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Geriatric Care and Screening

Geriatric care includes the prevention and diagnosis of diseases, as well as the management of diseases, disabilities, and other health concerns in individuals ≥ 65 years of age. Special consideration is given when addressing multiple aspects that are specific to aging. Preventive measures such as vaccinations as well as cancer and disease screening Screening Preoperative Care are essential in this age group because of the high risk for infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease and developing cancer and chronic diseases. A majority of older individuals have at least 1 chronic medical condition, which increases the likelihood of polypharmacy and adverse drug reactions. Vision Vision Ophthalmic Exam, hearing, cognitive function, gait Gait Manner or style of walking. Neurological Examination, and balance are among the functions that decline in the geriatric population. These disease- and age-related factors affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment the activities of daily living. Assessing the financial and social resources of the elderly is also important, given the direct impact of these factors on their health. A multidisciplinary approach involving various professionals in the healthcare field is important in achieving comprehensive care for the elderly.

Last updated: Jun 9, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Caring for Older Adults

Geriatric population

  • In the US, over 20% of the population will be > 65 years of age by 2030.
  • Many factors affect the functional status of individuals in this age group:
    • 80% of individuals have at least 1 chronic condition and 50% have at least 2 chronic conditions.
    • Geriatric syndromes (e.g., falls, vision Vision Ophthalmic Exam, and hearing impairment Hearing impairment Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss) impair function.
  • Apart from addressing chronic conditions, comprehensive preventive care with functional and psychosocial evaluation are essential in improving geriatric well-being.

Assessment of older adults

Care for the elderly is a team-based approach that involves various professionals (e.g., physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship, social workers, nutritionists, physical therapists) working together to assess the following:

  • Physical health:
    • Address and manage current chronic conditions (e.g., heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR), hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease).
    • Discuss nutrition and medication use.
    • Appropriate screening Screening Preoperative Care for other diseases
    • Update the necessary vaccinations.
  • Functional ability:
    • Ask about impairments in activities of daily living (ADLs).
    • Address any limitations Limitations Conflict of Interest in their physical and mental abilities:
      • Check for cognitive decline and memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment disturbances.
      • Hearing and vision Vision Ophthalmic Exam assessment
      • Driving assessment
      • Falls and other incidents contributing to functional limitations Limitations Conflict of Interest
  • Psychosocial health:
    • Depression may go undetected, as symptoms present in atypical ways.
    • Suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide rate is higher in the elderly than in the general population.
    • Social environment:
  • Advanced care planning

Physical Health

Nutrition

Alcohol and tobacco use

  • Alcohol use:
    • Approximately 50% of adults > 65 years of age consume alcohol.
    • Alcohol use in older adults is associated with:
      • Increased risk of falls
      • Negative effects on function, cognition, and general overall health
    • The American Geriatrics Society recommends asking older adults specific questions regarding the frequency and quantity of alcohol consumption.
  • Tobacco use:
    • Older adults should be asked about tobacco use.
    • If current smokers, counseling on smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases cessation and methods of quitting should be offered.

Physical activity

  • Exercise is recommended for all adults and is associated with better overall health, decreased healthcare costs, and fewer mobility Mobility Examination of the Breast limitations Limitations Conflict of Interest.
  • Generally, the American Heart Association American Heart Association A voluntary organization concerned with the prevention and treatment of heart and vascular diseases. Congestive Heart Failure recommends the following regimen for adults:
    • At least 150 minutes of moderate-intensity exercise every week OR 
    • 75 minutes of vigorous activity 3 days a week
    • Strength training (e.g., weight training, resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing training, or weight-bearing calisthenics) to maintain or improve strength
    • A gradual increase in time and intensity is recommended.
  • Routine testing such as ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) or stress testing is not recommended for asymptomatic older adults prior to initiating an exercise program.
  • Medical clearance is recommended prior to commencing an exercise program:
    • In symptomatic individuals (e.g., with a complaint of chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain or dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea)
    • In individuals with known heart disease or with renal or metabolic disease (factoring in the desired exercise intensity)

Medication Management

Considerations

  • Age-related changes can affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment drug absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption, distribution, metabolism, and excretion as well as physiologic effects in older adults:
    • The volume of distribution may increase with age, secondary to a relative increase in body fat and a decrease in lean LEAN Quality Measurement and Improvement muscle mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast.
    • Drug metabolism may be impaired by a decline in hepatic function.
    • Decreased drug clearance due to a natural, age-related decline in renal function
    • Increased sensitivity to the effects of a medication may be seen with increasing age.
  • Caution with polypharmacy (the use of 5–10+ medications), which is associated with:
    • ↑ Risk of adverse events
    • ↑ Risk of hospital admissions
    • ↓ Physical and cognitive functioning
  • Monitor for drug-drug interactions and adverse effects:
    • Ask about herbal medicines, supplements, and over-the-counter medications due to potential interactions.
    • Closely monitor for adverse effects when initiating a new medication.
    • Avoid “prescribing cascades” (adding a medication to treat a new symptom), as they can have adverse effects.
  • Safe prescribing practices include:
    • Regular Regular Insulin review of current medications
    • Stopping unnecessary medications
    • Using the minimal dose required for clinical benefit
    • Considering nonpharmacological approaches when possible

Beers criteria

  • The most widely used criteria developed to reduce potentially inappropriate prescribing and harmful polypharmacy in the geriatric population
  • Provides a list of drugs that can pose a risk to the elderly due to adverse effects, drug-drug interactions, and drug dose adjustments
  • Over-the-counter medications are included.
  • NSAIDs NSAIDS Primary vs Secondary Headaches are the most commonly used medications that are considered potentially inappropriate.
Table: Medications that are potentially inappropriate for older adults
Medications Side effects
Antipsychotics
  • Associated with a high risk of falling and fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Higher risk of mortality Mortality All deaths reported in a given population. Measures of Health Status when used for behavioral control in dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders
Glyburide Long-acting sulfonylurea associated with a high risk of hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia
Benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines Increased risk of delirium Delirium Delirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium, sedation, and falls
Opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics Increased risk of delirium Delirium Delirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium, sedation, falls, constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium, and respiratory depression
Anticholinergics Anticholinergics Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs (includes some antidepressants and antihistamines Antihistamines Antihistamines are drugs that target histamine receptors, particularly H1 and H2 receptors. H1 antagonists are competitive and reversible inhibitors of H1 receptors. First-generation antihistamines cross the blood-brain barrier and can cause sedation. Antihistamines) Increased risk of delirium Delirium Delirium is a medical condition characterized by acute disturbances in attention and awareness. Symptoms may fluctuate during the course of a day and involve memory deficits and disorientation. Delirium, sedation, falls, constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, and urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium
NSAIDs NSAIDS Primary vs Secondary Headaches
  • Increased risk of GI bleeding, especially with concomitant anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants
  • Increased risk of renal impairment
  • Possible cardiovascular risk
α-Blockers Increased risk of hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
Proton pump Pump ACES and RUSH: Resuscitation Ultrasound Protocols inhibitors (PPIs)
  • Increased risk of Clostridium difficile Clostridium difficile A common inhabitant of the colon flora in human infants and sometimes in adults. The type species clostridioides difficile is formerly known as Clostridium difficile. It is a causative agent for clostridioides infections and is associated with pseudomembranous enterocolitis in patients receiving antibiotic therapy. Clostridia infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
  • Increased risk of vitamin B12 Vitamin B12 A cobalt-containing coordination compound produced by intestinal microorganisms and found also in soil and water. Higher plants do not concentrate vitamin B 12 from the soil and so are a poor source of the substance as compared with animal tissues. Intrinsic factor is important for the assimilation of vitamin B 12. Folate and Vitamin B12 malabsorption Malabsorption General term for a group of malnutrition syndromes caused by failure of normal intestinal absorption of nutrients. Malabsorption and Maldigestion

Screening Exams

Screenings in the elderly population should consider risk factors beyond merely the individual’s age. The elderly individual and/or caregivers should be involved in decision-making about pursuing screening Screening Preoperative Care. Most screenings are generally not indicated if the life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is < 5 years.

Abdominal aortic aneurysm Abdominal aortic aneurysm An aortic aneurysm is the abnormal dilation of a segment of the aorta. Abdominal aortic aneurysm is the most common aortic aneurysm, occurring frequently in the infrarenal area. Most aneurysms are asymptomatic, but can cause compression of surrounding structures or rupture, which is a life-threatening emergency. Abdominal Aortic Aneurysms

Men between 65 and 75 years of age with a history of tobacco use should undergo abdominal ultrasound screening Screening Preoperative Care once.

Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer

Based on the US Preventive Services Task Force (USPSTF):

Mammography breats cancer

The 1st image shows mammography Mammography Radiographic examination of the breast. Breast Cancer Screening of normal breast tissue; the 2nd image shows cancerous breast tissue. Mammography Mammography Radiographic examination of the breast. Breast Cancer Screening is done for early detection of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer.

Image: “Mammo breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer” by National Cnacer Institute. License: Public Domain

Cardiovascular disease

  • Screening for hypertension:
    • Hypertension is a major risk factor for ischemic heart disease and stroke.
    • USPSTF: screen all adults > 18 years of age for blood pressure at the clinic.
    • Confirm diagnosis with outside blood pressure measurements (before initiation of treatment).
  • Screening Screening Preoperative Care for diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus:
    • Part of cardiovascular risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care
    • The USPSTF recommends diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus screening Screening Preoperative Care for individuals who are 35–70 years of age and those who are overweight or obese ( BMI BMI An indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese). Obesity ≥ 25).
    • Fasting glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance or HbA1c HbA1c Products of non-enzymatic reactions between glucose and hemoglobin a, occurring as a minor fraction of the hemoglobin components of human erythrocytes. Hemoglobin a1c is hemoglobin a with glucose covalently bound to the terminal valine of the beta chain. Glycated hemoglobin a is used as an index of the average blood sugar level over a lifetime of erythrocytes. Diabetes Mellitus screening Screening Preoperative Care (abnormal result needs a repeat test for confirmation) 
  • Screening Screening Preoperative Care for lipids Lipids Lipids are a diverse group of hydrophobic organic molecules, which include fats, oils, sterols, and waxes. Fatty Acids and Lipids:
    • Formal cardiovascular risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care for all individuals who are 40–79 years of age:
      • Includes identifying risk factors: hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases, obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity, family history Family History Adult Health Maintenance of CVD and elevated cholesterol Cholesterol The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. Cholesterol Metabolism, CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease
      • Obtain lipid profile Lipid profile Lipid Disorders.
    • No definite studies that indicate the appropriate age to stop screening Screening Preoperative Care
    • If > 1 prior lipid profiles have been normal, screening Screening Preoperative Care can be stopped at 65 years of age.
  • Aspirin Aspirin The prototypical analgesic used in the treatment of mild to moderate pain. It has anti-inflammatory and antipyretic properties and acts as an inhibitor of cyclooxygenase which results in the inhibition of the biosynthesis of prostaglandins. Aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis. Nonsteroidal Antiinflammatory Drugs (NSAIDs) use is considered on a case-to-case basis (due to the risk of bleeding).

Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer

  • Population at risk:
    • For 30‒65 years of age, the options are:
      • Cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening every 3 years
      • High-risk HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) (hrHPV) screening Screening Preoperative Care every 5 years
      • Cytology with hrHPV co-testing every 5 years
    • Screening Screening Preoperative Care ends at age 65 years of age in the case of adequate negative screening Screening Preoperative Care, which is defined as:
      • 3 consecutive negative cytology results, with the last result within the past 3 years
      • 2 consecutive negative co-test results within the past 10 years, with the most recent test within the past 5 years
      • 2 consecutive negative primary HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) tests within the past 10 years, with the most recent test within the past 5 years
  • If adequate screening Screening Preoperative Care has not been performed, continue annual screening Screening Preoperative Care with co-testing for 3 years and then every 5 years until 80 years of age.
  • The decision to continue depends on whether the life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is ≥ 10 years and a discussion with the individual.
  • May be discontinued in individuals who have had a total hysterectomy:
    • With cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy removed for benign Benign Fibroadenoma causes
    • Without a history of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer or cervical intraepithelial neoplasia ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer)
Pap test

Pap test:
A speculum is inserted into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy to widen the area. Next, a brush is inserted into the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor: Anatomy to collect cells from the cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy. The cells are checked under a microscope for signs of disease.

Image by Lecturio.

Colorectal cancer Colorectal cancer Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer

  • 45–75 years of age: routine screening Screening Preoperative Care recommended for everyone
  • 76–85 years of age: selective screening Screening Preoperative Care (decision to continue based on individual preferences, prior screening Screening Preoperative Care results, and overall health status/ comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus)
  • Screening Screening Preoperative Care may be discontinued if the life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is < 10 years.
  • Screening Screening Preoperative Care options:
    • Annual high-sensitivity guaiac fecal occult blood test Fecal occult blood test Colorectal Cancer ( HSgFOBT HSgFOBT Stool-based test – Identifies hemoglobin in stool Colorectal Cancer Screening)
    • Annual fecal immunochemical test Fecal immunochemical test Stool-based test – Measures hemoglobin in the stool Colorectal Cancer Screening (FIT)
    • Stool DNA DNA A deoxyribonucleotide polymer that is the primary genetic material of all cells. Eukaryotic and prokaryotic organisms normally contain DNA in a double-stranded state, yet several important biological processes transiently involve single-stranded regions. DNA, which consists of a polysugar-phosphate backbone possessing projections of purines (adenine and guanine) and pyrimidines (thymine and cytosine), forms a double helix that is held together by hydrogen bonds between these purines and pyrimidines (adenine to thymine and guanine to cytosine). DNA Types and Structure (sDNA)-FIT test every 3 years
    • Flexible sigmoidoscopy Sigmoidoscopy Endoscopic examination, therapy or surgery of the sigmoid flexure. Colorectal Cancer Screening every 5 years (limited to the distal part of the colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy)
    • Flexible sigmoidoscopy Sigmoidoscopy Endoscopic examination, therapy or surgery of the sigmoid flexure. Colorectal Cancer Screening every 10 years + annual FIT
    • Colonoscopy Colonoscopy Endoscopic examination, therapy or surgery of the luminal surface of the colon. Colorectal Cancer Screening every 10 years
    • CT colonography CT colonography A non-invasive imaging method that uses computed tomographic data combined with specialized imaging software to examine the colon. Colorectal Cancer Screening every 5 years
Representation of colonoscopy

Representation of a colonoscopy Colonoscopy Endoscopic examination, therapy or surgery of the luminal surface of the colon. Colorectal Cancer Screening

Image by Lecturio.

Lung cancer Lung cancer Lung cancer is the malignant transformation of lung tissue and the leading cause of cancer-related deaths. The majority of cases are associated with long-term smoking. The disease is generally classified histologically as either small cell lung cancer or non-small cell lung cancer. Symptoms include cough, dyspnea, weight loss, and chest discomfort. Lung Cancer

  • 50–80 years of age: annual screening Screening Preoperative Care using low-dose CT of the chest for the following individuals:
    • 20 pack-year smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases history
    • Current smokers 
    • Have quit within the past 15 years
  • Screening Screening Preoperative Care is discontinued when:
    • Age ≥ 80 years
    • The individual has not smoked for 15 years.
    • Life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is limited.

Osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis

  • Women ≥ 65 years of age: Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types mineral density (BMD) screening Screening Preoperative Care is recommended.
  • The USPSTF states that there is not enough evidence to support screening Screening Preoperative Care in men.
  • However, other organizations (e.g., American College of Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship, Endocrine Society) recommend BMD screening Screening Preoperative Care in men > 70 years of age.
  • The most commonly used test is the central dual-energy X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests absorptiometry (DXA) of the hip and lumbar spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.

Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer

  • 2nd-most common cancer diagnosis in men; however, most men will die of another cause due to the typically slow growth of prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer. Thus, screening Screening Preoperative Care is controversial.
  • Men aged 55‒69 years: 
    • Decision to screen is based on preferences, risk factors, and potential risks/benefits.
    • If elected, a blood test to detect PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer alone is recommended as a screening Screening Preoperative Care strategy every 1‒2 years.
    • Digital rectal examination Digital Rectal Examination A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening ( DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening) is not recommended as a screening Screening Preoperative Care method with or without a PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer test.
  • Age ≥ 70 years: PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer screening Screening Preoperative Care is not recommended.
Prostate cancer pressing onto the urethra

Depiction of prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer pressing on the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy (urinary symptoms result)

Image by Lecturio.

Vaccine Recommendations

Herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination

  • CDC recommends that adults ≥ 50 years of age should decrease the risk of developing herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox ( shingles Shingles Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox) and postherpetic neuralgia Postherpetic neuralgia Pain in nerves, frequently involving facial skin, resulting from the activation the latent varicella-zoster virus. The two forms of the condition preceding the pain are herpes zoster oticus; and herpes zoster ophthalmicus. Following the healing of the rashes and blisters, the pain sometimes persists. Herpes Zoster (Shingles).
  • Vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. Vaccination should be performed irrespective of previous vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. Vaccination status or disease history:
    • Shingrix vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination requires 2 doses that are 2–6 months apart.
    • Zostavax (live-attenuated vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination) is no longer used in the US as of 2020 but is still used in other countries.

Influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination

  • > 90% of influenza-related deaths occur in individuals > 60 years of age.
  • Influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination should be given to all adults annually unless there is a history of allergic reactions Allergic Reactions Type I hypersensitivity reaction against plasma proteins in donor blood Transfusion Reactions to vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination components.

Pneumococcal vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination

  • Reduces the risk of pneumococcal infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease, particularly with Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus pneumoniae, which is the leading cause of bacterial pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
  • In all immunocompetent adults ≥ 65 years of age:
    • 1 dose of pneumococcal polysaccharide vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination (PPSV)23 is recommended.
    • If PPSV23 was given before the individual attained 65 years of age, give due dose at least 5 years after the previous dose.
  • Pneumococcal conjugate vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination (PCV)13 in adults ≥ 65 years of age:
    • PCV13-type disease has declined significantly among individuals ≥ 65 years of age due to pediatric vaccinations.
    • Shared decision-making is recommended in the case of PCV13 vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. Vaccination (if with risk factors, immunocompromising diseases, and impaired splenic function).
    • If PCV13 is to be administered, it is given 1st followed by PPSV23 after ≥ 1 year.

Tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus and diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria toxoids (Td) or Tdap

  • Approximately 60% of all tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus cases in the US occur in individuals > 60 years of age.
  • Vaccines:
    • Tdap ( tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination, reduced diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination, and acellular pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough))
    • Td
  • In the US:
    • Tdap or Td is given intramuscularly every 10 years to all adults with complete prior immunization to tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus and diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria.
    • If an adult has not been vaccinated against tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus and diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria, a 3-vaccine series is initiated with Tdap as the preferred 1st dose, followed by Td or Tdap.
  • Older adults:
    • Likely to have decreased antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions either from not having received the initial vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination or the subsequent booster doses
    • Tdap is important for older adults, especially those in contact with children < 1 year of age:
      • Tdap may be given once instead of the Td booster.
      • Tdap can be administered regardless of the interval since the last Td booster.

Functional Assessment

Functional status

  • Functional status is divided into 3 levels of ADLs:
    • Basic ADLs: self-care tasks such as bathing, dressing, feeding, and toileting
    • Instrumental ADLs (IADLs): complex skills to maintain independence such as driving, preparing meals, shopping, managing finances, and performing housework
    • Advanced ADLs: ability to fulfill various societal and familial roles and participate in recreational and occupational tasks
  • Screening Screening Preoperative Care:

Cognitive function

Hearing

  • Hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss:
    • 3rd-most common chronic condition (after hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension and arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis) among older adults in the US
    • Associated with cognitive decline, depression, social isolation, and functional disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment
    • Sensorineural hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss is caused by natural aging of the auditory system.
  • The USPSTF has no recommendations for or against screening Screening Preoperative Care for hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss in asymptomatic older adults.
  • Clinically recommended screening Screening Preoperative Care for hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss in individuals ≥ 65 years of age:
    • Pure tone audiometry Audiometry The testing of the acuity of the sense of hearing to determine the thresholds of the loWest intensity levels at which an individual can hear a set of tones. The frequencies between 125 and 8000 hz are used to test air conduction thresholds and the frequencies between 250 and 4000 hz are used to test bone conduction thresholds. Ménière Disease:
      • Gold standard to screen for hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss
      • Not readily available in primary care offices
    • Whispered-voice test:
      • Stand behind the individual (to prevent them from lip-reading) and mask the hearing in 1 ear.
      • A sequence of letters and numbers is whispered and the individual is asked to repeat them.
  • Refer to otolaryngology for any failed hearing test, chronic otitis media, and sudden hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss.
  • Hearing aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS for treatment

Vision Vision Ophthalmic Exam

  • Older adults are at a higher risk of visual impairments from conditions such as macular degeneration Macular degeneration Age-related macular degeneration (AMD) is visual impairment due to changes in the macula, the area responsible for high-acuity vision. It is marked by central vision loss with peripheral vision relatively spared. Risk factors include advanced age, smoking, family history, and cardiovascular disease. Macular Degeneration and cataracts.
  • The USPSTF has no recommendations for or against routine vision Vision Ophthalmic Exam screening Screening Preoperative Care in asymptomatic adults.
  • Clinically, vision Vision Ophthalmic Exam assessment is recommended for individuals with visual complaints, recent cognitive decline, functional impairments, or falls.

Falls

  • An important cause of morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status and mortality Mortality All deaths reported in a given population. Measures of Health Status among older adults
  • Approximately ⅓ of community-dwelling older adults > 65 years of age have a fall each year.
  • Evaluate the risk of falls:
    • Tinetti assessment tool:
    • Timed Up and Go (TUG) test:
      • Ask the individual sitting on a chair to stand, walk 10 feet forward, turn around, walk back, and sit down.
      • In general, ≥ 12 seconds suggests a high risk of falls.
      • Factors affecting results (e.g., age, joint problems, underlying conditions such as Parkinson’s disease) should be considered during the assessment.
  • Prevention:
    • PT and targeted training activity
    • Vitamin D Vitamin D A vitamin that includes both cholecalciferols and ergocalciferols, which have the common effect of preventing or curing rickets in animals. It can also be viewed as a hormone since it can be formed in skin by action of ultraviolet rays upon the precursors, 7-dehydrocholesterol and ergosterol, and acts on vitamin D receptors to regulate calcium in opposition to parathyroid hormone. Fat-soluble Vitamins and their Deficiencies supplementation
    • Securing the household environment (e.g., no clutter or loose rugs) 
    • Use of assistive devices and equipment (e.g., walkers, bedside commode, shower chair, grab bars)

Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence

  • A cause of major social and emotional distress in the geriatric population
  • Obtain a targeted history and conduct an examination:
    • Inquire about the presence or absence of urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence biannually.
    • Determine the onset of urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence (acute or chronic), type (e.g., urge, stress, overflow, mixed), and precipitating factors (e.g., cough, medications).
    • Examine:
      • For signs of fluid overload
      • Pelvic (genital and rectal) area
      • Neurologic evaluation
    • Urine and blood tests as indicated, depending on the presenting factors
  • Routine urodynamic testing is not recommended.

Psychosocial Evaluation

Depression

Financial and social support

  • Ask about financial and social resources.
  • Limited resources directly impact an individual’s health.
  • Provide information regarding the availability of assistance for the elderly in the community (e.g., food pantries, centers for seniors, organizations helping with prescriptions).

Elder abuse

  • Up to 8% of older adults are affected by elder abuse.
  • USPSTF: Ask older individuals specific questions about abuse.
  • Further inquiry and referral to social services are required if the individual exhibits the following signs of abuse and/or neglect Neglect Child Abuse:
    • Contusions, burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns, bite marks
    • Genital or rectal trauma
    • Pressure ulcers
    • BMI BMI An indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese). Obesity < 17.5 (without clinical explanation)

Advanced directives

  • It is important to have discussions with older adults regarding advanced care directives while they still have the cognitive capacity to make decisions.
  • Preferences regarding specific treatments, end-of-life interventions, and the appointed healthcare proxy should be documented.

References

  1. Albrecht, M.A., Levin, M.J. (2021). Vaccination for the prevention of shingles (herpes zoster). UpToDate. Retrieved January 4, 2021, from https://www.uptodate.com/contents/vaccination-for-the-prevention-of-shingles-herpes-zoster
  2. Barry, E., Galvin, R., Keogh, C., Horgan, F., Fahey, T. (2014). Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatrics. 14. https://doi.org/10.1186/1471-2318-14-14
  3. Elmore, J.G., Lee, C.I. (2020). Screening for breast cancer: Strategies and recommendations. UpToDate. Retrieved December 18, 2020, from https://www.uptodate.com/contents/screening-for-breast-cancer-strategies-and-recommendations
  4. Feldman, S., Goodman, A., Peipert, J.F. (2020). Screening for cervical cancer in resource-rich settings. UpToDate. Retrieved December 18, 2020, from https://www.uptodate.com/contents/screening-for-cervical-cancer-in-resource-rich-settings
  5. Heflin, M.T. (2021). Geriatric health maintenance. UpToDate. Retrieved August 25, 2021, from https://www.uptodate.com/contents/geriatric-health-maintenance
  6. Hoffman, R.M. (2021). Screening for prostate cancer. UpToDate. Retrieved August 25, 2021, from https://www.uptodate.com/contents/screening-for-prostate-cancer
  7. Kiel, D. (2021). Falls in older persons: Risk factors and patient evaluation. UpToDate. Retrieved August 25, 2021, from https://www.uptodate.com/contents/falls-in-older-persons-risk-factors-and-patient-evaluation
  8. Morey, M.C. (2021). Physical activity and exercise in older adults. UpToDate. Retrieved February 16, 2021, from https://www.uptodate.com/contents/physical-activity-and-exercise-in-older-adults
  9. Musher, D.M. (2021). Pneumococcal vaccination in adults. UpToDate. Retrieved August 25, 2021, from https://www.uptodate.com/contents/pneumococcal-vaccination-in-adults
  10. Phelan, E.A., Mahoney, J.E., Voit, J.C., Stevens, J.A. (2015). Assessment and management of fall risk in primary care settings. The medical clinics of North America. 99, 281–293. https://doi.org/10.1016/j.mcna.2014.11.004
  11. Rochon, P.A. (2021). Drug prescribing for older adults. UpToDate. Retrieved February 16, 2021, from https://www.uptodate.com/contents/drug-prescribing-for-older-adults
  12. United States Preventive Services Task force. (2018). Final recommendation statement: Prostate Cancer: Screening. Retrieved August 25, 2021, from https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/prostate-cancer-screening
  13. United States Preventive Services Task force. (2016). Breast Cancer: Screening. Retrieved August 25, 2021, from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening
  14. United States Preventive Services Task force. (2016). Colorectal Cancer: Screening. Retrieved August 25, 2021, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
  15. United States Preventive Services Task force. (2021). Lung Cancer: Screening. Retrieved August 25, 2021, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
  16. United States Preventive Services Task force. (2019). Abdominal Aortic Aneurysm: Screening. Retrieved August 25, 2021, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/abdominal-aortic-aneurysm-screening
  17. United States Preventive Services Task force. (2018). Osteoporosis to Prevent Fractures: Screening. Retrieved August 25, 2021, from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening
  18. Vijan, S. (2021). Screening for lipid disorders in adults. UpToDate. Retrieved January 14, 2021, from https://www.uptodate.com/contents/screening-for-lipid-disorders-in-adults
  19. Ward, K.T., Reuben, D.B. (2021). Comprehensive geriatric assessment. UpToDate. Retrieved February 16, 2021, from https://www.uptodate.com/contents/comprehensive-geriatric-assessment
  20. Yu, E.W. (2021). Screening for osteoporosis in postmenopausal women and men. UpToDate. Retrieved February 16, 2021, from https://www.uptodate.com/contents/screening-for-osteoporosis

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