Prevention and Screening Tests in the Elderly Nick Butler

Geriatric syndrome screening Areas of Prevention Immunizations Cancer Cardiovascular Metabolic Infectious Geriatric syndrome screening Don’t screen for these

You have "outlived science.” Jerry Jogerst MD

United States Preventative Services Task Force U.S. Preventative Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions#grade-definitions-after-july-2012 Last Accessed 4/12/2017

Immunization National Center for Immunization and Respiratory Diseases

Cancer Screening Colorectal cancer screening USPSTF Grade A recommendation Start at age 50 for average risk individuals Stool-based testing (FIT, ect), direct visualization and serology test (SEPT9 DNA) are viable 76-85 yo have small benefit if previously screened Consider 10 year prognosis when screening age >75 USPSTF does recommend ASA for colorectal cancer prevention in average-risk individuals

Cancer Screening Lung Cancer Screening USPSTF Grade B recommendation Adults 55-80 with > 30 pack-year hx Current smoker or quit in past 15 yrs Also supported by American Association of Thoracic Surgery, American Cancer Society, American College of Chest Physicians/ American Society of Clinical Oncology, Canadian Task Force on the Periodic Health Examination, National Comprehensive Cancer Network Some differences in age to stop screening but otherwise similar. Start screening age 55 with 30 pack/year averted 521 lung cancer deaths with 24 radiation induced lung cancer deaths

Cancer Screening Breast cancer screening USPSTF Grade B for age 50-74 Routine Mammography Start age 50 in average risk individuals Q 1-2 years but varies by society/group (USPSTF q2yr) Screen to age 74. ACOG, ACR, ACS recommends screening after 75 if patient thought reasonably healthy and candidate for treatment BRCA only if family history has associated risk

Cancer Screening Prostate cancer screening USPSTF recent change to grade C was grade D No apparent improvement in all cause mortality NNH: 1 in 5 underwent prostate biopsy for false-positive 1 in 34 developed ED by prostate cancer tx 1 in 56 developed urinary incontinence by tx Controversial Autopsy studies show 2/3 older men have asymptomatic prostate cancer Inform and discuss risk and benefits with your patients Quaas, Joshua. PSA Screening for prostate cancer. Am Fam Physician. May 2015

Cancer Screening Cervical cancer screening Grade A for women 21-65 Stop screening age 65 or post hysterectomy (benign disease)

Unhelpful or harmful screening Ovarian cancer screening (D) Pancreatic cancer screening (D) Bladder cancer screening (I) Whole body PET/CT for general cancer screening (D) Colon cancer screening age > 85 (D)

Cardiovascular Screening Blood pressure USPSTF Grade A for yearly age > 18 Grade A for home monitoring

Cardiovascular Screen Abdominal aortic aneurysm USPSTF grade B Men 65-75 who have ever smoked Men 65-75 never smoked grade D Women who have never smoked grade D Women who have smoked grade I Screen by abdominal ultrasonography One time screening Ever smoke = > 100 cigarettes in lifetime

Cardiovascular Screening Lipid testing and treatment Lipid testing every 5 years, more often if risk factors USPSTF Grade B for statins in primary prevention with atherosclerotic cardiovascular disease (ASCVD) risk > 10% USPSTF Grade C for statins in primary prevention with ASCVD 7.5-10%

Unhelpful or Harmful screening Carotid Artery Stenosis (D) EKG for heart disease in low risk adults (D) Vit E or B-carotene for CAD prevention (D) CAD screening with non-traditional risk factors (I) PAD asymptomatic assessment with ABI (I)

Metabolic screening Diabetes Mellitus Grade B 40-70 yo overweight or obese HbA1c, glucose tolerance test Limited evidence on interval of screening Every 3 years is reasonable

Metabolic Screening Osteoporosis Grade B 65+ or younger if risk factors Smoker, alcohol use, parental fracture hx, low BMI, ect. Duel-energy x-ray absorptiometry (DEXA) FRAX tool https://www.shef.ac.uk/FRAX/tool.jsp Treat if osteopenia with hip fracture risk >3% or major fracture >20%

Metabolic Screening Unhelpful or harmful Vitamin D deficiency screening in asymptomatic – I MVI for CVD and cancer prevention – I Thyroid in asymptomatic - I

Infectious screening Syphilis grade A if increased risk Chlamydia grade B if at risk Gonorrhea – grade B if at risk Hepatitis B – grade B if at high risk Hepatitis C – grade B if high risk or born 1945-1965 TB – if at increased risk

Geriatric syndromes screening Fall Prevention Exercise for community-dwelling age >65 grade B Vitamin D supplement for community-dwelling grade B Inquire about falls – Yearly

Geriatric syndromes screening Depression screening USPSTF Grade B recommendation Memory screening Not endorsed by USPSTF for all patients Yearly for patients of concern Hearing impairment screening Yearly Visual impairment screening

Unhelpful/Harmful Screening Menopausal hormone therapy for primary prevention – E&P or Estrogen alone (D) COPD screening in asymptomatic adults (D) Asymptomatic bacteriuria (D)

A Great Reference USPSTF age and risk based guidelines https://epss.ahrq.gov/ePSS/GetResults.do?method=search&new=true