Older Adult 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 are essential in this age group because of the high risk for infections 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, hearing, cognitive function, gait, and balance are among the functions that decline in the geriatric population. These disease- and age-related factors affect 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.

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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, and hearing impairment) 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, social workers, nutritionists, physical therapists) working together to assess the following:

  • Physical health:
    • Address and manage current chronic conditions (e.g., heart failure, hypertension, diabetes, CKD).
    • Discuss nutrition and medication use.
    • Appropriate screening for other diseases
    • Update the necessary vaccinations.
  • Functional ability:
    • Ask about impairments in activities of daily living (ADLs).
    • Address any limitations in their physical and mental abilities:
      • Check for cognitive decline and memory disturbances.
      • Hearing and vision assessment
      • Driving assessment
      • Falls and other incidents contributing to functional limitations
  • Psychosocial health:
    • Depression may go undetected, as symptoms present in atypical ways.
    • Suicide rate is higher in the elderly than in the general population.
    • Social environment:
      • Inquire about family members and support groups.
      • Home safety
      • Screen for any mistreatment.
      • Screen for financial constraints (directly affects health).
  • Advanced care planning

Physical Health

Nutrition

  • Appetite and body weight generally decline with age.
  • Lean mass decreases and fat mass usually increases in this population.
  • Unintentional weight loss occurs in 15%–20% of older adults.
    • Associated with higher risks for morbidity and mortality
    • Major causes include:
      • Cancer
      • Psychiatric or cognitive conditions
      • Medication side effects
      • Changes in social environment or isolation
    • Proceed with workup of unintentional weight loss based on presentation (e.g., labs, imaging studies, and cancer screening, if not yet completed).

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 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 limitations.
  • Generally, the American Heart Association 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 training, or weight-bearing calisthenics) to maintain or improve strength
    • A gradual increase in time and intensity is recommended.
  • Routine testing such as 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 or 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 drug 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 muscle mass.
    • 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 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 are the most commonly used medications that are considered potentially inappropriate.
Table: Medications that are potentially inappropriate for older adults
MedicationsSide effects
Antipsychotics
  • Associated with a high risk of falling and fracture
  • Higher risk of mortality when used for behavioral control in dementia
GlyburideLong-acting sulfonylurea associated with a high risk of hypoglycemia
BenzodiazepinesIncreased risk of delirium, sedation, and falls
OpioidsIncreased risk of delirium, sedation, falls, constipation, urinary retention, and respiratory depression
Anticholinergics (includes some antidepressants and antihistamines)Increased risk of delirium, sedation, falls, constipation, and urinary retention
NSAIDs
  • Increased risk of GI bleeding, especially with concomitant anticoagulants
  • Increased risk of renal impairment
  • Possible cardiovascular risk
α-BlockersIncreased risk of hypotension
Proton pump inhibitors (PPIs)
  • Increased risk of Clostridium difficile infections
  • Increased risk of vitamin B12 malabsorption

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. Most screenings are generally not indicated if the life expectancy is < 5 years.

Abdominal aortic aneurysm

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

Breast cancer

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

  • Women between 50 and 74 years of age: mammography screening every 2 years
  • Women > 75 years of age: insufficient evidence to support screening (American Cancer Society suggests the option of screening if life expectancy > 10 years)

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 for diabetes mellitus:
    • Part of cardiovascular risk assessment
    • The USPSTF recommends diabetes screening for individuals who are 40–70 years of age and those who are overweight or obese (BMI ≥ 25).
    • Fasting glucose or HbA1c screening (abnormal result needs a repeat test for confirmation) 
  • Screening for lipids:
    • Formal cardiovascular risk assessment for all individuals who are 40–79 years of age:
      • Includes identifying risk factors: hypertension, diabetes mellitus, smoking, obesity, family history of CVD and elevated cholesterol, CKD
      • Obtain lipid profile.
    • No definite studies that indicate the appropriate age to stop screening
    • If > 1 prior lipid profiles have been normal, screening can be stopped at 65 years of age.
  • Aspirin use is considered on a case-to-case basis (due to the risk of bleeding).

Cervical cancer

  • Population at risk:
    • For 30‒65 years of age, the options are:
      • Cervical cytology every 3 years
      • High-risk HPV (hrHPV) screening every 5 years
      • Cytology with hrHPV co-testing every 5 years
    • Screening ends at age 65 years of age in the case of adequate negative screening, 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 tests within the past 10 years, with the most recent test within the past 5 years
  • If adequate screening has not been performed, continue annual screening 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 is ≥ 10 years and a discussion with the individual.
  • May be discontinued in individuals who have had a total hysterectomy:
    • With cervix removed for benign causes
    • Without a history of cervical cancer or cervical intraepithelial neoplasia (CIN)

Colorectal cancer

  • 45–75 years of age: routine screening recommended for everyone
  • 76–85 years of age: selective screening (decision to continue based on individual preferences, prior screening results, and overall health status/comorbidities)
  • Screening may be discontinued if the life expectancy is < 10 years.
  • Screening options:
    • Annual high-sensitivity guaiac fecal occult blood test (HSgFOBT)
    • Annual fecal immunochemical test (FIT)
    • Stool DNA (sDNA)-FIT test every 3 years
    • Flexible sigmoidoscopy every 5 years (limited to the distal part of the colon)
    • Flexible sigmoidoscopy every 10 years + annual FIT
    • Colonoscopy every 10 years
    • CT colonography every 5 years

Lung cancer

  • 55–80 years of age: annual screening using low-dose CT of the chest for the following individuals:
    • 20 pack-year smoking history
    • Current smokers 
    • Have quit within the past 15 years
  • Screening is discontinued when:
    • Age ≥ 80 years
    • The individual has not smoked for 15 years.
    • Life expectancy is limited.

Osteoporosis

  • Women ≥ 65 years of age: Bone mineral density (BMD) screening is recommended.
  • The USPSTF states that there is not enough evidence to support screening in men.
  • However, other organizations (e.g., American College of Physicians, Endocrine Society) recommend BMD screening in men > 70 years of age.
  • The most commonly used test is the central dual-energy X-ray absorptiometry (DXA) of the hip and lumbar spine.

Prostate cancer

  • 2nd-most common cancer diagnosis in men; however, most men will die of another cause due to the typically slow growth of prostate cancer. Thus, screening 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 alone is recommended as a screening strategy every 1‒2 years.
    • Digital rectal examination (DRE) is not recommended as a screening method with or without a PSA test.
  • Age ≥ 70 years: PSA screening is not recommended.

Vaccine Recommendations

Herpes zoster vaccine

  • CDC recommends that adults ≥ 50 years of age should decrease the risk of developing herpes zoster (shingles) and postherpetic neuralgia.
  • Vaccination should be performed irrespective of previous vaccination status or disease history:
    • Shingrix vaccine requires 2 doses that are 2–6 months apart.
    • Zostavax (live-attenuated vaccine) is no longer used in the US as of 2020 but is still used in other countries.

Influenza vaccine

  • > 90% of influenza-related deaths occur in individuals > 60 years of age.
  • Influenza vaccine should be given to all adults annually unless there is a history of allergic reactions to vaccine components.

Pneumococcal vaccine

  • Reduces the risk of pneumococcal infections, particularly with Streptococcus pneumoniae, which is the leading cause of bacterial pneumonia
  • In all immunocompetent adults ≥ 65 years of age:
    • 1 dose of pneumococcal polysaccharide vaccine (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 (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 (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 and diphtheria toxoids (Td) or Tdap

  • Approximately 60% of all tetanus cases in the US occur in individuals > 60 years of age.
  • Vaccines:
    • Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis)
    • Td
  • In the US:
    • Tdap or Td is given intramuscularly every 10 years to all adults with complete prior immunization to tetanus and diphtheria.
    • If an adult has not been vaccinated against tetanus and 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 either from not having received the initial vaccine 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:
    • Screen for impairments in ADLs via direct questioning or based on standardized screening tools.
    • Assess driving ability and safety in individuals > 70 years of age (group with increased risk for motor vehicle accidents and higher risks of mortality).

Cognitive function

  • Screening is recommended for individuals with memory complaints using validated tools (e.g., Mini-Mental State Examination (MMSE), Mini-Cog, clock-drawing test).
  • Cognitive screening is not recommended for asymptomatic individuals.

Hearing

  • Hearing loss:
    • 3rd-most common chronic condition (after hypertension and arthritis) among older adults in the US
    • Associated with cognitive decline, depression, social isolation, and functional disability
    • Sensorineural hearing loss is caused by natural aging of the auditory system.
  • The USPSTF has no recommendations for or against screening for hearing loss in asymptomatic older adults.
  • Clinically recommended screening for hearing loss in individuals ≥ 65 years of age:
    • Pure tone audiometry:
      • Gold standard to screen for 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 aids for treatment

Vision

  • Older adults are at a higher risk of visual impairments from conditions such as macular degeneration and cataracts.
  • The USPSTF has no recommendations for or against routine vision screening in asymptomatic adults.
  • Clinically, vision assessment is recommended for individuals with visual complaints, recent cognitive decline, functional impairments, or falls.

Falls

  • An important cause of morbidity and mortality 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:
      • Also called Performance-Oriented Mobility Assessment (POMA) tool
      • Assesses balance and gait, scale-based scoring
    • 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 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

  • 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 biannually.
    • Determine the onset of 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

  • The USPSTF recommends screening all adults for depression.
  • Short screening tools, such as Patient Health Questionnaire-2, are available.
  • Refer to appropriate services when screening results are positive.

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:
    • Contusions, burns, bite marks
    • Genital or rectal trauma
    • Pressure ulcers
    • BMI < 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

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