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

Dale C. Moquist, MD

• C. Frank Webber Lecture

April 6, 2019

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GERIATRIC SCREENING in 2019

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.

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Learning Objectives

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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.

Ask a Question Up-Vote a Question

To Participate, look for the Audience Polling Questions button for each CME session, or visit tafp.cnf.io in your browser

Vote / Ask Questions / Respond to Polls

Respond to Polls when they appear Audience Polling Questions

Outline

Screening Issues Life Expectancy Ounce of Prevention Screening Recommendations The Email

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Screening Issues

Who Benefits?

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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

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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

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Choosing Wisely

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 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

Lag Time for Preventive Screening

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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

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 Men 2.3 2.1 1.9 1.8 1.6 1.1 Colorectal Women 2.2 2.0 1.9 1.8 1.6 1.0 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.

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Life Expectancy

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

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Life Expectancy

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 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 (75th percentile)

 Patients with significant comorbidity and functional impairment are

presumed to be in lower quartile (25th percentile)

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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.

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

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Risk Factors

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

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10-Year Mortality by Point Score

2.8% 1 4.0% 2 6.0% 3 9.1% 4 14% 5 21% 6 30% 7 40% 8 52 9 62% 10 71% 11 81% 12 85% 13 89% >14 95%

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Index to Predict 10-Year Mortality

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 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

Mortality Index for Adults >65

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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

Mortality Index for Adults > 65

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 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

Mortality Index for Adults > 65

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 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. 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

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Points 10-Year Mortality % Points 10 Year Mortality 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

Charlson Comorbidity Score

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

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Using Charlson Comorbidity Score

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

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Life Expectancy for Women

Age Life Expectancy Life Expectancy Life 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

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Life Expectancy for Men

Age Life Expectancy Life Expectancy Life 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

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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

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www.ePrognosis.ucsf.edu

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 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

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

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Ounce of Prevention

Vital Signs Immunizations Chemoprevention

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Start With Vital Signs

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 Blood Pressure – Consider every visit  Weight – Consider every visit  Height – Once a year

Adult Immunizations

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 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

Audience Polling 1 What would you recommend for pneumonia immunization in a naïve patient?

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• 1. Only PCV13
• 2. Only PPSV23
• 3. PSV13 bow followed by PPSV23 in 6-12 months
• 4. PPSV23 now followed by PCV13 in 1 year

How to Use PPSV23 (Pneumococcal Vaccine Polyvalent) and PCV13 (Pneumococcal Conjugate Vaccine)

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 PCV13 at age > 65 for vaccine-naïve persons  Followed by PPSV23 6-12 months later  Received PPSV23 at age > 65  PCV13 at least one year after pneumovax  People received PPSV23 before age 65  Give PCV13 at least one year after PPSV23  Give PPSV23 6-12 months after PCV13  Second dose of PPSV23 given at least 5 years after initial dose

Chemoprophylaxis

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 Multivitamins – not recommended  Hormone Therapy – not recommended  Vitamin D and Calcium therapy  Aspirin

Audience Polling 2 What are USPSTF recommendations?

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• 1. Recommends Vitamin D 400 IU and Calcium 1000 mg for primary

prevention of function in community-dwelling postmenopausal women

• 2. Recommends against daily supplementation with Vitamin D > 400 IU

and Calcium > 1000 mg in community dwelling postmenopausal women

• 3. Insufficient evidence for Vitamin D and Calcium supplementation for

primary prevention of function in men and women

• 4. Recommends Vitamin D supplementation to prevent falls in community

dwelling adults 65 or older

Audience Polling 3

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72 year-old woman comes to the office for her annual wellness visit. She reports she has oatmeal or a cold cereal without milk for breakfast. Lunch consist of crackers and 2 oz of low-fat cheese with carrots or beets. At dinner, she has another 2 oz of cheese. Which is the most appropriate recommendation for calcium intake for her bone health?

• 1. Continue with current dietary calcium intake
• 2. Add 2 oz of milk or cheese to her morning meal
• 3. Add calcium citrate 1200 mgm in divided doses
• 4. Add calcium carbonate 1200 mgm in a single dose
• 5. Add calcium carbonate 400 mgm in a single dose

AGS Recommendations

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 Consensus statement recommends Vitamin D supplementation of at least

1000 IU and Calcium supplementation of 500-1200 mg in community- dwelling older adults > 65 to reduce risks of fracture and falls

• 1. Recommend Vitamin D 4000 IU from all sources
• 2. Routine lab testing is not necessary
• 3. Vitamin D concentration of 30 ng/ml in patients at high risk of falls,

injuries, and fractures

• 4. If monitored should be measured after 4 months

USPSTF On Aspirin April 2016

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 Aged 60-69: Initiate low dose for primary prevention of

cardiovascular disease and colorectal cancer in adults aged 60-69 who have a 10% or greater 10-year cardiovascular disease should be an individual one – not at increased risk of bleeding, life expectancy > 10 years, and willing to take for > 10 years

 Insufficient evidence to assess balance of benefits and harms for

aspirin use for primary prevention of cardiovascular disease and colorectal cancer in adults 70 years or older

Recent ASA Evidence

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 Three articles in NEJM October 18, 2018  Higher all-cause mortality was observed among apparently healthy older

adults (>70) who received daily aspirin than among those who received placebo

 Aspirin use in healthy elderly persons did not prolong disability-free

survival over a period of 5 years but led to a higher rate of major hemorrhage than placebo

 Aspirin did not result in a significantly lower risk of cardiovascular

disease than placebo

Screening Recommendations

USPSTF Grade Definitions Case Discussions

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USPSTF Grade Definitions

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Grade Definition Suggestions for Practice

A

The USPSTF Recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service

B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service

C

The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. Offer or provide this service for selected patients depending on individual circumstances

D

The USPSTF recommends against the service.There is moderate

• r high certainty that the service has no net benefit or that the

harms outweigh the benefits. Discourage the use of this service

I

The USPSTF concludes the the current evidence is insufficient to assess the balance of benefits and harms of the service. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms

Case for Discussion

 Mrs. Olsen is a 76 y/o white female with hypertension and

• steoarthritis. She swims almost daily and is active in the community.

Her meds include 81 mg of ASA and HCTZ 12.5 mgm po daily. Her BMI is 21.

 She is asking you what preventive services she should receive? Her

numerous pap smears have been normal. She is not sexually active. Her colonoscopy was at age 62 with a benign polyp. Her last mammogram 5 years ago was normal. She has never smoked.

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What Screening Issues Does She Have?

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 Does she need to take daily ASA?  Does she need a pap smear?  Should she have a mammogram?  Should she be screened for colon cancer?  Is a bone density indicated?  What about a lipid panel?

Audience Polling 4 According to the USPSTF, Mrs. Olson should take daily ASA to prevent:

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• 1. Myocardial Infarction
• 2. Stroke
• 3. Colon Cancer
• 4. MIs and Strokes
• 5. Evidence is insufficient

Audience Polling 5 When would you do a pap smear for a woman of

• Mrs. Olson’s age?

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• 1. Less than 3 consecutive negative pap smears
• 2. In utero exposure to DES
• 3. History of cervical cancer 10 years ago
• 4. History of precancerous lesion 10 years ago
• 5. All of the above

USPSTF on Pap August 2018

 The USPSTF recommends against routinely screening women older than

age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical

• cancer. Grade: D Recommendation

 The USPSTF recommends against routine Pap smear screening in

women who have had a total hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous (CIN Grade 2 or 3) lesion or cervical cancer. Grade: D Recommendation.

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When Should You Do a Pap Smear?

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 Less than 3 consecutive negative pap smears or 2 consecutive neg HPV

results within 10 years with most recent test performed within 5 years

 Routine screening for at least 20 years after spontaneous regression or

appropriate management of a high-grade precancerous lesion even if this screening extends past 65 years

 Never have been screened: Limited access to care for women from

countries where screening is NOT available

 Utero exposure to DES  Immunocompromised

Audience Polling Based on the USPSTF there is insufficient evidence to recommend mammograms after age:

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• 1. 65 years
• 2. 70 years
• 3. 75 years
• 4. 80 years

Mammogram Evidence January 2016

 The USPSTF recommends biennial screening mammography for women

aged 50 to 74 years. Grade: B Recommendation

 The USPSTF concludes that the current evidence is insufficient to assess

the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Recommendation

 USPSTF concludes that the current evidence is insufficient to assess the

the balance of benefits and harms of breast ultrasound, MRI, DBT, or

• ther methods in dense breasts. Grade: I Recommendation

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Evidence For Mammograms

 The number of breast cancer deaths increases with age  Women aged 40-49 benefit the least  Women aged 60-69 benefit the most  Women aged 40-49 with first-degree relative with breast cancer have similar

risk as women aged 50-59

 Screening 10,000 Women over a 10-year period  Ages 50-59 result in 8 fewer breast cancer deaths  Ages 60-69 results in 21 fewer breast cancer deaths  Age 70-74 results in 13 fewer breast cancer deaths  Direct evidence for screening >75 is lacking

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Colon Cancer Screening June 2018



The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. Grade: A Recommendation



The USPSTF recommends routine screening for colorectal cancer in adults age 76 to 85 years should be an individual one taking into account the patient’s overall health and prior screening history.

 Adults who have never been screened are more likely to benefit.  Screening is most appropriate in adults who are healthy enough to undergo Rx and

do not have comorbid conditions that significantly limit their life expectancy



Grade: C Recommendation



Update in progress

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More Evidence

 The USPSTF recommends against screening for colorectal

cancer in adults older than age 85 years. Grade: D Recommendation

 The USPSTF concludes that the evidence is insufficient to assess

the benefits and harms of computed tomographic colonography. Grade: I Statement

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Potential Colonoscopy Complications

 Bowel prep with cardiac and renal complications  Potential for falls  Sedation causes CNS depressant  Aspiration concern  Perforation risk increased  Diverticular Disease  Prior Pelvic Disease  Bleeding risk

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Multi-Target Stool DNA Test

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 Medicare covers every 3 years  Cologuard  Must meet ALL these conditions  Age 50-85  No signs or symptoms of colorectal disease  Average risk of developing colorectal cancer

 No history of polyps, colorectal cancer and IBD  No family history of colorectal cancers or polyps, familial adenomatous

polyposis or hereditary nonpolyposis colorectal cancer

Colonoscopy in Elderly Patients

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 Retrospective cohort study: Patients 50 and older  History of colorectal cancer or adenomatous polyps  Reference group: 22,929 ages 50-74  4834 patients > 75 age: 55.8% male  Total 373 CRC: 368 reference and 5 among elderly  711 post hospitalizations: 184 reference and 527 elderly  Incidence: Elderly 0.24 and 3.61 in reference  Risk of hospitalizations: Age 75 and Charlson Score of 2

Tran A. Surveillance Colonoscopy in Elderly Patients: A Retrospective Cohort Study. JAMA Inter Med. Published Online August 11, 2014.

Bone Density Evidence June 2018

 The USPSTF recommends screening for osteoporosis with bone

measurement testing to prevent osteoporotic fracture in women aged 65 years or older. Grade: B Recommendation

 The USPSTF recommends screening for osteoporosis with bone

measurement testing to prevent osteoporotic fractures in postmenopausal women younger that 65 years who are at increased risk

• f osteoporosis. Grade: B Recommendation

 Risks: Parental history of hip fracture, smoking, excessive alcohol use,

corticosteroid use, rheumatoid arthritis, and low body weight

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What is Her Risk for Fracture?

 Risk tool has been developed  Multiple ethnic backgrounds  U.S. Caucasian  U.S. Black  U.S. Hispanic  U.S. Asian

www.shef.ac.uk/FRAX/tool.aspx?country=9

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FDA-Approved Medical Treatment

 Postmenopausal women and men >50  Hip or vertebral fracture  T-score < -2.5 at femoral neck or spine  Low bone mass (osteopenia) and 10-year probability of hip

fracture > 3% and 10-year probability of a major fracture > 20%

 Clinical judgment and/or patient preferences

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Statin Use for Primary Prevention November 2016

 The USPSTF recommends adults without a history of

cardiovascular disease (CAD or Ischemic Stroke) use a low to moderate dose statin for the prevention of CVD events and mortality when

 Aged 40-75  One or more risk factors: Dyslipidemia, diabetes, hypertension, or

smoking

 Calculated 10-year risk of cardiovascular event or 10% or greater

Grade: B Recommendation. November 2016

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More on Statins

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 Clinicians may choose to offer low-to-moderate dose statin in

certain adults for primary prevention without a history of cardiovascular when all of the following criteria are met:

 Aged 45-75  One or more cardiovascular risk factors: Dyslipidemia, diabetes,

hypertension, or smoking

 Calculated 10-year risk of cardiovascular event of 7.5% to 10.0%

Grade: C Recommendation. November 2016

Statin Use in Adults Older Than 76

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USPSTF concludes the current evidence is insufficient to assess the balance of benefits and harms of initiating statin use for the primary prevention of cardiovascular events and mortality in adults 76 years and older without a history of heart attack or stroke. Grade: I Recommendation. November 2016

Hyperlipidemia

 Strong evidence supports lipid-lowering  Specific trials in elderly are limited  Scandinavian Simvastatin Survival Study: Benefit similar in younger or

• lder than 65

 PROSPER: Prospective Study of Pravastatin in the Elderly: Significant

reduction in CHD mortality and nonfatal MI

 Heart Protection Study: Simvastatin reduced all-cause mortality,

coronary death, and nonfatal MI in > 70 y/o

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2018 ACC/AHA Cholesterol Guideline

 Benefit Groups  Clinical ASCVD: High Intensity  Diabetics with LDL-C > 70: Moderate  40 to 75 years of age and LDL-C 70-189 and 10 yr ASCVD risk >

7.5%: Moderate

 Severe Hypercholesterolemia LDL-C > 190: High  High Risk ASCVD & LDL-C > 70 consider addition of nonstatins to

statin therapy

 Diabetics aged 40-75 and LDL 70-189: Moderate Intensity

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Intensity of Statin Therapy

High Intensity Moderate Intensity Low Intensity

Daily Dose Lowers LDL- C on Average > 50% Daily Dose Lowers LDL-C

• n Average 30 to <50%

Daily Dose Lowers LDL- C on Average < 30% Atorvastatin 40-80 mg Rosuvastatin 20-40 mg Atorvastatin 10-20 mg Rosuvastatin 5-10 mg Simvastatin 20-40 mg Pravastatin 40-80 mg Lovastatin 40 mg Fluvastatin 40 mg BID Simvastatin 10 mg Pravastatin 10-20 mg Lovastatin 20 mg Fluvastatin 20-40 mg

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Electrocardiography

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 The USPSTF recommends against screening with resting or

exercise ECG for the prediction of Coronary Heart Disease events in asymptomatic adults at low risk for CHD events. Grade D. June 2018

 The USPSTF concludes that the current evidence is

insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events. Grade I. June 2018

Nontraditional Risk Factors

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 The USPSTF concludes that the current evidence is

insufficient to assess the balance of benefits and harms

• f adding the ankle-brachial index (ABI), high-

sensitivity C-reactive protein (hsCRP) level or coronary artery calcium (CAD) score to traditional risk assessment for cardiovascular disease in asymptomatic adults to prevent CVD events. Grade I. July 2018

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Second Case

 Mr. Johnson a 67 y/o male comes to your office for a health

assessment visit. He has been taking HCTZ 12.5 mgm daily for hypertension for 5 years. He has no surgical history. He quit smoking 10 years ago and has mild COPD with peripheral vascular disease. He is asking about screening for prostate

• cancer. He has heard about a shingles shot. He has never had a

pneumonia immunization. He heard something on the radio about screening for lung cancer.

 What would you advise?

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Prostate Cancer May 2018

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 For men aged 55 to 69 years, the decision to undergo

periodic PSA screening for prostate cancer should be an individual one. Should have an opportunity to discuss the potential benefits and harms of screening.

 Screening offers a small potential benefit of reducing the chance of

death from prostate cancer in some men.

 Many men will experience potential harms of screening.  The USPSTF recommends against PSA-based screening for

prostate cancer in men 70 years and older.

Domino on PSA Screening at FMX

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 1000 men get screened with PSA  240 will have a positive test: potential for cancer  100 will have biopsy proven cancer  140 will NOT have cancer  80 will choose surgery or radiation  3 will avoid cancer spreading to other organs  1 or 2 will avoid death  60 of the 80 treated will have chance of incontinence and impotence  5 of the 80 will still die from prostate cancer

Lung Cancer December 2013

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 USPSTF recommends screen annually for lung cancer with

low-dose computed tomography in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years

 Discontinue screening when the patient has not smoked for 15 years or

develops a health problem substantially limits life expectancy or the ability or willingness to have curative lung surgery. Grade B, December 2013 Update in progress

The Email

How would you answer?

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More Questions

 Mrs. Olson got an email from her property owners association

stating she could get screened by ultrasound of her legs, carotids, heel bone, and abdominal aorta at the POA office. They also do an EKG to screen for atrial fibrillation. Doctor it is only $139 with a $10 discount for all these tests! What a deal! Doctor how much would they cost if you ordered them?

 How would you answer Mrs. Olson?

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What is the Evidence for AAA Screening?

 The USPSTF recommends against routine screening for

abdominal aortic aneurysm (AAA) in women who have never smoked. Grade: D Recommendation. June 2014

 The USPSTF makes no recommendation for or against screening

for AAA in men aged 65 to 75 who have never smoked. Grade: C Recommendation. June 2014

 The USPSTF recommends one-time screening for AAA by

ultrasonography in men aged 65 to 75 who have ever smoked. Grade: B Recommendation. June 2014

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How About the Carotids and Legs?



The U.S. Preventive Services Task force (USPSTF) recommends against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population. Grade: D Recommendation. July 2014



The USPSTF Concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for peripheral artery disease and cardiovascular disease risk assessment with the Ankle-Brachial Index in adults. Grade: I Recommendation. July 2018

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More Evidence

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 USPSTF concludes that the current evidence is insufficient to

assess the balance of benefits and harms of screening for atrial fibrillation with EKG. Grade: I Recommendation. August 2018

Summary

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 Discussed who may benefit from geriatric screening  Discussed numerous screening tests and immunizations in the geriatric

population

 Discussed Electronic Preventive Services Selector (ePSS) for smart

phones and tablets

 Discussed 5 different tools to use in estimating life expectancy to

counsel patients about screening tests

 Do not forget ePSS and ePrognosis apps for your smart phones

How to Know You’re Growing Older

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 Everything hurts, and what doesn’t hurt, doesn’t work.  Your “little black book” (phone) contains only names ending in MD.  You get winded playing chess.  You join a health club and don’t go.  You look forward to a dull evening.  You sit in a rocking chair and can’t get it going.  Your knees buckle and your belt won’t.  Your back goes out more often that you do.  You sink your teeth into a steak and they stay there.  You turn out the light for economic, rather that romantic reasons.

Resources

 Walter LC. Development and Validation of a Prognostic Index for 1-

year Mortality in Older Adults after Hospitalization. JAMA. 285:2987- 2994.

 Lee SJ. Development and Validation of a Prognostic Index for a 4-year

Mortality in Older Adults. JAMA. 2006:801-808

 www.USpreventiveservicestaskforce.org/adultrec.htm. Accessed

February 9, 2019

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Audience Polling 7

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According to a 2013 USPSTF recommendation, which one of the following screening tests should be obtained for a 65-year-old woman?

• 1. Hepatitis A virus antibody
• 2. Hepatitis B surface antibody
• 3. Hepatitis C virus antibody
• 4. Hepatitis B surface antibody and Hepatitis C virus antibody
• 5. No testing for viral hepatitis is indicated

Audience Polling 8

94

82 year-old-man comes for a routine visit. History includes hypertension, Afib, and hypothyroidism. Meds are lisinopril 10, levothyroxine 125 mcg, and asa 81 mg. He is active with volunteer work. He drinks 8 oz of wine/day and asks whether he should continue to drinking wine daily. Which of the following is the most appropriate rec.?

• 1. Stop consuming alcohol
• 2. Decrease wine consumption to 5 oz daily
• 3. Seek behavioral counseling
• 4. No change is necessary

Audience Polling 9

95

67 year-old-man comes of for routine follow-up. He had a recent episode of shingles that has resolved without neuralgia. Two years ago he received PPSV23 and Tdap. He lives with his daughter and grandson. According to ACIP , which vaccine should he receive?

• 1. Hepatitis B
• 2. HIB
• 3. Td booster
• 4. Varicella zoster
• 5. No additional vaccines

Audience Polling 10

96

76 year-old-woman is admitted to the hospital for the second time in 3 months with COPD. Meds are inhaled salmeterol BID and inhaled albuterol

• QID. She is a former smoker. After treating with steroids her oxygen

saturation improves. Which of the following treatments is associated with reduced mortality?

• 1. Seasonal influenza vaccine
• 2. Continuous oxygen therapy
• 3. Daily prophylactic azithromycin
• 4. Inhaled Corticosteroid twice daily

Audience Polling 11

97

An 89-year-old man comes to the office for a routine visit. History includes PVD. He smoked cigarettes 4 packs/d for 20 years until age 40. Which one if most appropriate screening interval for AAA for this patient?

• 1. Annually
• 2. Biannually
• 3. Every 5 years
• 4. Screen once
• 5. Do not screen