Influenza vaccine

The influenza vaccine reduces the severity of disease, subsequent hospitalization, and mortality by about 70%–90%.[3] A “high-dose” inactivated influenza vaccine is available for adults older than 65. A recent study showed that among persons 65 years of age or older, high-dose vaccine induced significantly higher antibody responses and provided better protection against laboratory-confirmed influenza illness than did the standard dose.[4] During outbreaks, chemoprophylaxis with amantadine, rimantadine, zanamivir, and oseltamavir are effective for protection during the two weeks immediately after immunization until an antibody response provides protection.

Shingles vaccine

Herpes zoster (shingles) is a painful and sometimes pruritic vesicular skin eruption that occurs with reactivation of the varicella zoster virus in the dorsal root ganglia or cranial nerves.[5] Postherpetic neuralgia (PHN) is the major and most common complication of herpes zoster.[5] Both shingles and PHN are preventable conditions. The Centers for Disease Control and Prevention (CDC) recommends one single dose of the herpes vaccine (Zostavax) for persons aged 60 and over.[5, 6]

Hypertension

The aging process is a known dominant risk factor in the progression of hypertension and in some cases for its onset in later life.[7] Active screening for hypertension can take place only when the blood pressure of an individual is measured. In early 2014, the Eighth Joint National Committee (JNC8) published an evidence-based guideline for the management of high blood pressure in adults. With regards to the elderly patient, most of the national and international guidelines recommend treatment targets for patients ≥60 years of age toward systolic BP less than 150/90 [SOR=A].[8–10] Controversy exists as to whether there is any additional benefit to target systolic less than 140/90 mmHg due to the potential development of increasing frailty or further decline in quality of life or in end-organ function.[9, 10] Prevention of hypertension continues to include the recommendation for a low salt diet and moderate exercise three or four times per week.[8]

Lipid disorders

Recent new evidence-based guidelines on the treatment of blood cholesterol were developed and published by the American College of Cardiology (ACC) and the American Heart Association (AHA).[11] These new guidelines place less emphasis on specific low-density lipoprotein (LDL) targets and are developed to address more specific issues such as the optimal LDL and high-density lipoprotein (HDL) goals of treatment for both primary and secondary prevention. At this point in time, the evidence does not support the continuation of statin drugs for persons ≥75 years of age who are already taking and tolerating these drugs.[11] However, the use of moderate-intensity statin therapy for secondary prevention in individuals with atherosclerotic cardiovascular disease (ASCVD) in this age group is supported by a larger amount of data.[11] There is no support for high-intensity therapy for purposes of secondary prevention.[11] Furthermore there is insufficient data supporting a reduction benefit in primary prevention of ASCVD events for patients ≥75 years of age without clinical ASCVD.[11] There is also a lack of strong evidence of health benefits supporting recommendations for any of the other drug classes for primary treatment of LDL cholesterol (fibrates, niacin, bile acid sequestrants, ezetimibe, and omega-3 fatty acids). The clinical decision to initiate statin therapy for primary prevention of hyperlipidemia in patients ≥75 years of age involves the consideration of present comorbidities (as well as the potential of their increasing in number), safety concerns (drug interactions, polypharmacy, organ transplantation, etc.), and goals of care[11]. Calculation of the 10-year risk of ASCVD might also be helpful for clinical decision making (http://tools.cardiosource.org/ASCVD-Risk-Estimator).

In summary, four groups of individuals were identified through a rigorous review of randomized clinical trials, as demonstrating evidence of reduction in ASCVD events, with a good margin of safety, from the use of moderate- or high-intensive statin therapy:[11]

Osteoporosis

Osteoporosis is not an inevitable consequence of aging; it is a preventable disease. Osteoporotic fractures are a substantial contributor to mortality and morbidity in older adults and have a remarkable burden on the health-care system.[12] Prevention strategies are aimed at maximizing peak bone mass and minimizing bone loss with aging.

Screening and primary prevention form the core of most of the clinical guidelines for osteoporosis.[12] The Fracture Risk Assessment Tool (FRAX; www.shef.ac.uk/FRAX) is utilized to estimate the 10-year risk of hip and other osteoporotic fractures by assessing risk factors and bone mineral density (BMD) measurement.[12, 13] BMD testing can be utilized for both screening and diagnosis of osteoporosis. The findings of BMD testing can be entered into the FRAX tool to further refine the risk of osteoporotic fracture.[13] FRAX is designed to estimate osteoporotic fracture risk in postmenopausal women and men over the age of 50.[13] It is not validated for use with individuals who have received any treatment for osteoporosis unless there has been cessation of therapy for an interval of one to two years. Another screening tool, the Osteoporosis Self-Assessment Screening Tool (OST) was found in a recent study to be slightly better than FRAX at identifying individuals at low risk of osteoporosis for whom BMD screening can be omitted.[12] Further information on diagnostic criteria can be found in the National Osteoporosis Foundation guidelines for 2013.[13, 14]

Prevention of osteoporosis requires application of multiple intervention strategies, which include specifications on oral calcium intake, oral vitamin D intake, weight-bearing and muscle strengthening exercise, smoking cessation, and alcohol intake.[13–18]

Weight and physical activity

The American Heart Association (AHA) and the American College of Sports Medicine (ACSM) provide recommendations for adults over age 65 for various types of activity and guidance for implementing weight bearing and muscle strengthening exercise programs.[19] Exceeding the minimum amount will lead to greater health benefits; however it is recommended that the patient always consult a health-care provider prior to beginning any exercise program. Some of the minimum recommendations include:

The National Institute on Aging has an exercise and physical activity guide that is free to individuals or can be ordered in bulk for selected purposes (http://go4life.niapublications.org).

Hearing loss

It is a well-known fact that the prevalence of hearing loss increases with age.[21] Hearing loss can be divided into two categories: conductive and sensorineural. Conductive hearing loss is caused by the inability to mechanically transmit sound vibrations from the environment to the inner ear.[22] The majority of sensorineural hearing loss is a result of disorders of the inner ear itself and is not directly related to dysfunction of the vestibulocochlear nerve.[22]

The US Preventive Services Task Force (USPSTF) finds insufficient evidence for or against screening for hearing loss in asymptomatic adults 50 years or older.[23] However, the effectiveness of screening questionnaires and clinical tools are validated for use in the primary care clinic.[23] Examples of physical examination tools to screen for hearing loss include the whisper test, finger rub, and watch tick tests.[23, 24] Pure-tone audiometry can be performed with a hand-held audiometer.[23] Pure-tone audiometry requires a quiet testing environment with low levels of background noise because hearing loss is worsened with competing background noise.[23, 24]

Visual impairment

Persons over the age of 65 should be screened for vision problems every one to two years.[25] Most causes of vision loss are either preventable or treatable. The USPSTF recommends that visual acuity screening should be a part of the periodic health examination of individuals over the age of 65.[25] Disease-specific screening for diabetic retinopathy, cataracts, glaucoma, and macular degeneration, as well as screening for ophthalmological adverse effects of medications, is best conducted by an ophthalmologist.[25] The Early Treatment of Diabetic Retinopathy (ETDRS) chart or the Snellen Chart (hand-held or wall fixture) are useful for in-office screening of refractory errors.[25]

Cancer

Screening for the common causes of cancer death is controversial for the older adult. The USPSTF and other guideline panels by national medical specialty organizations all have separate and sometimes congruent recommendations for when to initiate and when to discontinue screening. For the older adult, decisions about screening for cancer should be individualized and centered on the current evidence-based guidelines, the patients’ life expectancy, the benefits and harms of screening, and integration of the values and preferences of the patient into the screening decisions.[26, 27] The following is a list of recommendations for the age of cessation for specific types of cancer screening and a summation of the conditions or exceptions to be followed:[27]*

It is important to note that cessation of cancer screening is primarily done to prevent harm and not to ignore problems or suspicious symptoms. A two-way dialogue based on evidence-based guidelines and individual preferences is pertinent in making a decision to continue or stop cancer screening.[26, 27] These are core principles of good medical practice and should be applied to cancer screening decisions.[27] Although some patients may be relieved with the thought of not undergoing further testing, others may feel discrimination on the basis of perceived ageism by the physician and/or the medical community.[26]

Depression

Depression is very common in older adults and frequently unrecognized by clinicians and patients alike.[28] Elderly patients with depression often present with vague symptoms such as fatigue, anorexia, insomnia, and weight loss.[28] Inadequate treatment of depression is known to contribute to higher risk of morbidity and poorer outcomes.[29]

The definition of major depressive disorder (MDD) has recently been modified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the removal of the bereavement and the persistent depressive disorder category.[30] Major depressive disorder is defined by a patient having one or more depressive episodes (MDE) and the lifetime absence of mania and hypomania.[30]

The USPSTF recommends screening adults for depression in clinical practices that have systems in place to ensure accurate diagnosis, effective treatment, and follow-up.[29] There is minimal benefit for screening if these systems are not in place. The USPSTF found no evidence of harms of screening for depression in adults and reports good evidence that treatment with antidepressants, psychotherapy, or both decreases clinical morbidity and improves outcomes in adults with depression, which is verified through screening in the primary care setting.[29]

For screening of depression, many different instruments are available. The USPSTF found no significant evidence that one instrument is superior to another, but positive results on any screening test should provide the impetus to move on to full diagnostic testing tools that use criteria at minimum from the DSM-IV.[29]

Screening tools for older adults include:[29, 31]

When results of screening tests indicate that depression is or could be present, the diagnosis needs to be confirmed according to DSM-IV or DSM-5 diagnostic criteria. If the diagnostic criteria are not met, the depressive symptoms could be due to other psychological syndromes. Be mindful when screening that several different medical conditions can also contribute to depressive symptoms in older adults.[29]

Hypothyroidism

Hypothyroidism is very common in older adults, with women being 10 times more likely to be affected than men.[32] In older adults, fatigue and weakness are the most common symptoms, and many of the classic signs and symptoms of hypothyroidism may be mistakenly assumed to be associated with normal aging.[32, 33]

There is no consensus among many medical professional organizations to guide screening for thyroid disease.[33] The USPSTF and the Canadian Task Force do not find enough evidence to recommend for or against screening in asymptomatic elderly women; however, a high index of suspicion and low threshold for evaluating thyroid function should be maintained in the at-risk population.[33, 34] Included in this category are those elderly patients who present with vague, nonspecific symptoms, persons older than 60, women, and persons with concomitant autoimmune disease.[33, 35] The American Academy of Family Physicians (AAFP) and the American Association of Clinical Endocrinologists (AACE) recommend measurement of thyroid function “periodically” in older, postmenopausal women.[35]

The most common tests that are ordered for screening of thyroid disease are the total thyroxine (TT4), free thyroxine index (FT4I), and the sensitive thyrotropin (sensitive-TSH).[36] Tests for triiodothyronine and anti-thyroid antibodies may be used as follow-up tests in some situations, but they have no utility as screening tests.[36] Patients who have low or undetectable TSH levels and an elevated free thyroxine level have overt hyperthyroidism, and patients who have a TSH level that is elevated (≥10 mU/L) and a low free thyroxine level have overt hypothyroidism.[34] A formal system to identify these patients with arrangement for follow-up evaluation should be a part of any screening program.[34]

Subclinical hypothyroidism (SCH) is a commonly encountered laboratory finding in clinical practice.[37] Lab results will often demonstrate an elevated TSH level in the serum and normal levels of free thyroxine based on the reported reference ranges.[37] The prevalence of SCH is difficult to determine, although it is thought to be more prevalent than overt thyroid disease.[33, 37] A percentage of individuals with SCH will progress to clinical or overt hypothyroidism with a variable incidence in research studies ranging from 2% to 26.2% after about two years.[37] A diagnosis of SCH, however, does not always merit treatment, especially if the TSH elevations are transient (persists less than three to six months) and the patient does not have risk factors for developing overt hypothyroidism.[37] Treatment should be individualized and restricted to high-risk patients.[33]

Dementia

Dementia is a debilitating and degenerative neurologic condition for which there is no cure.[38] Alzheimer’s disease, the most common form of dementia, causes the destruction of brain cells, which creates problems with memory, attention, language, decision making, and behavior. These problems are severe enough to negatively impact family, social, and occupational functioning, and eventually the most basic activities of daily living (BADLS).[39–41] There are many different types of dementia, and Alzheimer’s disease accounts for approximately 60% of all cases.[39] Mild cognitive impairment (MCI) is a different condition because patients are able to maintain independence with BADLS and instrumental activities of daily living, but detection may be useful for predicting the eventual development of dementia.[41]

The USPSTF in 2003 concluded that there was insufficient evidence to recommend for or against routine screening for dementia in older adults.[38, 41, 42] This is due to a lack of studies that evaluate the efficacy, benefits, and harms of dementia screening in primary care.[38]

Individuals with dementia usually present to their family physician first, who is also often the first physician to observe patients with possible dementia and the only physician to make the diagnosis.[39] Cognitive impairment might not be recognized with routine history and physical examination, and despite the benefits of early intervention, dementia continues to be underdiagnosed.[41] The Centers for Medicare and Medicaid Services (CMS) provides coverage for the costs of an annual wellness visit for Medicare beneficiaries; the visit includes, among its nine elements, detection for cognitive impairment.[38]

There are two primary methods of screening a patient for dementia.[39] One approach is to use a performance measure or screening tool, which is a test administered and scored.[39] A second approach is to interview an informant or someone close to the patient who can report how the cognition has changed and how the change has impacted the patient’s ability to perform everyday activities.[39]

With regards to performance-based tools, the Mini-Mental Status Examination (MMSE) has been used frequently and is the best study instrument, but it has inherent biases according to age, race, education, and socioeconomic status.[39] Several other screening tools are now available and are updated regularly to provide primary care physicians with effective diagnostic tools that are easy to administer. The Mini-Cognitive Assessment Instrument (Mini-Cog) is briefer and not associated with the same language or education biases as the MMSE.[39] Although more complex than the MMSE or Mini-Cog, the Montréal Cognitive Assessment (MoCA) has the advantage of testing multiple cognitive domains with an easy scoring system and is free for clinical use.[39] It was also developed to assist physicians with MCI.[39] Other screening tools that have been commonly utilized include the clock-drawing test (CDT), Word Fluency-Animal Naming, Sweet 16, Trail Making B, Kingston Standardized Cognitive Assessment-Revised (mini-KSCAr), and the Short Portable Mental Status Questionnaire (SPMSQ).[41, 43]

Informant-based screening tools include the Ascertain Dementia (AD-8), which is an eight-item, brief screening interview, and the short or full Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).[39, 41]

Screening for dementia by itself does not automatically lead to better clinical care.[40] Screening tools can sometimes lead to a wrong conclusion, particularly when relying on simple, single cut-off scores.[43] Corrections need to be made for age and intelligence or educational level.[43] Minor deviations while administering screening tools can alter results.[43] It also equally important to use cognitive screening tools with “updated norms” that reflect cohort differences to avoid compromising the screening accuracy.[43]