Clinical Geriatrics

As the New Year starts, it is a good time for all physicians to consider what is necessary for our patients’ care in the months ahead. Early recognition of problems through healthcare screening and preventive strategies are key to maintaining health and maximizing function throughout life. Unfortunately, many patients still fail to have simple tests and screenings that have become the standard of care. Having a list of agreed-upon recommendations in a patient’s file makes it easier to keep track of what is necessary as the year progresses. There are many places to seek recommendations, and no one source appears to have all the answers. I have always respected the opinion of the American Geriatrics Society, and have also used recommendations from many other organizations including the American Cancer Society, the U.S. Preventive Services Task Force, the American Thyroid Association, and the American College of Physicians, among others.

While the list of recommendations is too exhaustive to detail here, a few are as follows:

• Mammograms: It is recommended that women have mammograms done annually until age 75, then every 2-3 years unless life expectancy is less than 4 years.

• Cervical cancer screening: Should be done on all elderly women, unless they have had three or more negative exams in the 10 years prior to age 65. If an elderly woman has no record of these negative exams, it should be done regardless of age as long as the woman has a lifespan of several years. The American Cancer Society says to continue doing screening only until age 70.

• Colorectal cancer screening: Colorectal cancer screening appears to be beneficial throughout life, with colonoscopy suggested every 10 years or more often if an abnormal finding is noted.

• Vision and hearing screening: A good eye examination to check for glaucoma and macular degeneration is essential for all older persons, though the frequency that this is necessary depends on prior findings and coexisting illness. Physicians should assess their patients’ ability to see and hear under real-life circumstances. A false sense that all is fine may result if the physician only uses the Snellen test to assess vision and the “whisper test” to assess hearing. Just how does the older person see and hear under normal circumstances, such as reading the newspaper, watching TV, and hearing a voice in a busy restaurant or supermarket?

• Depression screening: Estimates run as high as 40% for elderly persons having mild or more significant depression. The CAGE questionnaire is also pertinent during later life, especially if life situations place one at greater risk of alcohol abuse. Elderly men who have recently lost their spouse reportedly have one of the highest rates of new alcohol abuse, and a high index of suspicion is necessary.

• Screening for cognitive function: The U.S. Preventive Services Task Force recommends that clinicians should assess cognitive function whenever cognitive impairment is suspected based on direct observation, patient report, or concerns raised by family members. Two commonly administered neuropsychological tests include the Mini-Mental Sate Examination and the Clock Drawing Test.

• Lipid screening: Suggested for those at increased risk, though there is mixed data on the value for those individuals past the age of 65 who have not had a prior abnormality noted. Lipid levels remain fairly stable during later life.

• Fall risk screening: There should be an assessment for fall risk, with some advocating that the Tinetti Balance and Gait Scale be used.

• Purified protein derivative test: Individuals with diabetes, chronic renal failure, or other immunocompromising illness should have a purified protein derivative test.

• Osteoporosis screening: All women age 65 years and older should be screened for osteoporosis. The U.S.