Stanford University Geriatric Education Resource Center  

HB41: Curriculum for Primary Care Geriatrics, 2nd Edition

 

Curriculum for Primary Care Geriatrics, 2nd Edition

Table of Contents.


  Preface
I. Ambulatory Geriatrics
A. General / Assessment
1. Preventive Health and Screening in the Elderly Deon Cox-Hayley, DO 1-11
2. Principles of Geriatric Assessment Joseph Shega, MD 12-25
3. Pharmacology of Aging Paula M. Podrazik, MD 26-37
4. Falls in the Elderly Shelley A. Sternberg, MD, MSCE, FRCP(C) 38-47
5. Failure to Thrive in the Geriatric Patient Miriam Rodin, MD, PhD 48-54
  6. Nutrition for Aging Manisha H. Maskay, RD, PhD 55-65
B. Cardiovascular
1. Hypertension in the Elderly Paula M. Podrazik, MD 66-75
2. Hypercholesterolemia: Risk, Screening and Treatment in the Elderly Miriam Rodin, MD, PhD 76-83
C. Endocrine
1. Osteoporosis and Hormone Replacement Therapy in the Elderly Andrea Bial, MD 84-98
D. Genitourinary
1. Urinary Incontinence in the Elderly Shelly A. Sternberg, MD, MSCE, FRCP(C) 99-110
2. Geriatric Sexuality Judith Arneson 111-124
3. Erectile Dysfunction Don Scott, MD 125-134
E. Psychiatric/Neurologic
1. Dementia Andrea Bial, MD & Fernette Eide, MD 135-155
2. Depression in Older Adults Don Scott, MD 156-171
F. Social Issues
1. Elder Abuse and Neglect Deon Cox-Hayley, DO 172-178
G. Ethical Issues
1. Decision-Making Capacity Greg A. Sachs, MD 179-180
2. Guardianship Greg A. Sachs, MD 181
3. Advance Directives and Advance Care Planning Greg A. Sachs, MD 182-185
H. Care of Dying Patients Greg A. Sachs, MD 186-189
II. NURSING HOME
A. Comprehensive Assessment of the Newly Admitted Nursing Home Patient Daniel J. Brauner, MD 190-191
B. Nursing Home Residents, Staff, and Physicians Daniel J. Brauner, MD 192-193
C. Nursing Home Regulations Daniel J. Brauner, MD 194-197
D. Geriatric Syndromes in the Nursing Home Daniel J. Brauner, MD 198-199
  1. Dementia in the Nursing Home Daniel J. Brauner, MD 200-205
  2. Infection Control in the Nursing Home Daniel J. Brauner, MD 206-209
  3. Ethical Issues in Nursing Home Care Greg A. Sachs, MD 210-211
  4. Pressure Sores Carla M. Tozer, MSN, ANP, GNP 212-222

PREVENTIVE HEALTH AND SCREENING IN THE ELDERY

Objectives
  1. Understand health prevention and screening recommendations in the elderly.
  2. Identify those areas of health care prevention and screening in which efficacy has been clearly established.
  3. Identify those areas of health care prevention and screening in which controversy exists.
  4. Outline an approach for those areas of health care screening and prevention in which a patient’s advanced
    age and medical conditions may clinically support or deter the clinician from a screening measure.
  1. UTILITY OF RECOMMENDING PREVENTIVE HEALTH MEASURES IN ELDERLY
    1. Are such measures effective? Data to support screening are lacking for many measures.
    2. Many recommendations but few with emphasis on elderly
    3. U.S. Preventive Services Task Force (USPSTF) did special evaluation of effectiveness of these services for
      elderly (>=65y/o) in 1991.
  2. CLASSIFICATIONS
    1. Primary prevention—interventions in asymptomatic persons who lack clinical evidence of target
      conditions, i.e., immunizations, chemoprophylaxis, and counseling about behavior
    2. Secondary prevention—screening tests for the early detection and treatment of modifiable risk factors or
      pre-clinical disease in asymptomatic persons
    3. Tertiary prevention—Prevention of further manifestations of clinically declared disease
  3. RECOMMENDATIONS FOR THE ELDERY BY THE USPSTF WITH PERTINENT UPDATES BASED ON MORE RECENT STUDY DATA
    1. Primary prevention
      1. Counseling
        1. Tobacco Use—Obtain history of tobacco use with smoking cessation counseling for those who smoke on a regular basis.
        2. Physical Activity—Explain role in disease prevention. Assist in selecting appropriate type of exercise.
        3. Nutrition—Prescribe diet designed to achieve and maintain a desirable weight. Instruct in low total fat intake unless undernourished.
        4. Alcohol and other drug use—Routinely ask about use, including quantity and frequency. If abuse or dependence confirmed, inform about health effects and offer help through counseling or other intervention.
        5. Unintentional injuries—including falls, MVA, fires and burns, drowning, choking. Advise home safety inspection, smoke detectors. Test visual acuity and monitor drugs associated with falls. Counsel regarding safety belts and not driving while intoxicated or riding with another intoxicated driver.
        6. Dental health—Recommend visit to a dentist on a regular basis, although frequency of visits not clearly known. Floss and brush teeth daily.
      2. Immunizations
        1. Pneumococcal vaccine—should be provided to all > 65 years. A single revaccination is recommended after 5 years for those who are immunocompromised.
        2. Tetanus—Combined tetanus-diphtheria (Td) vaccine to be given every 10 years
          throughout life. Those older adults, most often women, who have never been vaccinated,
          should complete the primary series of three toxoid doses over 6 to 12 months.
        3. Influenza vaccine—annually to all >65 years
          1. USPSTF recommends influenza prophylaxis for those “high risk” individuals in whom vaccine is contraindicated—amantadine 100mg daily through flu season. Note that high risk is not defined and concern about toxicity makes the case for prophylaxis a difficult one.
      3. Chemoprophylaxis
        1. Aspirin—insufficient evidence to recommend or advise against its prophylactic use. While aspirin at 80mg daily reduced the risk of MI in men aged 50-84, the adverse effects make the risk/benefit ratio uncertain.
        2. Estrogen replacement therapy in post-menopausal women—counseling recommended for all women regarding the potential risks and benefits. This remains a complex and evolving area of study.
        3. Lipid lowering agents—a thoughtful projection of overall prognosis should be made in those over the age of 75. But no hard data to support the use of such agents in primary prevention with the advance of age (refer to Hypercholesterolemia Chapter, Section V).
    2. Secondary Prevention
      1. Coronary Artery Disease
        1. Hypertension
          1. Routine measurements of blood pressure every 2 years if normotensive and annually if last diastolic was 85-89.
          2. Need measurements on three visits to diagnose hypertension.
          3. If hypertensive, recommend: Counseling regarding exercise, weight reduction and limited sodium and alcohol intake. Antihypertensives should be prescribed according to prevailing guidelines (refer to Hypertension in the Elderly Chapter, Sections III, IV, V, VI).
        2. Cholesterol (refer to Hypercholesterolemia Chapter, Sections V, VI)
          1. Insufficient evidence to recommend or advise against routine screening in asymptomatic patients over the age of 65. Cholesterol levels are not a reliable predictor of risk after age 75.
          2. If the patient has major coronary risk factors (smoking, hypertension, DM) and is otherwise healthy, he or she may be more likely to benefit from screening.
          3. The benefit of drug therapy in asymptomatic patients over the age of 65 has not been determined.
          4. For those with established coronary disease, there is strong evidence to support the efficacy for reducing acute coronary events in those aged 65 to 75 years with cholesterol-lowering therapy.
          5. In those over the age of 75 years and known coronary disease, it is clinically prudent to seriously consider instituting aggressive LDL-lowering therapy.
        3. Electrocardiograph (ECG)
          1. Insufficient evidence to recommend or advise against routine screening with rest or exercise ECG in asymptomatic patients.
          2. May be clinically prudent to screen men yearly who are asymptomatic but have 2 or more risk factors.
          3. Exercise ECG is more sensitive and specific for screening, but more expensive.
      2. Peripheral Artery Disease
        1. Routine screening not recommended
      3. Cerebrovascular Disease
        1. Recommendations as for CAD (re: hypertension, high cholesterol, smoking, physical inactivity, and dietary fat).
        2. Insufficient evidence to recommend or advise against non-invasive testing of carotid bruits for carotid stenosis
        3. Auscultate carotids in those with risk factors.
        4. Ask about TIA or other neurological symptoms.
      4. Abdominal Aortic Aneurysm
        1. Insufficient evidence to recommend or advise against routine screening by abdominal palpation or ultrasound in asymptomatic patients
      5. Dementia
        1. Insufficient evidence to recommend or advise against routine screening for dementia with standardized instruments in asymptomatic patients
        2. Clinicians should remain alert for possible signs of declining cognitive function in older patients and evaluate mental status in-patients who have difficulty performing daily activities, especially for those over age 85.
      6. Breast Cancer
        1. Annual clinical breast exam and mammography
        2. Age at which screening may be discontinued not yet determined
        3. While the USPTF says that there in insufficient evidence to continue screening over the age of 70, recommendations for screening should be based on life expectancy, personal wishes and other factors.
      7. Colorectal Cancer
        1. Screening is recommended for everyone over the age of 65 with annual fecal occult blood testing or sigmoidoscopy or both (periodicity unspecified).
        2. Insufficient evidence to determine which method is preferable
        3. Appropriate time to discontinue screening not determined
      8. Cervical Cancer
        1. Insufficient evidence to recommend or advise against an upper age limit for Pap testing
        2. If no cervix, no more paps indicated unless done because individual has history of cervical cancer.
        3. Recommend discontinuing routine pap testing over the age of 65 if regular past exams have been normal.
      9. Prostate Cancer
        1. While there is considerable controversy, it appears the weight of the evidence does not support routinely screening asymptomatic men over the age of 70 with prostate specific antigen, transrectal ultrasound, or digital rectal exam.
      10. Lung Cancer
        1. No routine chest x-rays or sputum cytology in asymptomatic persons
      11. Skin Cancer
        1. Routine screening by complete skin exam for those at high risk, e.g., family or personal history of skin cancer, clinical evidence of precursor lesions and increased exposure to sun
        2. Counsel should be given regarding use of sunscreen and protective clothing.
        3. No evidence to support advising skin self-exam
      12. Oral Cancer
        1. Routine exam only for those at high risk: Tobacco use (including smokeless), excess alcohol or other symptoms
      13. Ovarian Cancer
        1. Routine exam not recommended
      14. Diabetes Mellitus (DM)
        1. No routine screening for asymptomatic persons
        2. Measure blood glucose periodically if at high risk for DM, i.e., family history, markedly obese
      15. Obesity
        1. Routinely measure height and weight, periodicity unspecified
        2. For those greater than 20% above desirable weight, recommend dietary and exercise counseling
      16. Thyroid Disease
        1. Insufficient evidence for routine screening
        2. However, it may be clinically prudent to screen the elderly, especially women.
      17. Tuberculosis
        1. Yearly PPD for those at increased risk, i.e., NH residents, homeless, and alcoholics. Because of increased anergy in the elderly, a two-step tuberculin test is particularly indicated and recommended by the American Geriatric Society (AGS) for institutionalized elderly.
        2. If PPD is positive, chest X-ray and evaluation for clinical evidence of disease should be performed. If no active disease present, isoniazid prophylaxis should be given according to guidelines.
      18. Urine Abnormalities
        1. No routine testing for DM or asymptomatic bacteriuria
      19. Anemia
        1. No routine testing for asymptomatic persons
      20. Visual Acuity and Glaucoma
        1. Screening for decreased visual acuity by Snellen chart recommended, periodicity unspecified
        2. Clinically prudent to have glaucoma testing, frequency and method of screening not specified
      21. Hearing Impairment
        1. Questioning about hearing recommended (periodicity unspecified) and referral when appropriate
        2. Insufficient evidence to recommend or advise against routine audiometry
      22. Osteoporosis (see Osteoporosis Chapter)
        1. Insufficient evidence to recommend or advise against routine bone density testing in asymptomatic patients
        2. For high-risk women who would consider estrogen prophylaxis only to prevent osteoporosis, screening may be appropriate to assist treatment decisions.
        3. All women should receive counseling regarding preventive measures related to fracture risk including, calcium and vitamin D supplementation, weight-bearing exercise and smoking cessation.

Bibliography

  1. Canadian Task Force on the Periodic Health Examination. Task force report: The periodic health
    examination. Can Med Assoc J 121:1193-1254, 1979
  2. Sox HC: Preventive health services in adults. N Engl J Med 330:1589-1595, 1994
  3. U.S. Preventative Services Task Force: Guide to clinical preventative services. ed 2, Baltimore, Williams
    and Wilkins, 1996

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