GERIATRIC SCREENING in 2019 Dale C. Moquist, MD C. Frank Webber - PowerPoint PPT Presentation

GERIATRIC SCREENING in 2019 Dale C. Moquist, MD C. Frank Webber Lecture April 6, 2019 1

DISCLOSURE  Dr. Moquist has disclosed that the has no actual or potential conflict of interest in relation to this topic.  Dr. Moquist will not discuss or present information that is related to an off-label or investigational use of any therapy, product, or device. 2

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Learning Objectives By the end of this educational activity, the participant should be better able to: 1. Discuss the U.S. Preventive Services Task force Level A and B Recommendations. 2. Determine the predicted longevity of your geriatric patients. 3. Give your patients an improved understanding of screening procedures. 4. Determine which patients will benefit. 4

To Participate, look for the Audience Polling Questions button for each CME session, or visit tafp.cnf.io in your browser Respond to Polls when Ask a they appear Question Audience Polling Up-Vote a Questions Question Vote / Ask Questions / Respond to Polls

Outline Screening Issues Life Expectancy Ounce of Prevention Screening Recommendations The Email 6

Screening Issues Who Benefits? 7

Effective Medical Screening  Common disease and significant mortality  Accurate test  Tolerable  Positive result allow for beneficial intervention  Test is cost effective  Cure is cost effective 8

Quandary  We have many healthy active older adults  Guidelines do NOT address these adults  No evidence of one age at which potential benefits of screening suddenly cease or potential harms suddenly become substantial  Need to consider life expectancy  Need to consider comorbidities  Lifetime risk of dying from a particular cancer  Patient preferences 9

Choosing Wisely  Society of General Medicine  Don’t recommend cancer screening in adults with life expectancy of less than 10 years  Mortality benefit emerges years after the test is performed  Expose patients to immediate potential harms 10

Lag Time for Preventive Screening Lag Time to Benefit Common Clinical Intervention Screening 1-2 Months SSRIs for Depression 6 Months Statins for Secondary Prevention of Cardiovascular Disease, Finasteride for BPH 1-2 Years BP Control for Primary Prevention of Cardiovascular Disease 1-3 Years Strict BP and Lipid Control in Type 2 Diabetes 8-10 Years Tight Glycemic Control for Prevention of MV CX 10 Years Colon and Breast Cancer Screening for Reducing Mortality 11

Risk (%) of Dying of Cancer for Patients at Average Risk Type 50 70 75 80 85 90 Breast 3.1 2.2 1.8 1.5 1.2 0.8 Colorectal 2.3 2.1 1.9 1.8 1.6 1.1 Men Colorectal 2.2 2.0 1.9 1.8 1.6 1.0 Women Cervical 0.26 0.15 0.12 0.10 .07 .05 Walter LC, Covinsky KE. Cancer Screening in Elderly Patients: A framework for individualized decision making. JAMA. 2001;285 (21):2752. 12

Life Expectancy Lee 10-year Mortality Prediction Schonberg 10-year Mortality Prediction Charlson Comorbidity Index Charlson Online www.ePrognosis.ucsf.edu 13

Life Expectancy  No survival benefit unless LIFE EXPECTANCY exceeds TEN years for cancer screening  AGS, ACP , AAFP , and USPSTF reflect this uncertainty  Lack of direct evidence for patients > 70  Good functional status and NO comorbidities are presumed to be in the upper quartile (75 th percentile)  Patients with significant comorbidity and functional impairment are presumed to be in lower quartile (25 th percentile) 14

Table 2—Average Life Expectancy Based on Estimates of HealthAge Quartile of Life Expectancy (years) Women Men 75th 50th 25th 75th 50th 25th 65 26.9 21.2 14.2 24.3 18.3 11.4 70 22.2 16.9 10.7 19.8 14.4 8.5 75 17.8 12.9 7.6 15.6 10.8 6.0 80 13.6 9.3 5.1 11.8 7.7 4.0 85 9.9 6.3 3.2 8.5 5.2 2.5 90 6.9 4.1 1.9 5.9 3.4 1.6 95 4.7 2.6 1.2 4.1 2.2 1.0 SOURCE: Data from Arias E. National Vital Statistics Reports. Natl Vital Stat Reports. 2015;64(11):1–63. 15

Prognostic Tool for Life Expectancy Lee SJ. Development and Validation of a Prognostic Index for 4-year Mortality in  Older Adults. JAMA. 2006: 295;801-808 and JAMA 2013;309:874-876.  Community-based Older Adults: Mean age 67 years  Comorbid conditions and functional measures  Requires NO medical records or lab data  Needed information can be obtained from patient  Uses risk factors and assigns points  Use total of points to determine mortality in the next 4 and 10 years 16

Risk Factors Disease/Function Points Diabetes 1 Age Points Cancer 2 60-64 1 Lung Disease 2 65-69 2 Heart Failure 2 70-74 3 BMI < 25 1 75-79 4 Current Smoker 2 80-84 5 Bathing Problem 2 85 or older 7 Managing Finances 2 Male 2 Walking Several City Blocks 2 Female 0 Pushing/Pulling (Living Room Chair) 1 17

10-Year Mortality by Point Score 7 40% 0 2.8% 8 52 1 4.0% 9 62% 2 6.0% 10 71% 3 9.1% 11 81% 4 14% 12 85% 5 21% 13 89% >14 95% 6 30% 18

Index to Predict 10-Year Mortality  National Health Interview Survey  Community dwelling  Self-reporting  Developed and validated in 1997-2000: 24,139  Retested in 2001-2004: 22,057 with follow-up in 2006  Men 42%  11 Factors: Function, illnesses, behaviors, and demographics  Excellent discrimination after 14 years 19

Mortality Index for Adults >65 Age: 65-69: 0 Points  70-74: 1 Point 75-79: 3 Points 80-84: 5 Points 85+: 7 Points Sex: Female: 0 Points – Male: 3 Points  BMI < 25 2 Points  Your Health in General is: Excellent/Very Good: 0 Points  Good: 1 Point Fair/Poor: 2 Points 20

Mortality Index for Adults > 65  Have been told by doctor you have: No: 0, Yes: 2 points  Emphysema/Chronic Bronchitis  Cancer (exclude skin)  Diabetes (include borderline)  Do you need help in ADLs or IADLS – No: 0, Yes: 2 points  How difficult is it for you to walk a quarter of a mile – about 3 city blocks?  Not at all difficult: 0 points  Little difficult to very difficult: 3 points  Can’t do at all: 3 points 21

Mortality Index for Adults > 65  Which best describes your cigarette use? Never smoked (less than 100 in entire life): 0 points  Former smoker: 1 point  Current smoker: 3 points   During the past 12 months, how many times were you hospitalized overnight? None: 0 points  Once: 1 point  Twice or More: 3 points  Schonberg M. External Validation of an Index to Predict Up to 9-Year Mortality of Community Dwelling Adults Aged 65 and Over. JAGS. August 2011; 59:1444-1451. 22 Schonberg M. Predicting Mortality up to 14 Years Among Community Dwelling Adults Aged 65 and Over. JAGS. June 2017;65:1310-1315

10-Year Mortality Using the Index Points 10-Year Points 10 Year Mortality % Mortality 0 5 10 53 1 11 11 60 2 9 12 60 3 12 13 68 4 15 14 74 5 21 15 76 6 26 16 87 7 37 17 86 8 37 18+ 92 9 44 23

Charlson Comorbidity Score Points 1 2 3 6 MI Hemiplegia Mild Liver Mod-Severe Renal Mod-Severe Liver Metastatic Solid Tumor Disease Disease Disease ConnectiveTissue DM with End Organ Disorder COPD Cancer AIDS DM (no organ) Cerebrovascular Dementia PUD PVD CHF 24

Using Charlson Comorbidity Score  Total score of 0: Upper 25%  Total score of 1 or 2: Middle 50%  Total score of > 3: Lower 25% 25

Life Expectancy for Women Age Life Life Life Expectancy Expectancy Expectancy Lower 25% Middle 50% Upper 25% 70 9.5 15.7 21.7 75 6.8 11.9 17 80 4.6 8.6 13 85 2.9 5.9 9.6 90 1.8 3.9 6.8 95 1.1 2.7 4.8 26

Life Expectancy for Men Age Life Life Life Expectancy Expectancy Expectancy Lower 25% Middle 50% Upper 25% 70 6.7 12.4 18 75 4.9 9.3 14.2 80 3.3 6.7 10.8 85 2.2 4.7 7.9 90 1.5 3.2 5.8 95 1 2.3 4.3 27

Charlson Comorbidity on Line  Free online  Go to www.medal.org  Sign up with username and password  Search for Charlson  Put in data and submit 28

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www.ePrognosis.ucsf.edu  Calculators vs. cancer screening vs. communicating prognosis  Living at home vs. nursing home vs. hospital vs. hospice  United States vs. not in the US  Time Frame: 1 year vs. 4 to 14 years  65 years or older  Gives you Lee and Schonberg indexes  Email or print report 32

Five Methods to Determine Life Expectancy  Use point system designed by Lee to determine 10-year mortality  Use Schonberg index to determine 10-year mortality  Use point system with Charlson comorbidity index  Use online Charlson comorbidity score to determine chance of 10-year survival  www.ePrognosis.ucsf.edu 33

Ounce of Prevention Vital Signs Immunizations Chemoprevention 34

Start With Vital Signs  Blood Pressure – Consider every visit  Weight – Consider every visit  Height – Once a year 35

Adult Immunizations  Annual Influenza  Pneumococcal series after age 65  Herpes Zoster – once after age 60 – series of two  Tetanus booster every 10 years –Tdap  Recommended for adults > 65 with close contact with an infant < 12 months  https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html  Go to App store and search for shots 36