11

To Treat or Torture?To Treat or Torture?

Preventative CarePreventative Care

in the Elderlyin the Elderly

Christi Stewart, MD

March 31, 2010

22

ObjectivesObjectives

1.1. Know the primary physician’s role in Know the primary physician’s role in counseling for prevention. counseling for prevention.

2.2. Have a basic understanding of Have a basic understanding of prognosis and life expectancy and how it prognosis and life expectancy and how it relates to screening recommendations.relates to screening recommendations.

3.3. Learn the current screening guidelines for Learn the current screening guidelines for common conditions.common conditions.

4.4. Determine cost-effectiveness of screening Determine cost-effectiveness of screening specifically in the geriatric population.specifically in the geriatric population.

5.5. Come up with a screening guideline for patients Come up with a screening guideline for patients at various “stages” of the aging process.at various “stages” of the aging process.

33

Topics of ReviewTopics of Review

Counseling Recommendations:Counseling Recommendations:– DietDiet– Tobacco cessationTobacco cessation– Alcohol consumptionAlcohol consumption

Screening Recommendations:Screening Recommendations:– Breast cancerBreast cancer– Cervical cancerCervical cancer– Prostate cancerProstate cancer– Colon cancerColon cancer– OsteoporosisOsteoporosis– Abdominal aortic aneurysm Abdominal aortic aneurysm – DiabetesDiabetes– Hypercholesterolemia Hypercholesterolemia

ImmunizationsImmunizations

44

Leading Causes of Death in the US - 2006 Heart disease - 631,636 Cancer - 559,888 Stroke - 137,119 Chronic respiratory illness - 124,583 Accidents - 121,599 Diabetes - 72,449 Dementia - 72,432 Influenza or Pneumonia - 56,326 Renal disease - 45,344 Septicemia - 34,234

44

55

Counseling

Given leading causes of death, changes in lifestyle behaviors will influence mortality, even in older adults.

Why we don’t do it?– Lack of time– Lack of perceived benefit– Lack of patient cooperation

55

66

Tobacco Cessation

USPSTF recommends asking all adults about tobacco use (2009).– Recommends providing tobacco

cessation interventions for those who use tobacco products.

Average recommended length of counseling session - 3 minutes

Survival benefit for individuals >65yo:– 1.4 - 2 years for men– 2.7 - 3.7 years for women

66

Level A Recommendation

77

Alcohol Counseling

USPSTF recommends screening and behavioral counseling interventions to reduce alcohol misuse in primary care settings (B recommendation).

There is evidence that brief counseling interventions and follow-up show small to moderate reductions in alcohol consumption that are sustained over 6-12 months.

Interventions lead to positive health outcomes 4+ years post-intervention.

Little evidence to show that counseling reduces alcohol related morbidity. 77

Level B Recommendation

88

Nutrition Counseling

USPSTF notes evidence is insufficient to recommend for or against routine behavioral counseling to promote healthy diet in the general population.

Does recommend dietary counseling in patients with diet-related illnesses:– Diabetes– HTN– Hyperlipidemia– Those at high risk for CAD

88

Level I & B Recommendation

99

No Evidence to Support Counseling For: Exercise Prevention of low back pain Benefits of ASA for primary prevention of

CAD/CVA in adults >80yo. Self breast exams Dental services Illicit drug use Domestic abuse/ Elder abuse Seat belt use Driving while under the influence Use of multi-vitamins

99

1100

Definition of ScreeningDefinition of Screening

Examination of a group of Examination of a group of asymptomatic individuals to asymptomatic individuals to

detect those with a high detect those with a high probability of having a given probability of having a given

disease, typically by means of disease, typically by means of an an inexpensiveinexpensive diagnostic diagnostic

test. test.

1111

Cancer Screening

Cancer is the second leading cause of death in individuals >65 yo.

Survival benefit (in general) from cancer screening is not seen unless the life expectancy exceeds 5 years.

1111

1122

Life Expectancy

Predictors:– Functional status– Comorbid medical conditions

Four-year mortality index – See handout– Incorporates age, sex, self-reported

behaviors, comorbid conditions and functional status

Jumping point for discussion of benefits v risks of screening tests

1122

11331133

Life Expectancy in Older Women

Life Expectancy in Older Men

1144

Breast CancerBreast Cancer

#1 female non-dermatologic cancer#1 female non-dermatologic cancer #2 cause of cancer deaths in #2 cause of cancer deaths in

femalesfemales– 66% of deaths occur in women >65yo.66% of deaths occur in women >65yo.

10% of women older than 70 will 10% of women older than 70 will have breast cancer.have breast cancer.

8.6% lifetime risk for general 8.6% lifetime risk for general populationpopulation

1155

How to screenHow to screen

Mammogram Mammogram is accepted is accepted route of route of screening for screening for breast cancer.breast cancer.– Digital Digital

imaging v MRI imaging v MRI no better than no better than plain film.plain film.

                          

Yes, I did have my mammogramtoday... Why do you ask?

1166

USPSTF RecommendationsUSPSTF Recommendations

Recommends biennial screening Recommends biennial screening mammography for all women aged 50-mammography for all women aged 50-74 years old.74 years old.

Concludes that the current evidence is Concludes that the current evidence is insufficient to assess the additional insufficient to assess the additional benefits v harms of screening women benefits v harms of screening women older than 75.older than 75.

Concludes that the current evidence is Concludes that the current evidence is insufficient to assess the benefits v insufficient to assess the benefits v harms of clinical breast exams beyond harms of clinical breast exams beyond screening mammography.screening mammography.

2009

1177

Evidence

Screening biennially from ages 50 to 69 years achieved a median 16.5% (range, 15% to 23%) reduction in breast cancer deaths versus no screening.

Biennial screening after age 69 years yielded some additional mortality reduction in all models, but over-diagnosis increased most substantially at older ages.

There is a lack of primary data on the natural history of breast cancer and an absence of screening trial data for patients after age 74 years. 11

77

1188

Evidence

1188

Age #Trials

RR for Breast Cancer Mortality (95% Crl)

NNI to Prevent 1 Breast Cancer Related Death

39-49y 8 0.85 (0.75-0.96) 1904

50-59y 6 0.86 (0.75-0.99) 1339

60-69y 2 0.68 (0.54-0.87) 377

70-74y 1 1.12 (0.73-1.72) Not available

Pooled RRs for Breast Cancer Mortality From Mammography Screening Trials for All Ages

1199

CostCost

Cost of mammogram: Cost of mammogram:

$11.00$11.00 Cost of radiology read of Cost of radiology read of

mammogram: mammogram: $70.00$70.00

2200

Bottom Line-Breast CancerBottom Line-Breast Cancer

Biennial breast cancer screening in Biennial breast cancer screening in women between ages 50-74 women between ages 50-74

reduces mortality at reasonable reduces mortality at reasonable costs for women without clinically costs for women without clinically

significant comorbid conditions significant comorbid conditions and with a life expectancy of at and with a life expectancy of at

least 5 years.least 5 years.

2211

Cervical CancerCervical Cancer

16,000 new cases/year 16,000 new cases/year Incidence of invasive cervical Incidence of invasive cervical

cancer in US 2006-2008 cancer in US 2006-2008 – 14.2 per 100,000 Hispanic women14.2 per 100,000 Hispanic women– 7.3 per 100,000 non-Hispanic 7.3 per 100,000 non-Hispanic

women women Abnormal Pap smear ratesAbnormal Pap smear rates

– 10.3% at age 18-28 years10.3% at age 18-28 years– 0.8% at age > 65 years 0.8% at age > 65 years

2222

Geriatric Considerations

25% of newly diagnosed cervical 25% of newly diagnosed cervical cancers are in women >64yo who cancers are in women >64yo who have never had previous screening.have never had previous screening.

40% of cervical cancer deaths will 40% of cervical cancer deaths will occur in women >64 years old.occur in women >64 years old.

2222

2233

How to screenHow to screen

Pap (Papanicolaou) smear is the Pap (Papanicolaou) smear is the accepted route of screening for accepted route of screening for cervical cancer. cervical cancer.

TraditionalTraditional

Thin PrepThin Prep

2244

USPSTF RecommendationsUSPSTF Recommendations

Recommends against routinely Recommends against routinely screening women older than age 65 screening women older than age 65 for cervical cancer if they have had for cervical cancer if they have had adequate recent screening with adequate recent screening with normal Pap smears and are not normal Pap smears and are not otherwise at high risk for cervical otherwise at high risk for cervical cancer.cancer.

Recommends against routine Pap Recommends against routine Pap smear screening in women who have smear screening in women who have had a total hysterectomy for benign had a total hysterectomy for benign disease.disease.

2003

2255

What factors make a What factors make a woman high risk?woman high risk? HIV infectionHIV infection ImmunosuppressionImmunosuppression Diethylstilbestrol in utero exposureDiethylstilbestrol in utero exposure History of cervical cancer History of cervical cancer Onset of sexual activity before age 16 Onset of sexual activity before age 16 > 4 sexual partners in lifetime > 4 sexual partners in lifetime History of sexually transmitted disease History of sexually transmitted disease < 3 normal Pap smears < 3 normal Pap smears No Pap smears within previous 7 yearsNo Pap smears within previous 7 years

2266

Other RecommendationsOther Recommendations

American Geriatrics SocietyAmerican Geriatrics Society– Regular Pap smear screening at 1 to 3 Regular Pap smear screening at 1 to 3

year intervals should continue to age 70.year intervals should continue to age 70. American Cancer SocietyAmerican Cancer Society

– Women age 70 or older may elect to stop Women age 70 or older may elect to stop cervical cancer screening if they have had cervical cancer screening if they have had 3 consecutive satisfactory normal test 3 consecutive satisfactory normal test results and no abnormal pap smears in results and no abnormal pap smears in the prior 10 years.the prior 10 years.

American College of OB-GYNAmerican College of OB-GYN– Recommends individualization based upon Recommends individualization based upon

annual assessment of risk factors and annual assessment of risk factors and examination.examination.

2277

EvidenceEvidence

Systematic review of 12 cohort studiesSystematic review of 12 cohort studies– Risk of CIN III or cancer per 1,000 women Risk of CIN III or cancer per 1,000 women

screenedscreened 2.3/1000 for first screen at age 50-642.3/1000 for first screen at age 50-64 1.7/1000 for first screen at age 651.7/1000 for first screen at age 65 <1/1000 for women >60yo with no prior <1/1000 for women >60yo with no prior

abnormal Pap smearsabnormal Pap smears

2288

Cultural variabilityCultural variability

Incidence rates for cervical cancer Incidence rates for cervical cancer in Vietnamese women are more in Vietnamese women are more than two and a half times those for than two and a half times those for any other racial or ethnic group.any other racial or ethnic group.

The next highest rates occurred The next highest rates occurred among Hispanic women.among Hispanic women.

Cervical cancer mortality is 2.5 Cervical cancer mortality is 2.5 times higher for African American times higher for African American women than for Caucasian women than for Caucasian women.women.

2299

Cost Cost

Cost of Pap smear (Thin Prep):Cost of Pap smear (Thin Prep):

$67.00$67.00 Cost of office visit to perform Pap Cost of office visit to perform Pap

smear:smear:

$77.00$77.00 Extra cost if pathology read is Extra cost if pathology read is

necessary:necessary:

$60.00$60.00

3300

Cost Effective?Cost Effective?

In elderly women who were never In elderly women who were never screened, annual Pap smear screened, annual Pap smear screening would cost less than screening would cost less than $6500 per year of life saved. $6500 per year of life saved.

In elderly women who have In elderly women who have received regular screening, annual received regular screening, annual Pap smear screening would cost Pap smear screening would cost $33,572 per year of life saved. $33,572 per year of life saved.

JAMA Vol. 259 No. 16, April 22, 1988 JAMA Vol. 259 No. 16, April 22, 1988     

3311

Medicare ReimbursementMedicare Reimbursement

Covers high risk women once every Covers high risk women once every 12 months. 12 months.

Covers low risk women once every Covers low risk women once every 24 months. 24 months.

20% copayment is required for test 20% copayment is required for test collection, but no copay required collection, but no copay required for lab fees.for lab fees.

3322

Bottom Line-Cervical cancerBottom Line-Cervical cancer

Women older than 65 years old who Women older than 65 years old who have never had a Pap smear, have never had a Pap smear,

should be screened with annual should be screened with annual Pap smears for at least three Pap smears for at least three

consecutive years.consecutive years.

Women older than 65 who are at low Women older than 65 who are at low risk and have at least three risk and have at least three

previously normal Pap smears may previously normal Pap smears may stop screening.stop screening.

3333

Prostate CancerProstate Cancer

#1 non-dermatologic cancer in #1 non-dermatologic cancer in menmen

#2 in cancer deaths in men #2 in cancer deaths in men 30% of men > 50 have occult 30% of men > 50 have occult

cancer at autopsy. cancer at autopsy. 18% of all new cancer in US 18% of all new cancer in US

3344

How to screenHow to screen

Digital rectal examDigital rectal exam– May identify May identify

prostatic nodules or prostatic nodules or occult bloodoccult blood

Prostate specific Prostate specific antigen (PSA)antigen (PSA)– A glycoprotein that A glycoprotein that

is expressed by is expressed by both normal and both normal and neoplastic prostate neoplastic prostate tissue tissue

Are you ready for your prostate exam?

3355

USPSTF RecommendationsUSPSTF Recommendations

Recommends against routine Recommends against routine screening for prostate cancer in screening for prostate cancer in men >75 years old.men >75 years old.

Concludes that the current Concludes that the current evidence is insufficient to evidence is insufficient to recommend for or against routine recommend for or against routine screening in men younger than screening in men younger than 75 years old.75 years old.

2008

3366

Other RecommendationsOther Recommendations

American College of Preventive MedicineAmerican College of Preventive Medicine– Recommend against routine screeningRecommend against routine screening

International Union for Cancer ControlInternational Union for Cancer Control– Does not endorse universal screeningDoes not endorse universal screening

American Cancer SocietyAmerican Cancer Society– PSA and DRE should be offered annually at age PSA and DRE should be offered annually at age

50 and older for men with a life expectancy at 50 and older for men with a life expectancy at least 10 years.least 10 years.

American Urological AssociationAmerican Urological Association– ““All men over 40 should speak with their doctors at the

the time of their annual physicals and develop a proactive prostate health plan that is right for them based on their lifestyles and family history.”

– Recommends getting a baseline PSA along with a DRE at age 40.

3377

Evidence-DREEvidence-DRE

DRE during previous 10 years DRE during previous 10 years associated with reduced risk of associated with reduced risk of prostate cancer mortality prostate cancer mortality (observational study).(observational study).

If a prostate nodule was found in If a prostate nodule was found in an asymptomatic 65yo man, an asymptomatic 65yo man, biopsy might give an average biopsy might give an average patient 1.1 extra months of life patient 1.1 extra months of life expectancy.expectancy.

3388

PSA InformationPSA Information

Recommendations are that PSA levels be Recommendations are that PSA levels be adjusted for age and race.adjusted for age and race.– PSA cutoff levels of normal for black menPSA cutoff levels of normal for black men

Age 60-69 – PSA>4.5Age 60-69 – PSA>4.5 Age 70-79 – PSA>5.5Age 70-79 – PSA>5.5

– PSA cutoff levels of normal for white menPSA cutoff levels of normal for white men Age 50-79 – PSA>3.5Age 50-79 – PSA>3.5

Also, PSA velocity >0.75/year suggests Also, PSA velocity >0.75/year suggests need for prostate biopsy, but requires at need for prostate biopsy, but requires at least 3 PSA tests 12-18 months apart all least 3 PSA tests 12-18 months apart all performed under similar circumstances.performed under similar circumstances.

3399

Overall evidenceOverall evidence

WashingtonWashington 11.8% received PSA11.8% received PSA 1.85% received 1.85% received

biopsybiopsy 2.7% received 2.7% received

radical radical prostatectomyprostatectomy

3.9% received 3.9% received radiationradiation

ConnecticutConnecticut 2.2% received PSA2.2% received PSA 0.84% received 0.84% received

biopsybiopsy 0.5% received 0.5% received

radical radical prostatectomyprostatectomy

3.1% received 3.1% received radiationradiation

Observational study comparing fixed cohorts from Observational study comparing fixed cohorts from WA v CT aged 65-79WA v CT aged 65-79

No differences between two groups in prostate specific mortality.

BMJ 2002;325:740

4400

Why not to screenWhy not to screen

Overdiagnosis of prostate cancerOverdiagnosis of prostate cancer– Computer simulated study showed Computer simulated study showed

significant overdiagnosis rates:significant overdiagnosis rates: 29% in white men29% in white men 44% in black men44% in black men

Pain from diagnostic proceduresPain from diagnostic procedures– 55% of men surveyed after prostate 55% of men surveyed after prostate

biopsy found the procedure caused biopsy found the procedure caused discomfort.discomfort.

– 2% had pain persisting longer than 1 2% had pain persisting longer than 1 week.week.

4411

Risks of TherapyRisks of Therapy

Radical prostatectomyRadical prostatectomy– Operative mortality in men >75yo = 1%Operative mortality in men >75yo = 1%– Complications include urinary incontinence, Complications include urinary incontinence,

sexual dysfunction, and bowel problems.sexual dysfunction, and bowel problems. 20-70% have decreased sexual function20-70% have decreased sexual function 15-50% have urinary problems15-50% have urinary problems

External beam radiationExternal beam radiation– 20-45% of men experience erectile dysfunction20-45% of men experience erectile dysfunction– 2-16% of men experience urinary incontinence2-16% of men experience urinary incontinence– 6-25% of men experience bowel dysfunction6-25% of men experience bowel dysfunction

4422

““The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death.”

4422

4433

CostCost

Digital rectal examDigital rectal exam$30.00$30.00

PSAPSA$92.00$92.00

4444

Medicare ReimbursementMedicare Reimbursement

Medicare will reimburse for Medicare will reimburse for annual prostate screening for all annual prostate screening for all men >50 years old, with both PSA men >50 years old, with both PSA and DRE.and DRE.

Copay (20%) will apply for DRE.Copay (20%) will apply for DRE. Copay will not apply for PSA.Copay will not apply for PSA.

4455

Bottom Line-Prostate CancerBottom Line-Prostate Cancer

There is no evidence supporting that There is no evidence supporting that screening men >65 years old with screening men >65 years old with either a PSA or a DRE decreases either a PSA or a DRE decreases mortality due to prostate cancer.mortality due to prostate cancer.

Screening should be discussed with Screening should be discussed with men with a life expectancy of 10 men with a life expectancy of 10

years or more after careful years or more after careful education regarding risks of education regarding risks of

treatment for prostate cancer treatment for prostate cancer are explained. are explained.

4466

Colorectal CancerColorectal Cancer

#2 cause of non-dermatologic #2 cause of non-dermatologic cancer in US cancer in US

#3 cause of cancer death in men #3 cause of cancer death in men and womenand women

Average age at diagnosis is 63. Average age at diagnosis is 63. 5% lifetime risk of diagnosis.5% lifetime risk of diagnosis.

4477

How to ScreenHow to Screen

Fecal occult blood test Fecal occult blood test yearlyyearly– Set of 3 fecal occult Set of 3 fecal occult

blood cardsblood cards Sigmoidoscopy every Sigmoidoscopy every

5 years 5 years

Colonoscopy every 10 yearsColonoscopy every 10 years

4488

USPSTF RecommendationUSPSTF Recommendation

Recommends screening for individuals Recommends screening for individuals between the ages of 50-75 yo.between the ages of 50-75 yo.

Recommends against routine Recommends against routine screening for individuals between the screening for individuals between the ages of 75-85y.ages of 75-85y.– ““There may be clinical considerations that There may be clinical considerations that

support colorectal screening in individuals support colorectal screening in individuals in this age group.”in this age group.”

Recommends against screening Recommends against screening individuals older than 85.individuals older than 85.

2008

4499

Evidence-FOBTEvidence-FOBT

50 positive tests are obtained for every case of 50 positive tests are obtained for every case of colorectal cancer identified.colorectal cancer identified.

4 positive tests are obtained for every polyp found.4 positive tests are obtained for every polyp found. Cochrane review:Cochrane review:

– 1,237 patients need to be screened with FOBT to prevent 1,237 patients need to be screened with FOBT to prevent

1 colon cancer death.1 colon cancer death.

NEJM trial using yearly or biyearly screening:NEJM trial using yearly or biyearly screening:– 14.1 deaths per 1,000 in unscreened group14.1 deaths per 1,000 in unscreened group

– 9.5 deaths per 1,000 in yearly screened group (NNT 217)9.5 deaths per 1,000 in yearly screened group (NNT 217)

– 11.2 deaths per 1,000 in biyearly screened group (NNT 345)11.2 deaths per 1,000 in biyearly screened group (NNT 345)

5500

Evidence-SigmoidoscopyEvidence-Sigmoidoscopy

65mm scope can reach 50% of colon cancers65mm scope can reach 50% of colon cancers Stats:Stats:

– 78% sensitivity (reports as low as 35% in women)78% sensitivity (reports as low as 35% in women)

– 66%-82% specificity (reports as high as 95% in 66%-82% specificity (reports as high as 95% in women)women)

– 19%-38% positive predictive value19%-38% positive predictive value

– 96%-98.5% negative predictive value96%-98.5% negative predictive value

In persons older than 80:In persons older than 80:– 22% of men could only be examined to 50cm22% of men could only be examined to 50cm– 32% of women could only be examined to 50cm32% of women could only be examined to 50cm

Persons older than 70 are at increased risk for Persons older than 70 are at increased risk for incomplete screening with sigmoidoscopy.incomplete screening with sigmoidoscopy.

5511

Evidence-ColonoscopyEvidence-Colonoscopy

No direct evidence that colonoscopy No direct evidence that colonoscopy prevents deaths from colorectal prevents deaths from colorectal cancer.cancer.

Indirect evidence given that all Indirect evidence given that all screening methods are compared to screening methods are compared to gold standard of colonoscopy, and gold standard of colonoscopy, and screening decreases risk.screening decreases risk.

Sensitivity and specificity difficult to Sensitivity and specificity difficult to ascertain as colonoscopy is its own ascertain as colonoscopy is its own reference standard.reference standard.

5522

Comparing colonoscopy Comparing colonoscopy to sigmoidoscopyto sigmoidoscopy Random controlled study screening Random controlled study screening

first with sigmoidoscopy, then first with sigmoidoscopy, then colonoscopy showed 1.6% of patients colonoscopy showed 1.6% of patients who had a negative sigmoidoscopy who had a negative sigmoidoscopy had a proximal advanced neoplasm. had a proximal advanced neoplasm.

It would be necessary to screen 64 It would be necessary to screen 64 patients with colonoscopy rather than patients with colonoscopy rather than sigmoidoscopy to find one additional sigmoidoscopy to find one additional person with an advanced neoplasm. person with an advanced neoplasm.

5533

Risks of screeningRisks of screening

Perforation rate of colonoscopy:Perforation rate of colonoscopy:– 0.03%-0.19%0.03%-0.19%

Perforation rate of Perforation rate of sigmoidoscopy:sigmoidoscopy:– 0.004%-0.088%0.004%-0.088%

5544

CostCost

Stool cards:Stool cards:

$21.00$21.00 Flexible sigmoidoscopy:Flexible sigmoidoscopy:

$176.00$176.00 Colonoscopy:Colonoscopy:

$950.00 physician’s fee$950.00 physician’s fee

$750.00 facility fee$750.00 facility fee

5555

Medicare reimbursementMedicare reimbursement

FOBT is fully reimbursed without FOBT is fully reimbursed without copay.copay.

Flexible sigmoidoscopyFlexible sigmoidoscopy– Covered once every four yearsCovered once every four years

ColonoscopyColonoscopy– Covered once every 10 years, but not Covered once every 10 years, but not

within 48 months of a screening within 48 months of a screening flexible sigmoidoscopy.flexible sigmoidoscopy.

5566

Bottom Line-Colorectal CancerBottom Line-Colorectal Cancer

All persons between 50-75 years old All persons between 50-75 years old with a life expectancy of 5 years with a life expectancy of 5 years should undergo routine screening should undergo routine screening

for colorectal cancer.for colorectal cancer.

No clear evidence exists as to which No clear evidence exists as to which screening method is superior, so screening method is superior, so

the choice should be an the choice should be an individualized to each patient, with individualized to each patient, with

his/her input.his/her input.

5577

OsteoporosisOsteoporosis

Affects about 25 million in US Affects about 25 million in US 7% ambulatory postmenopausal 7% ambulatory postmenopausal

women > 50 years old have women > 50 years old have osteoporosis osteoporosis

The presence of osteoporosis was The presence of osteoporosis was associated with a four-fold increase associated with a four-fold increase in fracture rate.in fracture rate.– vertebral fractures occur in 1/3 women vertebral fractures occur in 1/3 women

>65 >65 – hip fractures occur in 1/3 women >90 hip fractures occur in 1/3 women >90

(10-15% mortality) (10-15% mortality)

5588

How to screenHow to screen

Sahara scanSahara scan– Calcaneal ultrasoundCalcaneal ultrasound

DEXA scanDEXA scan– dual energy dual energy

x-ray x-ray absorbimetry absorbimetry

5599

USPSTF RecommendationsUSPSTF Recommendations

Women aged 65 and older should Women aged 65 and older should be screened routinely for be screened routinely for osteoporosis.osteoporosis.

2002

6600

National Osteoporosis Foundation Recommendations

Women >65 years old Men >70 years old

– Regardless of clinical risk factors

6600

6611

EvidenceEvidence

Comparison study with >3,000 Comparison study with >3,000 women who did or did not receive women who did or did not receive screening DEXA scans and risk of screening DEXA scans and risk of hip fractureship fractures– 4.8/1,000 fractures in those screened4.8/1,000 fractures in those screened– 8.2/1,000 fractures in those not 8.2/1,000 fractures in those not

screenedscreened– NNT 56NNT 56

6622

CostCost

Sahara screenSahara screen

FreeFree DEXA scanDEXA scan

$150$150

6633

Medicare ReimbursementMedicare Reimbursement

Medicare will pay for a screening Medicare will pay for a screening DEXA scan once every two years DEXA scan once every two years for patients at risk of losing bone for patients at risk of losing bone mass (postmenopausal females).mass (postmenopausal females).

Will not pay for DEXA scans for Will not pay for DEXA scans for men for routine screening.men for routine screening.– Will pay with other risk factors.Will pay with other risk factors.

6644

Bottom Line-OsteoporosisBottom Line-Osteoporosis

While few studies exist showing direct While few studies exist showing direct benefits of screening for osteoporosis, benefits of screening for osteoporosis, fracture cost is an enormous source of fracture cost is an enormous source of

financial burden and mortality among the financial burden and mortality among the elderly.elderly.

All women over 65 should be screened at All women over 65 should be screened at least once every five years for osteoporosis.least once every five years for osteoporosis.

Screening should not be stopped based on Screening should not be stopped based on patient age, as lifetime risk of fractures patient age, as lifetime risk of fractures

increases with age.increases with age.

6655

Abdominal Aortic AneurysmAbdominal Aortic Aneurysm

Prevalence rates vary from 2-9% Prevalence rates vary from 2-9% Annual death rates from ruptured AAAAnnual death rates from ruptured AAA

– 1.2% males > 651.2% males > 65– 0.6% females > 650.6% females > 65

80-94% overall mortality rate from 80-94% overall mortality rate from rupture rupture

It has been estimated that the excess It has been estimated that the excess prevalence associated with smoking prevalence associated with smoking accounts for 75% of all aneurysms that accounts for 75% of all aneurysms that are >4.0 cm in diameter. are >4.0 cm in diameter.

6666

How to screenHow to screen

Retroperitoneal Retroperitoneal ultrasoundultrasound

PalpationPalpation

6677

USPSTF RecommendationUSPSTF Recommendation

Recommends one time screening Recommends one time screening for AAA by ultrasound in men aged for AAA by ultrasound in men aged 65-75 who have ever smoked.65-75 who have ever smoked.

Makes no recommendation for or Makes no recommendation for or against screening for AAA in men against screening for AAA in men 65-75 who have never smoked.65-75 who have never smoked.

Recommends against routine Recommends against routine screening for AAA in women.screening for AAA in women.

2005

6688

Evidence re: palpationEvidence re: palpation

Using ultrasound as the gold Using ultrasound as the gold standardstandard– sensitivity – 50%sensitivity – 50%– specificity – 91%specificity – 91%– positive predictive value – 35%positive predictive value – 35%

Sensitivity varies with patient’s Sensitivity varies with patient’s BMI:BMI:– AAA were missed in 50% of patients AAA were missed in 50% of patients

<70yo with a BMI greater than 24. <70yo with a BMI greater than 24.

6699

More EvidenceMore Evidence

Prevalence of population with risk Prevalence of population with risk factors (tobacco use) was 9%.factors (tobacco use) was 9%.

Expected gain in life expectancy from Expected gain in life expectancy from screening using a combination of screening using a combination of abdominal palpation + ultrasound was abdominal palpation + ultrasound was 5.4 years.5.4 years.

Four randomized trials of one-time Four randomized trials of one-time screening using rupture as an end point screening using rupture as an end point noted reductions in aneurysm-related noted reductions in aneurysm-related mortality of 21%-68% with screening. mortality of 21%-68% with screening.

Re-screening men with negative initial Re-screening men with negative initial screen not useful at 4 years.screen not useful at 4 years.

7700

Why screen?Why screen?

Mortality rates of elective surgical Mortality rates of elective surgical repair of AAA are 4%-6%.repair of AAA are 4%-6%.

Mortality rates of emergency Mortality rates of emergency surgical repair after rupture are surgical repair after rupture are 37%.37%.

7711

CostCost

Retroperitoneal ultrasound:Retroperitoneal ultrasound:

$270$270 Radiology read of retroperitoneal Radiology read of retroperitoneal

U/S:U/S:

$146$146

7722

Medicare ReimbursementMedicare Reimbursement

Medicare will pay for one time Medicare will pay for one time screening U/S for those at riskscreening U/S for those at risk– Family history of AAAFamily history of AAA– Men aged 65-75 yo with a history of Men aged 65-75 yo with a history of

tobacco use tobacco use >100 cigarettes in a life-time>100 cigarettes in a life-time

Must be ordered as part of the Must be ordered as part of the Welcome to Medicare physicalWelcome to Medicare physical– Order must be obtained within 12 Order must be obtained within 12

months of enrollment in Medicare Part months of enrollment in Medicare Part B.B.

7733

Bottom Line-AAABottom Line-AAA

Screening has been shown to be cost Screening has been shown to be cost effective in men aged 65-75 with risk effective in men aged 65-75 with risk

factors (HTN, CAD, history of factors (HTN, CAD, history of tobacco use), there is good tobacco use), there is good

evidence to support long term (10 year) evidence to support long term (10 year) cost-effectiveness of screening cost-effectiveness of screening

all men older than 65.all men older than 65.

7744

DiabetesDiabetes

Estimated 6-8% US adults have diabetes. Estimated 6-8% US adults have diabetes. Estimated lifetime risk of diabetes for Estimated lifetime risk of diabetes for

persons born in US in 2000 is 32.8% for persons born in US in 2000 is 32.8% for males and 38.5% for females. males and 38.5% for females.

Incidence of diabetes declines with old age. Incidence of diabetes declines with old age. Diabetes is fourth most common diagnosis Diabetes is fourth most common diagnosis

made during family physician visits. made during family physician visits. DMII caused 69,301 deaths in United States DMII caused 69,301 deaths in United States

in 2000 in 2000– death rate 25.2 per 100,000 populationdeath rate 25.2 per 100,000 population

7755

How to screenHow to screen

Fasting blood glucoseFasting blood glucose 2 hour post-prandial glucose2 hour post-prandial glucose Glycosylated Glycosylated

hemoglobinhemoglobin

7766

USPTSF RecommendationUSPTSF Recommendation

Recommends screening Recommends screening individuals who have a sustained individuals who have a sustained BP (treated or untreated) BP (treated or untreated) >135/80.>135/80.

Current evidence is insufficient to Current evidence is insufficient to assess the risks v benefits in assess the risks v benefits in screening those with BP less than screening those with BP less than 135/80.135/80.

2008

7777

Evidence-FBSEvidence-FBS

The sensitivity and specificity of the The sensitivity and specificity of the fasting blood glucose as a fasting blood glucose as a screening test vary according to screening test vary according to the population tested and the the population tested and the threshold used to define diabetes. threshold used to define diabetes.

Among people ages 40 to 74:Among people ages 40 to 74:– Specificity of a FBS >140 = 91%Specificity of a FBS >140 = 91%– Sensitivity of a FBS >126 = 50%Sensitivity of a FBS >126 = 50%– Sensitivity and specificity decrease for Sensitivity and specificity decrease for

persons >65yo.persons >65yo.

7788

Evidence-HgbA1CEvidence-HgbA1C

Of patients with HgbA1C>7%Of patients with HgbA1C>7%– 89.1% had diabetes89.1% had diabetes– 7.1% had impaired glucose 7.1% had impaired glucose

tolerancetolerance More convenient and cost-More convenient and cost-

effective than oral glucose effective than oral glucose challenge testing.challenge testing.

No studies comparing to FBS.No studies comparing to FBS.

7799

Evidence-Post-prandial glucoseEvidence-Post-prandial glucose

Post-prandial glucose >200 Post-prandial glucose >200 correlates with increased risk of correlates with increased risk of diabetic retinopathy.diabetic retinopathy.– 15% v 2%15% v 2%

More sensitive than fasting glucose More sensitive than fasting glucose for early diabetes mellitus.for early diabetes mellitus.

8800

EvidenceEvidence

No evidence exists that supports No evidence exists that supports universal screening.universal screening.

Prevalence of diabetes in otherwise low-Prevalence of diabetes in otherwise low-risk population was 0.2%.risk population was 0.2%.

Research on cost-effect suggests Research on cost-effect suggests targeted screening to those with targeted screening to those with hypertension between 55-75yo.hypertension between 55-75yo.

Early detection of diabetes has not been Early detection of diabetes has not been shown in any study to improve long-term shown in any study to improve long-term outcomes.outcomes.

8811

CostCost

Fasting blood glucose:Fasting blood glucose:$22.00$22.00

Glycosylated hemoglobin:Glycosylated hemoglobin:$66.00$66.00

8822

Medicare ReimbursementMedicare Reimbursement

No Medicare reimbursement for No Medicare reimbursement for screening general population over screening general population over 65 for diabetes.65 for diabetes.

Does pay for screening in those Does pay for screening in those with HTN, hyperlipidemia, obesity, with HTN, hyperlipidemia, obesity, history of high blood sugar.history of high blood sugar.– Up to twice yearlyUp to twice yearly

Reimbursement does exist for Reimbursement does exist for diabetes self-management diabetes self-management training.training.

8833

Bottom Line-DiabetesBottom Line-Diabetes

No evidence exists for screening the No evidence exists for screening the general population over 65 years old for general population over 65 years old for

diabetes.diabetes.

It has been found minimally cost-effective It has been found minimally cost-effective to screen patients with hypertension to screen patients with hypertension

between 65-75yo.between 65-75yo.

Early detection of diabetes does not seem Early detection of diabetes does not seem to decrease future risk of diabetic to decrease future risk of diabetic

complications.complications.

8844

Hyperlipidemia

Prevalence of dyslipidemia is Prevalence of dyslipidemia is approximately 40-48% in the general approximately 40-48% in the general population.population.

Progressive elevation in total Progressive elevation in total cholesterol levels with aging.cholesterol levels with aging.

It has been estimated that 40% or It has been estimated that 40% or more of those above age 65 meet the more of those above age 65 meet the National Cholesterol Education National Cholesterol Education Program guidelines for treating Program guidelines for treating hypercholesterolemia.hypercholesterolemia. 88

44

8855

How to screenHow to screen

Fasting lipid Fasting lipid profileprofile

Total Total cholesterolcholesterol

8866

USPSTF RecommendationUSPSTF Recommendation

Recommends that clinicians Recommends that clinicians routinely screen men aged 35 years routinely screen men aged 35 years and older and women aged 45 and older and women aged 45 years and older for lipid disorders years and older for lipid disorders and treat abnormal lipids in people and treat abnormal lipids in people who are at increased risk of who are at increased risk of coronary heart disease.coronary heart disease.– Screening should include measurement Screening should include measurement

of total cholesterol and high-density of total cholesterol and high-density lipoprotein cholesterol (HDL).lipoprotein cholesterol (HDL).

8877

EvidenceEvidence

Relationship between lipid levels Relationship between lipid levels and CAD is weak and controversial and CAD is weak and controversial in older adults.in older adults.– Relative risk between lipids and CAD Relative risk between lipids and CAD

declines with age.declines with age. LOW cholesterol associated with LOW cholesterol associated with

increased mortality in elderly.increased mortality in elderly.– Sign of poor nutritional status.Sign of poor nutritional status.

8888

Evidence from AGSEvidence from AGS

American Geriatrics Society study (2004)American Geriatrics Society study (2004)– Enrolled 5,000 patients >65yo (men and Enrolled 5,000 patients >65yo (men and

women)women)– None of lipid measures were associated with None of lipid measures were associated with

total mortality. total mortality.– Total and LDL levels were very weakly related Total and LDL levels were very weakly related

to stroke and MI risk.to stroke and MI risk.– Total and LDL levels do not improve risk Total and LDL levels do not improve risk

prediction in older adults.prediction in older adults.– Low HDL associated with greater risk of Low HDL associated with greater risk of

CAD mortality.CAD mortality.– High HDL associated with lower risk of High HDL associated with lower risk of

ischemic stroke.ischemic stroke.

8899

CostCost

Total cholesterol:Total cholesterol:$17.00$17.00

Fasting lipid profile:Fasting lipid profile:$72.00$72.00

– If TG >200, automatic direct LDL is run If TG >200, automatic direct LDL is run = $53 more= $53 more

9900

Medicare ReimbursementMedicare Reimbursement

Medicare will pay for screening Medicare will pay for screening q5years.q5years.– Total cholesterolTotal cholesterol– HDLHDL– Triglyceride levelTriglyceride level

No copay exists for patients.No copay exists for patients.

9911

Bottom Line-CholesterolBottom Line-Cholesterol

No evidence exists supporting general No evidence exists supporting general screening for hypercholesterolemia screening for hypercholesterolemia

in persons >65yo with no known in persons >65yo with no known history of CAD.history of CAD.

Treating low-risk patients who qualify Treating low-risk patients who qualify for hypercholesterolemia therapy for hypercholesterolemia therapy

has not been shown to have effects has not been shown to have effects on morbidity or mortality.on morbidity or mortality.

9922

ImmunizationsImmunizations

Centers for Disease Control (CDC) Centers for Disease Control (CDC) comparing vaccinations in elderly comparing vaccinations in elderly adults in 1989 and 2003: adults in 1989 and 2003: – pneumococcal vaccine: pneumococcal vaccine:

15% to 64%15% to 64%– annual influenza: annual influenza:

33% to 70% 33% to 70%

9933

What to give (per CDC)What to give (per CDC)

Influenza vaccine:Influenza vaccine:– One dose annually to all those >65yoOne dose annually to all those >65yo

Pneumococcal vaccine:Pneumococcal vaccine:– One dose over lifetimeOne dose over lifetime– Dose should be 5 years from administration of last Dose should be 5 years from administration of last

dose if patient received vaccination at <64yo.dose if patient received vaccination at <64yo. Tetanus booster:Tetanus booster:

– One dose booster every 10 years.One dose booster every 10 years. Tetanus immunization series:Tetanus immunization series:

– Once to all patients >65yo who have never been Once to all patients >65yo who have never been immunized.immunized.

Zoster vaccine:Zoster vaccine:– One dose to all those >60yoOne dose to all those >60yo

9944

Evidence-Flu vaccineEvidence-Flu vaccine

90% of influenza related deaths are in patients >60yo90% of influenza related deaths are in patients >60yo 2005 cohort study: Among residents of long term care 2005 cohort study: Among residents of long term care

facilities, vaccines well-matched for the circulating facilities, vaccines well-matched for the circulating influenza viruses were not effective against influenza influenza viruses were not effective against influenza (relative risk [RR] 1.04).(relative risk [RR] 1.04).– Vaccines were associated with significant 54 to 58 percent Vaccines were associated with significant 54 to 58 percent

reductions in pneumonia, hospital admission, and death reductions in pneumonia, hospital admission, and death from influenza or pneumoniafrom influenza or pneumonia

A similar conclusion was reached for elderly patients living in the community– Vaccine did not reduce the rate of pneumonia in this

population A separate pooled cohort study demonstrated a small

but significant reduction in mortality in vaccinated elderly individuals (1.0 versus 1.6 percent in unvaccinated individuals)

9955

Evidence-PneumovaxEvidence-Pneumovax

2008 Cochrane meta-analysis of randomized 2008 Cochrane meta-analysis of randomized control trials vaccinating elderly in developed control trials vaccinating elderly in developed countries countries – Strong evidence of efficacy against invasive Strong evidence of efficacy against invasive

pneumococal disease pneumococal disease Bacteremia or meningitisBacteremia or meningitis

– Inconclusive evidence regarding prevention of PNAInconclusive evidence regarding prevention of PNA– No reductions in all-cause mortalityNo reductions in all-cause mortality

In a subsequent study of 3415 patients with In a subsequent study of 3415 patients with CAP requiring hospitalization:CAP requiring hospitalization:– Individuals who received pneumococcal vaccine had Individuals who received pneumococcal vaccine had

a 40 percent lower rate of mortality or ICU admission a 40 percent lower rate of mortality or ICU admission compared with those who had not been vaccinated.compared with those who had not been vaccinated.

9966

Evidence-Tetanus boosterEvidence-Tetanus booster

In USA, tetanus primarily affects In USA, tetanus primarily affects the elderly.the elderly.– 35% of 127 cases of tetanus in 1995-35% of 127 cases of tetanus in 1995-

1997 occurred in patients >60yo.1997 occurred in patients >60yo.– Chronic wounds were noted in 15% of Chronic wounds were noted in 15% of

cases of tetanus reported to CDC cases of tetanus reported to CDC (decub ulcers, leg ulcers).(decub ulcers, leg ulcers).

Only 27.8% of those >70yo have Only 27.8% of those >70yo have antibodies to tetanus.antibodies to tetanus.

9977

Evidence-Zostavax

Shingles Prevention Study– Double-blind randomized, placebo-

controlled study involving 38,546 participants

Zoster vaccine reduced:– Incidence of zoster by 51.3%– Incidence of post-herpetic neuralgia by

66.5%– Shortened course of PHN – Reduced severity of zoster by 57%– Reduced the degree of interference with

ADLs

9977

9988

Efficacy of Zostavax

Efficacy decreases with increasing age.– Efficacy highest among patients 60-69yo– Efficacy of vaccine reduced to 18% in those

>80yo. Vaccine retains efficacy against the

severity of zoster better than zoster itself in all age groups.

CDC recommends one-time administration in all those >60yo– Regardless of age– Regardless of prior history of zoster or

varicella

9988

9999

CostCost

Cost to administer any vaccine:Cost to administer any vaccine:$13.00$13.00

Flu vaccine:Flu vaccine:$25.50$25.50

Pneumococcal pneumonia vaccine:Pneumococcal pneumonia vaccine:$56.60$56.60

Tetanus booster: Tetanus booster: $28.25 $28.25

Zoster vaccine:Zoster vaccine:$193$193

110000

Medicare ReimbursementMedicare Reimbursement

Flu shots: one per yearFlu shots: one per year Pneumococcal pneumonia: once Pneumococcal pneumonia: once

per lifetime.per lifetime. Tetanus: no reimbursement as Tetanus: no reimbursement as

primary preventionprimary prevention– There must be an acute injury.There must be an acute injury.

Zostavax: reimbursed under Zostavax: reimbursed under Medicare D (prescription drug Medicare D (prescription drug plan) - varies with individual plansplan) - varies with individual plans

110011

What Not to Screen For:What Not to Screen For:

Alzheimer’s diseaseAlzheimer’s disease Asymptomatic bacteriuriaAsymptomatic bacteriuria Bladder cancerBladder cancer Carotid artery stenosisCarotid artery stenosis Coronary artery diseaseCoronary artery disease Depression (when staff-assisted depression care Depression (when staff-assisted depression care

supports are not in place)supports are not in place) Lung cancerLung cancer Ovarian cancerOvarian cancer Skin cancerSkin cancer Visual acuityVisual acuity

110022

110033

ReferencesReferences

US Preventative Services Task Force. Recommendations for Screening. Available at US Preventative Services Task Force. Recommendations for Screening. Available at http://www.ahrq.gov/clinic

Van Dijck, Holland, et al. Efficacy of Mammographic Screening of the Elderly: a Case-Referent Van Dijck, Holland, et al. Efficacy of Mammographic Screening of the Elderly: a Case-Referent Study in the Nijmegen Program in The Netherlands. Journal of the National Cancer Institute. Study in the Nijmegen Program in The Netherlands. Journal of the National Cancer Institute. 1994. 86(12):934-938.1994. 86(12):934-938.

Lucus FL, Cauley JA, et al. Bone Mineral Density and Risk of Breast Cancer. American Journal Lucus FL, Cauley JA, et al. Bone Mineral Density and Risk of Breast Cancer. American Journal of Epidemiology 1998. 148 (1): 22-29.of Epidemiology 1998. 148 (1): 22-29.

Ostbye T, Greenburg GN, et al. Screening Mammography and Pap Tests Among Older Ostbye T, Greenburg GN, et al. Screening Mammography and Pap Tests Among Older American Women 1996–2000: Results from the Health and Retirement Study (HRS) and Asset American Women 1996–2000: Results from the Health and Retirement Study (HRS) and Asset and Health Dynamics Among the Oldest Old (AHEAD). Annals of Fam Med 2003. 1:209-17.and Health Dynamics Among the Oldest Old (AHEAD). Annals of Fam Med 2003. 1:209-17.

Fahs MC, Mandelblatt J, et al. Cost Effectiveness of Cervical Cancer Screening in the Elderly. Fahs MC, Mandelblatt J, et al. Cost Effectiveness of Cervical Cancer Screening in the Elderly. Ann of Int Med 1992. 117(6): 520-7.Ann of Int Med 1992. 117(6): 520-7.

Screening for Cervical Cancer. AHRQ Systematic Evidence Review 2002 Jan:25.Screening for Cervical Cancer. AHRQ Systematic Evidence Review 2002 Jan:25.

Mandelblatt JS, Fahs MC. The cost-effectiveness of cervical cancer screening fro low-income Mandelblatt JS, Fahs MC. The cost-effectiveness of cervical cancer screening fro low-income elderly women. JAMA 1988. Vol. 259 No. 16.elderly women. JAMA 1988. Vol. 259 No. 16.

Dynamed. Prostate Cancer Screening. Available at Dynamed. Prostate Cancer Screening. Available at https://access.lancastergeneral.org/Detail.aspx,DanaInfo=dynamed102.epnet.com..

Lu-Yao G, Albertsen PC, Stanford JL, et al. Natural experiment examining impact of aggressive Lu-Yao G, Albertsen PC, Stanford JL, et al. Natural experiment examining impact of aggressive screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area screening and treatment on prostate cancer mortality in two fixed cohorts from Seattle area and Connecticut. BMJ 2002;325:740.and Connecticut. BMJ 2002;325:740.

J Am Geriatr Soc 2001 May;49(5):655J Am Geriatr Soc 2001 May;49(5):655

110044

References ContinuedReferences Continued

AHRQ Systematic Evidence Review 2002 Jan:25

Dynamed. Osteoporosis Screening.Dynamed. Osteoporosis Screening.

Dynamed. Colorectal Cancer Screening.Dynamed. Colorectal Cancer Screening.

Dynamed. Abdominal Aortic Aneurysm Screening.Dynamed. Abdominal Aortic Aneurysm Screening.

Ortqvist A, , Hedlund J, et al. Randomised trial of 23-valent pneumococcal capsular , et al. Randomised trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. Lancet. 1998 Feb 7;351(9100):399-403.Lancet. 1998 Feb 7;351(9100):399-403.

Arun S. Karlamangla, PhD, MD; Burton H. Singer, PhD; David B. Reuben, MD; Teresa E. Arun S. Karlamangla, PhD, MD; Burton H. Singer, PhD; David B. Reuben, MD; Teresa E. Seeman, PhD. Increases in Serum Non-High-Density Lipoprotein Cholesterol May Be Seeman, PhD. Increases in Serum Non-High-Density Lipoprotein Cholesterol May Be Beneficial in Some High-Functioning Older Adults. J Am Geri Soc 2004. 52 (9), 1442–1448.Beneficial in Some High-Functioning Older Adults. J Am Geri Soc 2004. 52 (9), 1442–1448.

Center for Disease Control. Recommendations for Vaccination. Available at Center for Disease Control. Recommendations for Vaccination. Available at http://www.cdc.gov/nip/.http://www.cdc.gov/nip/.