1. Geriatric Screening Guidelines
Bilquis Khot, MD, FACP
Consultant, Department of Medicine
Al-Jahra Hospital

2. “An ounce of prevention is worth a pound of cure.”
-Benjamin Franklin

3. Screening Guidelines Primary prevention Secondary prevention
Tertiary prevention
For screening, condition should be sufficiently common, cause significant morbidity and mortality if untreated, have a preclinical stage to allow detection and have a effective available treatment that will improve prognosis.

4. Geriatric screening Increased life expectancy.
By 2050 adults > % of world population
High prevalence of chronic illnesses.
Age alone not a sole determinant of interventions.
Lag time to benefit from screening and life expectancy.
Individual patient’s health status, comorbidities, preferences and priorities guide preventive and treatment decisions.
Evidence based interventions to preserve function maximize quality and quantity of life based on guidelines from organizations and quality indicators.

5. Lifestyle modifications
Physical Activity: Decreases all cause
morbidity and decreases mortality.
Aerobic, weight bearing, flexibility, balance
Tobacco use: Counseling (ask, advice, assess, assist and arrange), nicotine replacement and pharmacotherapy.
Nutrition: Appetite, serial weights for weight loss as well as obesity, mini nutritional assessment tool
Multivitamins and vitamin D: Daily 800 IU of vit. D along with 1.2g of elemental calcium reduce risk of hip fractures and falls. Multivitamins help in elderly with insufficient food intake.

6. Immunization
Tetanus: 60% of all cases in > 60. Booster Td every 10 years, Tdap once by ACIP in 2010.
Influenza: 90% of deaths in ≥ 60. Reduced hospitalization and significant ↓mortality with annual inactivated vaccine for ≥ 65.
Pneumococcal: PPSV23, PCV13 sequentially for adults ≥65
Herpes Zoster: 8-10 fold increase in risk in late life decreased cell mediated immunity. A one time live attenuated vaccine recommended in ≥ 50 years immunocompetent adults to decrease risk and complications of shingles. ↓ risk of zoster over 3 years by 51%.

7. Aspirin for primary prevention
22% ↓ non fatal MI over 10 years, 24%↓
incidence of CA colon over 20 years, 6-8% ↓
in overall mortality, Significant increase in
major nonfatal bleeding over 10 years.
Most benefit for years old with 10% 10
year risk for CVD with no increased bleeding
risk with life expectancy of 10 years.

8. Cardiovascular Screening
Blood Pressure: High prevalence, 65% among ≥ 60 years. Leading risk factor for IHD and CVA. Screening every visit or at least annually. Ambulatory or home BP check encouraged as White coat hypertension in 10-20%.
Treatment decreases all cause mortality.
Intensive treatment harmful for elderly. ACP &
AAFP most recent March 2017,target 150/90mmHg
except with high risk like CVA, TIA, Diabetes,
metabolic syndrome, CKD, target 140mm Hg.
Lower targets led to syncope, hypotension & falls
Orthostatic and postprandial hypotension
Isolated systolic hypertension common.

9. Cardiovascular Screening
Lipid Screening: No upper limit for initial screen Stop at age 65 if normal previous screenings.
Benefits of screening and treatment for
primary prevention outweighs harm but decisions
should be individualized based on risk factors
Abdominal aortic aneurysm: One time screen with ultrasound for men between who have ever smoked or have a first degree relative with aneurysm repair. Smoking risk factor for 75% of aneurysms. 4-6 times more common in males and family history doubles the risk.

10. Cardiovascular Screening
Diabetes: Screen year olds with BMI of ≥𝟐𝟓𝒌𝒈/ 𝒎 𝟐 or history of hypertension (135/80) or hyperlipidemia as part of CV risk assessment ADA screen all regardless of weight starting at age 45
Screen with Fasting Blood sugar or HBA1C and
repeat abnormal results in absence of symptoms.
FBS of ≥7.0mmol/L (126mg/dl), random or PPS of ≥11.1mmol/L (200mg/dl) or HBA1C ≥ 6.5 with symptoms of diabetes confirms diagnosis.
Early diagnosis and treatment prevents micro
and macro vascular complications.

11. Functional Screening
ADL: Katz index Bathing, dressing, toileting, transferring, continence & feeding.
IADL: Lawton scale from 0-8. Assess independence.
Advanced ADL
Fall risk and mobility assessment: 40% of community dwelling > 65 fall each year. Screen for falls recommended. Timed up and go test, gait speed, balance, vision, orthostatic hypotension, medication history.

12. Psychosocial Screening
Cognitive Screen: Targeted screen with memory complaints and functional decline. MMSE, Mini-cog. Informant reported memory loss with inability to retain new information, difficulty with complex tasks, reasoning, spatial ability and orientation
Depression: Unrecognized, leads to somatic symptoms, cognitive, functional, sleep problems with fatigue. Screening recommended initially by 2 question screening and if positive GDS.
Thyroid: Can consider screening with TSH for ≥ 60. with any symptom or risk factor, should screen >50 years of age.

13. Cancer Screening
Colorectal: 20-30% ↓ in cancer specific mortality. Routine screening between years per 2016 recommendations by USPSTF. Colonoscopy every 10 years, sigmoidoscopy every 5 years without FIT or every 10 years with FIT annually, FIT annually single sample, Multitargeted stool DNA every 3 years, Guaiac stool 3 samples annually or virtual colonoscopy every 5 years.
Colonoscopy procedure of choice. Sigmoidoscopy less preferred in elderly as advanced neoplasms tend to occur more proximally. Decision about screening based on age, comorbidities, life expectancy and patient preference.

14. Cancer Screening
Breast: 19-30% ↓ in mortality with screening. Routine screening between years with biennial digital mammography per USPSTF Benefits most patients years with most deaths avoided (21/10,000 screened). Shared decision making after weighing risk and benefit with at least 10 year life expectancy. Clinical breast exam by itself not recommended.
Prostate: No significant ↓ in mortality. Men between with family history to be screened with PSA after informed decision making and life expectancy of 10 years. PSA not very specific to cancer prostate. Can increase morbidity and over-diagnosis.

15. Cancer Screening
Lung: NLST 2012 showed low dose chest CT decreased relative risk of all cause mortality by 6.7% and 20%↓ in lung CA deaths compared to chest radiograph in patients Drawback is false positive results, invasive procedures and radiation exposure. USPSTF recommends annual low dose chest CT for screening years with 30 pack years of smoking. To stop once quit smoking for 15 years.
Cervical: Most elderly never screened & have higher incidence and should get Pap cytology. Women previously having 3 negative tests can stop screening at age 65.

16. Osteoporosis
NOF recommends DXA in women ≥ 65 and men ≥ 70 without risk factors and for younger with risk factors. With osteopenia (T score ), screen every 2 years.
Osteoporosis by BMD T score ≤-2.5 or hip fracture or vertebral compression or fragility fracture.
Vertebral imaging if women >70 or men >80 if T score≤ -1.0, women or men with T score of ≤-1.5, women or men if historic height loss of 4cm or new loss of 2cm, glucocorticoid use or low trauma fracture.
FRAX tool by WHO to calculate 10 year fracture risk with osteopenia ages based with online FRAX calculator. If risk of major fracture ≥20% or hip fracture ≥3%, should receive pharmacological treatment.
Evaluate for secondary causes of low Bone mineral density.

17. General Screening
Incontinence: Common in elderly. Targeted history for type of incontinence and ruling out treatable causes of incontinence. Routine urodynamic study not recommended.
Vision: Screen with cognitive functional decline.
Hearing: Whispered voice test as effective as formal hearing questionnaire.
Polypharmacy: Up-to-date medication list at every visit especially with hospitalization with special attention to drug-drug interactions and side effects.
Driving: Vision, hearing, psychomotor skills and cognitive decline should be assessed in elder drivers.