1. Geriatric Health Maintenance
Kevin Barnett, Emily Crossfield, Cameron Jones, Trey Martin, Khaki Marquette, Sam Scanlon

2. Introduction Profile of aging has changed dramatically
Life expectancy was 47 years in 1900, up to 79 by 2014
Increasing Percentage of Elderly
By 2030, percentage of people over 65 will exceed 20%
By 2050, there will be over 2 billion people over the age of 60

3. Health and Wellbeing
Adults surviving into late life suffer form high rates of chronic illness
80% have at least 1 chronic illness
50% have at least 2 chronic illnesses
There is a strong correlation between the presence of chronic illnesses and dependency in activities of daily living
RR: 2.1 with one condition, and 6.6 with 3 or more conditions
Decline in function and loss of independence are not an inevitable consequence of aging
Due to the high prevalence of chronic conditions in the elderly, evidence based interventions are necessary to maximize quality and quantity of life

4. Goals of Care for Older Adults
Because of the great variety in physiological and functional status among older adults treatment decisions, both therapeutic and preventive should be considered based on individual needs.
The overall goal should be to preserve function and maximize quality of life
Studies suggest that many patients are either under or over screened depending on the disorder in question
Following slides will focus primarily on the preventive care aspect in the care of older adults

5. Healthy Lifestyle
Studies have shown that the risk of developing moderate or severe disability was greater for individuals with low or intermediate levels of activity
Physical Activity:
Aerobic-30 minutes of moderate-intensity exercise of 5 days each week or 20 minutes of vigorous activity on 3 days each week. Definitions depend on the person’s baseline
Stretching-10 minutes of static stretching on days where physical activity is performed
Balance- Static balance includes learning to recover on a tilting balance platform and Dynamic balance does not require special equipment, Tai Chi

6. Healthy Lifestyle Tobacco Use Alcohol Use
Long history of high rates of smoking and excess smoking-related mortality from lung cancer, CV disease and COPD in the older generation
Studies have shown that the benefits of smoking cessation are demonstrable at all age groups
Older adults should be questioned about smoking and counseled on how to quit if they currently smoke
Alcohol Use
The American Geriatrics Society recommends specific questioning regarding the frequency and quantity of alcohol use
The National Institute on Alcohol Abuse and Alcoholism has developed a clinician tool for helping patients who consume alcohol to excess

7. Immunizations
Tetanus Vaccine: Although rare in the US, it occurs predominantly in unvaccinated or under immunized individuals
Patients over 60 account for over 60% of cases
Recommendation is booster dose of tetanus and diphtheria toxoid every 10 years
Influenza Vaccine: More than 90% of influenza related deaths occur in people >60 years old
CDC began recommending annual flu vaccines for adults in Flumist is not approved for adults over 50

8. Immunizations
Pneumococcal: Significant cause of morbidity and mortality in the elderly, sharp increase in pneumococcal disease after age 65
ACIP recommends both PCV13 and PCV23 be given sequentially to adults >65
Herpes Zoster: Affects 30% of adults in their lifetime, can lead to postherpetic neuralgia, encephalitis and myelitis
Recommended for immunocompetent adults over 60 in 2006 and was FDA approved for individuals over 50 in 2011

9. Cancer Screening
Prostate Cancer: The USPSTF recommends against screening. The ACP recommends individual discussion of the risks and benefits.
Colorectal Cancer: Studies show a 20-30% reduction in cancer specific mortality in those screened
Recommendations are to offer screening for average risk individuals from age Options include colonoscopy every 10 years, CT every 5 years, Flex Sig every 5 years, Stool Fecal Occult Blood Testing annually
Breast Cancer: 19-30% reduction in breast cancer mortality in screened vs. unscreened individuals
Recommendations include screening women of average risk every 2 years beginning at age 50

10. Cancer Screening
Cervical Cancer: Older women who have never been screened have the highest incidence and mortality from cervical cancer
Most major guidelines recommend stopping cervical cancer screening at age 65 for women who have adequate recent screening and are not at increased risk for cervical cancer. 3 consecutive negative cytology tests or 2 consecutive negative HPV/Pap Co tests in the previous 10 years, most recent test in the last 5 years
Lung Cancer: Annual screening by low dose CT has been shown to decrease RR of all cause mortality by 6.7%. Recommended for men and women aged with at least a 30 pack year smoking history

11. Cardiovascular Screening
Blood Pressure: 60-80% of older adults have hypertension and it is the leading risk factor for ischemic heart disease and stroke
The ACP and ACOVE recommend annual screening for all older adults
Lipids: Older adults have a higher overall annual risk of coronary heart disease and stand to benefit from lipid reduction
For those with an overall risk of CHD exceeding 10% over 10 years screening and treatment appear to be substantiated
Abdominal Aortic Aneurysm: One time abdominal ultrasound screening has been shown to decreased aneurysm-related deaths and all-cause mortality in men
One time screening for men age if they have ever smoked

12. Cardiovascular
Diabetes: USPSTF recommends screening for diabetes as part of CV risk assessment in adults years old with BMI>25. Those with Hypertension or hyperlipidemia should be screened as well.

13. Other Screening Measures
Osteoporosis: Osteopenia is found in 37% of post-menopausal women, and osteroporosis in 7%.
Recommendations include a Bone Mineral Density test for all women 65 and older and men who have either manifestations of low bone mass or risk for fracture
Recommendations for DEXA scan include women and men with low bone mass(T-score: -2 to -2.49) at any site or have risk factors for ongoing bone loss with follow up every 2 years.
Women 65 and older with low bone mass (T-Score: -1.5 to -1.99) at any site and with no risk factors, follow up every 3-5 years
Women 65 and older with normal or slightly low bone mass at baseline and no risk factors for accelerated bone loss, follow up every years

14. Other Screening Measures
Vision: Low vision in 15% of adults over 75 and is associated with significant decline in health, function and quality of life
However, evidence has been inconclusive to support routine vision screening. But vision assessment should be part of the routine workup for an older adult with recent cognitive decline, functional impairment, or falls
Hearing: 3rd most common ailment after hypertension and arthritis to affect older adults. Associated with depression and social isolation.
Insufficient evidence to determine benefits and harms but it is suggested that primary providers screen adults 65 and older for hearing loss and vulnerable older adults at risk for functional decline

15. Other Screening Measures
Nutrition: 15% of older outpatients and half of the hospitalized older patients are malnourished which leads to increased morbidity and mortality
No well validated general lab screens for this condition. A combination of serial weight measurements and inquiry about changing appetite are likely the most useful methods of assessing nutritional status in older adults.
Vitamin D: It appears that vitamin D and calcium may reduce the risk of hip fracture in older adults.
Experts advise that daily intake of vitamin D in older adults should be at least 800 international units and at least 1.2g of elemental calcium.

16. Falls
30% of older adults fall each year. That incidence increases to 50% in patient over 80 years of age.
5% of falls result in fracture or hospitalization
Providers should regularly inquire about the occurrence of recent falls in older patients, review medications for causative agents, inquire about home safety and perform a cognitive exam as well as orthostatic vitals.

17. Summary and Conclusion
The wide range in states of health among older adults means that treatment decisions, both preventive and therapeutic, should be based on individual needs.
Age alone should not be the sole determinant for many interventions and treatment and all treatment should aim to preserve function and maximize quality of life.

18. References UptoDate, Geriatric Health Maintenance
US Preventative Task Force Services
National Institute on Alcohol Abuse and Alcoholism
Medline Plus