committee for Immunization Practices (ACIP) Voluntary committee Administered by CDC Aim is to reduce the incidence of vaccine preventable diseases and increase the safe use of vaccines and related biological products Recommendations are the basis of coverage decisions

29 Vitamins and minerals Vitamin D and calcium supplementation No recommendation (USPSTF) 800 IU D3 if > 71; 1200 mg Ca if > 71 (IOM) Multivitamin supplements to prevent CHD or cancer No recommendation (USPSTF) Do not take beta carotene or Vitamin E (USPSTF)

30 FRAX for Osteoporosis Age (used as a continuous variable) Previous fragility fracture as an adult Parent fractured hip Glucocorticoid therapy (> 3 m of > 5 mg prednisone) Low body weight Current cigarette smoking Alcohol (> 3 drinks/day) Rheumatoid arthritis Secondary osteoporosis* (e.g., type I DM, untreated longstanding hypothyroidism, hypogonadism, premature menopause, malabsorption, CLD) *not needed if BMD value is entered into FRAX

31 FRAX-NOF: The Reality White US, non smoker, No: prior Fx, parent fx, glucocorticoids, RA, 2 causes NOF: treat if 10-y hip >3.0% or major >20% Age Sex Height Weight 10-y Hip 10-y Major 75 M lbs 3.5% 7.9% 71 F lbs 3.3% 13%

32 Medicare Annual Wellness Visit What is it? Personalized Prevention Plan Services and Health Risk Assessment Who is eligible? > 12 months in Part B and no Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months

33 Medicare Annual Wellness Visit Review of medical and family history Updating list of providers & prescriptions Height, weight, blood pressure, visual acuity Screen for cognitive impairment & depression/mood disorders Assessment of functional ability and safety End-of-life planning Education, counseling, referral based on issues identified Screening schedule for appropriate preventive services

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