First Report
American Academy of Family Physicians 2009 Scientific Assembly
October 14-17, 2009; Boston, MA
Screening and Preventive Care in the Elderly
Boston, MA—Aubrey L. Knight, MD, FAAFP, presented a session at the American Academy of Family Physicians (AAFP) meeting on screening and preventive care in the elderly. Challenges for clinicians include the fact that most trials exclude patients over age 75, data from trials are not necessarily applicable to individual patients, and trials do not address how individual characteristics affect the benefit versus harm calculation; therefore, there are factors other than age alone that must be considered. The objectives were to develop a systematic way to think about the benefits and harms of screening tests in older adults, understand the importance of patient preferences in screening decisions, learn how to consider life expectancy when making screening recommendations, and discuss preventive strategies likely to provide improved health and function.
In estimating life expectancy it is possible to estimate if a person is likely to live substantially longer or shorter than the average. The clinician should look at the number/severity of comorbid conditions or functional impairments that would result in life expectancy below average (eg, class III or IV heart failure, chronic obstructive pulmonary disease with home oxygen, dementia with Mini-Mental State Examination < 10, dependence in most activities of daily living), or whether there are no comorbid conditions or functional impairments, which would result in life expectancy above average. As a rule of thumb, a life expectancy of greater than 5 years is required in order for a cancer screening test to result in a survival benefit; for some other tests, the lag time may be days to weeks (hearing, vision, depression, falls risk).
Benefits of screening include identifying a disease before it becomes evident, improved function/prevention of functional decline, and improved quality of life (screening for falls, visual impairment, hypertension). Cancer screening is unlikely to benefit if life expectancy is less than 5 years. Harms of screening include false negative leading to false reassurance, false positive leading to unnecessary and potentially harmful tests, identification and treatment of clinically unimportant disease that would not have progressed to symptoms in the patient’s lifetime, no benefit from early detection with the potential for a diversion of resources, and potential harms intrinsic to the screening test. For example, with the prostate-specific antigen test, 50-80% of men have prostate cancer at autopsy, and only 4% of men die from prostate cancer. Treatment of prostate cancer carries great risk of death, impotence, and urinary/fecal incontinence. Dr. Knight also discussed the harms of colorectal cancer screening such as false-positives and complications (higher in frail elders) (Lieberman DA et al, N Engl J Med, 2000) and cervical cancer screening (Sawaya G et al, Ann Intern Med, 2000).
Clinicians should assess how a patient views potential benefits/harm and integrate values/preferences into decisions. This is different from the public health strategy in which experts weigh benefits/risks and decide what is best for a population. Discuss screening as a choice, not an obligation. Inform patients of the impact, and describe screening as a “double-edged sword.” Psychological harm can occur with the emotional pain of a cancer diagnosis in people whose lives were not extended or with the alarm of false-positive results. However, public health trumps preferences when the screening has public health implications, such as screening for tuberculosis prior to nursing home admission.
General recommendations for cancer screening are: (1) recommend against cancer screening if estimated life expectancy is < 5 years; (2) if life expectancy is 5-10 years, decision is a “close call,” and preferences play a major role in the decision; and (3) if estimated life expectancy is > 10 years, recommend mammography every 2 years and colon cancer screening.
Medicare Part B covers screenings for breast (yearly), cervical (Pap test every other year), vaginal, colorectal (flexible sigmoidoscopy every 4 yr, or barium every 5 yr, or colonoscopy every 10 yr), prostate, osteoporosis, lipid disorders (every 5 yr), and immunizations (influenza, pneumococcal, hepatitis B). Since 2002, guidelines agree that screening should continue if an older person is healthy.
The U.S. Preventive Services Task Force (USPSTF) recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk. The optimal age to discontinue screening is not clear, but risk of cervical cancer and yield of screening decline steadily through middle age.
Attendees were referred for information to the Cochrane Database, the Centre for Evidence-Based Medicine, the Centers for Disease Control and Prevention, the USPSTF, The American Geriatrics Society, and the AAFP.
Identifying Clinical Features of Elder Abuse
Boston, MA—John M. Heath, MD, FAAFP, and Lisa M. Gibbs, MD, spoke at the AAFP meeting on the importance of identifying those clinical features of elder mistreatment most relevant to primary care ambulatory practice settings. The first step is recognition (but not necessarily making the firm diagnosis); step 2 is enlisting help (adult protective services, institutional ombudsmen, legal or law enforcement, or other social service resources). Elder mistreatment encompasses physical abuse, neglect, financial exploitation, psychological abuse, or abandonment. Physical abuse can be manifested as inadequately explained fractures, bruises, welts, cuts, sores, burns, or evidence of inappropriate physical restraints. Aging, disease, and medication effects can all complicate assessment (Cooper, Age Ageing, 2008; Wiglesworth, J Am Geriatr Soc, 2009). With financial exploitation, the perpetrator is most often a known and loved caregiver. Protective legal interventions such as powers of attorney, conservatorships, or guardianships are often undertaken too late.
Neglect includes acts of omission (eg, lack of hygiene, food, required medical care services, necessary supervision) and acts of commission (eg, abandonment, inappropriate care provision). Clinicians suspecting abuse should enlist the help of supportive and investigative agencies. Different settings may have differing responding agency jurisdictions.
The speaker referred to the “Red Flags of Elder Abuse” issued by the Center of Excellence in Elder Abuse and Neglect at the University of California, Irvine. These include inadequately explained fractures, bruises, welts, cuts, sores, burns; untreated pressure “bed” sores; lack of basic hygiene; lack of adequate food; lack of medical aids (glasses, walker, teeth, hearing aid, medications); lack of clean, appropriate clothing; person with dementia left unsupervised; bed-bound person left without care; home cluttered, filthy, in disrepair, or having fire and safety hazards; home without adequate facilities (stove, refrigerator, heat, cooling, working plumbing, and electricity); and hoarding. Financial abuse is evidenced by lack of amenities the victim could afford, the elderly person “voluntarily” giving inappropriate financial reimbursement for needed care and companionship, the caregiver having control of elderly person’s money but failing to provide for the person’s needs, the caretaker “living off” the elderly person, or the elderly individual signing over property transfers (eg, power of attorney, new will) when unable to comprehend the transaction. Psychological abuse is evident when a caregiver isolates the elderly person (doesn’t let anyone into the home or speak to the elderly individual); the caregiver may be aggressive, controlling, addicted, or uncaring.
Reporting suspected elder abuse is vital for clinicians. For a referral to the appropriate agency, call the national Eldercare Locator, a public service of the U.S. Administration on Aging at (1-800-677-1116). In case of an emergency, call your local police station or 911.
MRI, Arthroscopy, and Osteoarthritis of the Knee
Boston, MA—One of the Journal Club presentations at the AAFP meeting posed the question, “Osteoarthritis of the knee: Is MRI useful?” Orthopedic surgeons favor it (Englund et al, N Engl J Med, 2008). In the Framingham study, ambulatory 50-90-year-old patients were selected, regardless of symptoms, to have a knee MRI; 991 subjects were studied, and researchers found a meniscus tear/degeneration in: women, age 50-59, 19% (CI 15-24%) and in men, age 50-90, 56% (CI 46-66%). In actuality, 63% of those with with knee pain had a meniscal tear, and 60% of those without knee pain also had a meniscal tear. Of those with a meniscal tear, 61% had had no symptoms in the last month. Researchers concluded that meniscal tears are very common in those without symptoms. The corollary: Don’t blame the pain on the meniscus.
The question was raised: For osteoarthritis of the knee, does “scoping” help? The thinking has been to clean and smooth out the knee, and it will cure the pain. A randomized controlled trial of arthroscopic surgery for osteoarthritis of the knee looked at patients with grade 2-4 knee osteoarthritis by the Kellgren-Lawrence classification, 277 patients were screened, with 188 randomized; six did not complete the trial (Kirkley et al, N Engl J Med, 2008). Patients were randomized to arthroscopy, irrigation, and clean-up versus optimal physical therapy plus medical management. Exclusions were those who were post-infectious, had inflammatory arthritis, had previous arthroscopy, had varus or valgus deformity > 5%, among other factors. Outcomes at 2 years are measured as follows: primary: Total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score; secondary: Short Form-36 (SF-36) Physical Component Summary score (range, 0-100; higher scores indicate better quality of life). They found no difference in any outcome, which may not have been surprising (Moseley et al, N Engl J Med, 2002).
For additional information on these sessions and more from the AAFP 2009 Scientific Assembly, go to www.AAFP.org.
