Update in Health Promotion, Prevention for the older adult Greg W Mennie, PA-C, MSEd Associate Professor MBKU PA Program adapted from Teri Scott, ARNP Objectives 1. Have working knowledge of various up to date health and screening recommendations for primary care providers. 2. Understand Sensitivity and Specificity. 3. Identify the common adult health screening exams. 4. Understand the pharmacological treatment regimens associated with abnormal screening exam outcomes. 5. List the current up to date recommendations for women's preventative health. 6. List the current up to date recommendations for the current common adult screening requirements. 7. Develop a strategy for targeting and counseling patients on when to discontinue health screening evaluations. 8. Compare and contrast the current screening recommendations to your current practice habits. 9. Incorporate common anticipatory guidance issues into your current practice profile.
What makes a good screening test Find undetected disease in an asymptomatic individual at a stage when treatment can be more effective than it would be after the patient develops signs and symptoms identification of risk factors that increase the likelihood of developing the disease The disease in question should be a common condition with significant morbidity and mortality have available treatment with a potential for cure that increases with early detection The test for the disease must be capable of detecting a high proportion of disease in its preclinical state be safe to administer be reasonable in cost lead to demonstrated improved health outcomes be widely available Sensitive Specific Where do guidelines come from? Colleges- ACOG Specialty Orgs AAFP.. Govt. CDC, USPSTF.
Am I old? Arbitrary Not adaptable (Africa) Financial drive for definition associated with pension benefits start WHO 65 y.o. = 'elderly' or older person UN 60+ years Friendly Societies Act (Britain) > 50 Survey Says 60, 59, 74, 80. 90 is the new 25.. Growing Old in America: Expectations vs. Reality. Pew research Center June 29, 2009 Grade Definition Suggestions for Practice A B C The USPSTF recommends the service. There is high certainty that Offer or provide this service. the net benefit is substantial. The USPSTF recommends the service. There is high certainty that Offer or provide this service. the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. The USPSTF recommends selectively offering or providing this Offer or provide this service for selected patients depending on service to individual patients based on professional judgment and individual circumstances. patient preferences. There is at least moderate certainty that the net benefit is small. D I The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Discourage the use of this service. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. CANCER SCREENING
Breast Ca Risk Factors Age > 55 years of age Obesity BMI >30 Dense breast tissue up to 2xs risk Menarche/Menopause Menarche < age 12 Menopause > age 55 Parity No children 1 st child after age of 30 History / genetics Personal history of breast cancer + BRCA1 or BRCA2 Ethnicity Caucasian www.cancer.org Breast Cancer Screening Breast Self Exam Clinical breast exam Mammography Genetic Testing Saslow D, Boetes C, Burke W, et al for the American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89 Zadek,B, Reichman,M, Arleo,E, Babagbemi,K, Rosenblatt,R Digital Mammography Screening for Patients in Their Forties in New York City (2007-2010): A Retrospective Study Examining the Potential Impact of the USPSTF s Changed Recommendations for Breast Cancer Screening.Radiological Society of North America 2012 Scientific Assembly and Annual Meeting. Braithwaite D, et al. Screening Outcomes in Older US Women Undergoing Multiple Mammograms in Community Practice: Does Interval, Age or Comorbidity Score Affect Tumor Characteristics or False Positive Rates? NCI J Natl Cancer Inst (2013) doi: 10.1093/jnci/djs645 JAMA. 2015;314(15):1599-1614. doi:10.1001/jama.2015.12783. Bottom Line Mammography Grade B Start Age 50 biennial screening through age 74. Insufficient evidence to recommend for or against screening for women 75 or older. Discuss patient s preference Breast Self Exam Grade D Recommends against teaching breast self-examination (BSE). Clinical Breast Exam Grade I Insufficient evidence to assess the additional benefits and harms of clinical breast examination (CBE) >40 y.o.
BReastCAncer Tumor suppressors Help maintain cells DNA stability No standard criteria for recommending or referring Most informative to first test a family member who has breast or ovarian cancer 2% of women have the following family hx pattern: Not of Ashkenazi Jewish descent:» Two first-degree relatives (mother, daughter, or sister) + breast cancer, one of whom was diagnosed at age 50 or younger.» Three or more first-degree or second-degree (grandmother or aunt) +breast cancer regardless of their age at diagnosis.» Combination of first- and second-degree relatives + breast cancer and ovarian cancer (one cancer type per person).» First-degree relative with + cancer in both breasts.» Combination of two or more first- or second-degree relatives diagnosed with ovarian cancer regardless of age at diagnosis.» First- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis; and breast cancer diagnosed in a male relative. Ashkenazi Jewish descent:» First-degree relative diagnosed with breast or ovarian cancer.» Two second-degree relatives on the same side of the family diagnosed with breast or ovarian cancer. U.S. Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: Recommendation Statement. Bottom Line BRCA Grade D Recommends against routine genetic counseling or BRCA testing for women whose family history is not associated with an increased risk for potentially harmful mutations in BRCA1 or BRCA2 genes. Must have risk factors to screen - Grade B Ovarian Ca Risk Factors Age > after menopause. Half > 63 years of age or older. Obesity BMI >30 Fertility drugs? Clomid - Inc ovarian tumors Androgens +/- conflicting studies Estrogen therapy? if used after menopause Family history of ovarian cancer, breast cancer, or colorectal cancer Primary relative Personal history of breast cancer + BRCA1 or BRCA2 Talcum powder? talcum be carcinogenic (cancer-causing) to the ovaries. (asbestos old studies) increased risk for the mucinous type. www.cancer.org
Ovarian cancer Transvaginal Ultrasound CA 125 Bi Manual Does not equate to a cytology test Discuss the need for pelvic exams No randomized trial has assessed the role of bimanual for cancer screening NCI PLCO Trial discontinued as a screening strategy American Cancer Society. Can Ovarian Cancer Be Found Early? Available at: ttp://www.cancer.org/docroot/cri/content/cri_2_4_3x_ Can_ovarian_cancer_be_found_early_33.asp?sitearea. Accessed April 2, 2003. American College of Obstetricians and Gynecologists. Committee Opinion No. 280. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Gynecol Oncol.2002;87(3):237 239. Bottom Line Ovarian cancer Screening Grade D Recommends against routine screening. Cervical Ca Risk Factors Virus > HPV HIV Contraception Use > 5 years Multiparity > 3 deliveries Multiple Sex partners? if used after menopause www.cancer.org
Cervical Cancer Screening Pap HPV testing Cervical cancer Screening Grade A Pap/Cytology/HPV Grade D Bottom Line Age 21 to 65 years with cytology (Pap smear) every 3 years Age 30 to 65 years with a combination of cytology and human papillomavirus (HPV) testing every 5 years No screening > age 65» Negative prior screening» 3 negs or 2 co test negs <10 yrs with most recent < 5yrs TAH» No history of CIN 2 or higher 2018 guidelines in the works Prostate Cancer Risks Age > 65 yo History 2xs more likely one or more affected first-degree relative Ethnicity African American Meds Omega 3 = >risk High grade CA Obesity >BMI Serum phospholipid fatty acids and prostate cancer risk: results from the prostate cancer prevention trial. Brasky TM, Till C, White E, Neuhouser ML, Song X, Goodman P, Thompson IM, King IB, Albanes D, Kristal AR Am J Epidemiol. 2011 Jun;173(12):1429-39. Epub 2011 Apr 24. Plasma Phospholipid Fatty Acids and Prostate Cancer Risk in the SELECT Trial. Brasky TM, Darke AK, Song X, Tangen CM, Goodman PJ, Thompson IM, Meyskens FL Jr, Goodman GE, Minasian LM, Parnes HL, Klein EA, Kristal AR. J Natl Cancer Inst. 2013;105(15):1132.
Prostate Cancer Screening PSA DRE Bottom Line Prostate cancer Screening Grade D PSA recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. DRE Not recommended as a screening for prostate cancer. 2017 guidelines in the works Colon Cancer Risks Age > 50 yo History Family IBD Polyps Diet Red meats/processed Obesity >BMI
Colon Cancer Screening FOBT annual Colonoscopy 10 yrs Flex-Sigmoidoscopy 5 yrs FOBT HemoccultSENSA Sp88%-92% Se80% Rehydrated Hemoccult Sp90% Se90+% FIT Heme Select variants Sp95% Se70%-82% antibodies specific for human globin and are specific for colorectal bleeding not affected by diet or medications Accuracy close to colonoscopy FOBT v FIT Young GP. Fecal Immunochemical Tests (FIT) vs. Office-Based Guaiac Fecal Occult Blood Test (FOBT) Practical Gastroenterology 2004 Colonoscopy vs Flex Sig Colonoscopy Cancers have a Proximal Shift Flex sig would? miss >age 65 Women 1.8x s perforation risk vs flex-sig Schoenfeld P, Cash B, Flood A, et al. Colonoscopic screening of average-risk women for colorectal neoplasia. N Engl J Med 2005;352:2061 8 Yamaji Y, et al. Right-side shift of colorectal adenomas with aging. Gastrointest Endosc. 2006 Mar;63(3):453-8. Gatto N, et al. Risk of Perforation After Colonoscopy and Sigmoidoscopy: A Population-Based Study. Oxford Journals Medicine JNCI J Natl Cancer Inst Volume 95, Issue 3 Pp. 230-236.
Bottom Line AGE 50-75 Grade A Recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults. Age 76-85 (2016) The decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient s overall health and prior screening history. Adults in this age group who have never been screened for colorectal cancer are more likely to benefit. Screening would be most appropriate among adults who 1) are healthy enough to undergo treatment if colorectal cancer is detected and 2) do not have comorbid conditions that would significantly limit their life expectancy. AGE >85 Grade D Recommends against screening for colorectal cancer Toxins Asbestos Lung Cancer Risks Radiation LDCT 1.5 Low Dose CT Screening Chest x ray (PA film) = 1 airline flight 0.02millisieverts msv = 2.4 days of living on Earth CT Chest 5 msv = 250 CXR = 1.7 years CT abdomen 8 msv = 400 CXR = 2.7 years Average effective dose in millisieverts (msv) as compiled by Fred A. Mettler, Jr., et al., "Effective Doses in Radiology and Diagnostic Nuclear Medicine: A Catalog," Radiology Vol. 248, No. 1, pp. 254-263, July 2008
Bottom Line Low Dose CT Grade B Age 55-80 Annual screening adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery CARDIOVASCULAR SCREENING USPSTF and ATP guidelines Hypertension Bottom Line Grade A annual screening for high blood pressure in adults aged 18 years or older. obtain measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
4 Statin Benefit Groups ATP guidelines 1. Individuals with clinical ASCVD 2. Individuals with primary elevations of LDL C 190 mg/dl 3. Individuals 40 to 75 yo with diabetes with LDL-C 70-189 mg/dl 4. Individuals 40 to 75 yo no clinical ASCVD or DM LDL-C 70-189 mg/dl and > 7.5% 10-year ASCVD risk New Perspective on LDL C and/or Non-HDL C Treatment Goals No RCT evidence to support titration to specific numeric target Non-Statin therapies offered no significant risk reduction or safety profile to statin Global Risk Assessment for Primary Prevention Pooled cohort data to more adequately assess higher risk individuals for statin therapy Focus therapy on those most likely to benefit May consider no statin use in higher risk groups found not to benefit (CHF, Hemodialysis) Risk Calculator Tool Safety Recommendations Severe/mild/moderate ASCVD risk reduction vs adverse effects Role of Biomarkers and Noninvasive Tests Adjunctive help for non statin benefit groups CRP, CAC, ABI ATP guidelines High to moderate statin therapy Adults < 75 w ASCVD or LDL >190 (unless hx of statin complication) > reduction in ASCVD events Adults >75 years (no pooled data >79) high versus moderate» No clear evidence of <ASCVD events Adults w DM 40-75 years no ASCVD moderate»? High if 10 yr risk > 7.5%» + additional risk factors Cholesterol Bottom Line (USPSTF) Grade A/B/C Every 5 years, but in those over age 65, lipid levels do not rise dramatically. IF known CAD, screen and treat to age 80. Treat numbers and risk factors - ATP IV
AAA One time screening Ultrasound 95% sens. 100% spec. +/-Higher risk concerns Atherosclerotic disease Caucasian Obesity Fem/Pop aneurysm Women Less likely to have issue until age 80 Lederle FA, Johnson GR, Wilson SE. Abdominal aortic aneurysm in women, Aneurysm Detection and Management Veterans Affairs Cooperative Study. J Vasc Surg. 2001;34(1):122. McFarlane MJ. The epidemiologic necropsy for abdominal aortic aneurysm. JAMA. 1991;265(16):2085. Bottom Line Grade B AAA Screening Male smokers Ages 65-75 one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography who have ever smoked. Grade C Male Non-smokers age 65-75 selectively offer screening Grade I Women smokers age 65-75 insufficient to assess the balance of benefits and harms of screening for AAA Grade D Women Non-smokers age 65-75 recommends against screening ENDOCRINE SCREENING
Osteoporosis Screening The FRAX algorithms 10-year probability of fracture Dual-energy X-ray absorptiometry (DXA/DEXA) T - Score standard deviations same sex and ethnicity average 30-year-old -2.5 and lower = osteoporosis -1 to -2.5 = osteopenia -1 = normal Z - Score (pre-men/younger) same age, sex and ethnicity -2.0 = low above -2.0 = Normal Osteoporosis screening Bottom Line Grade I Men No rec. Grade B recommends screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors Screening >/= every two years (consider 1,3,5) Cadarette SM, Jaglal SB, Kreiger N, et al. Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. Can Med Assoc J 2000;162:1289-94. Cadarette SM, Jaglal SB, Murray T, et al. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA 2001;286(1):57-63. Thyroid Disease Screening Bottom Line Grade I current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant, asymptomatic adults.
Diabetes Screening Bottom Line Grade B Overweight- Obese Adults 40-70 recommends screening every 3 years for abnormal blood glucose as part of cardiovascular risk assessment.» fasting plasma glucose, 2-hour post load plasma glucose, or hemoglobin A 1c Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. INFECTIOUS DISEASE SCREENING USPSTF and CDC guidelines Baby Boomers 1945-65 Hepatitis C CDC 2012 75% of all cases Routinely screen high-risk adult IVDA +partner exposure clotting factor concentrates made before 1987, blood transfusions or solid organ transplants before 1992 Chronic hemodialysis patients known exposures to HCV health care workers after needle sticks involving HCV-positive blood Persons with HIV infection Children born to HCV-positive mothers Smith BD, Patel N, Beckett GA, Jewett A, Ward JW. Hepatitis C virus antibody prevalence, correlates and predictors among persons born from 1945 through 1965, United States, 1999 2008 [Abstract]. American Association for the Study of Liver Disease, November 6, 2011. CDC. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945 1965. MMWR 2012;61(No. RR-4).
Hepatitis C Screening Bottom Line Grade B recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965. Lifestyle Screening Bottom Line Diet/Exercise Grade B recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention Alcohol Grade B Recommends counseling for high risk patients» 1 drink nightly is considered low risk Tobacco Grade A clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA) approved pharmacotherapy for cessation to adults who use tobacco Drugs Grade I current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use STI s Grade B recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs). Other potential screenings Immunizations Influenza annual Pneumococcal once after 65 if before 65 then one booster 5 years later Tetanus booster every 10 years Zoster once after age 60 Advanced Directives Counsel patient on preparing end of life procedures and documents Sensory Hearing / Vision Increased safety issues and function if hearing or vision impaired ADL s Be mindful of patients concern over loss of independence Support Network Who helps the patient Is family close by Does patient need placement in assisted living Safety Falls Driving Vulnerabilities Fiduciary Abuse
Summary Individualize your approach Multiple guidelines can be contradictory Many of the guidelines use vague language at best Might, May, Consider Choose your expert It s ok to have different experts Just more confusing when not the same recommendations Remember patient autonomy The patient gets to ultimately decide Benefit should outweigh risk Do no Harm Duty to protect the patient The best treatment is prevention