• Evaluate preventive health recommendations to determine if they make sense in an older person.
• Recognize that recommendations for younger adults still apply for functional younger geriatric patients.
• Recognize the use of screening tests for occult conditions in older adults.

Angela R. Curtis, PhD
Managing Editor
Assistant Professor, Geriatric Education Manager

Andrew S. Duxbury , MD., FACP
Associate Professor, Division of Gerontology, Geriatrics, and Palliative Care
Medical Director, UAB Geriatrics Clinic

Division of Gerontology, Geriatrics and Palliative Care
University of Alabama at Birmingham
Birmingham, Alabama

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

One of the most difficult areas in geriatric medicine is that of screening and preventive care. While the medical community is in agreement on recommendations for appropriate screening of healthy young and midlife adults, there are far fewer consensus agreements available for the geriatric age group. The U.S. Preventive Services Task Force, a project of the Agency for Healthcare Research and Quality, has taken the many conflicting and confusing standards and looked at screening modalities using rigorous evidence-based scientific methods to determine which recommendations make sense.[1] While their recommendations are fair and clear for the general adult population, many of their recommendations for the older population are left open to clinical discretion, due to the heterogeneous nature of health and wellness amongst older adults. This leaves the practicing physician somewhat at sea in terms of deciding which preventive measures are useful.

In 1992, Klinkman and Zazove et al. published an article in the Journal of Family Practice outlining a method of determining if any particular preventive health service should be used in an older person.[2,3] Their criteria included six evaluative steps which are useful in decision making regarding older persons and their need for screening:

1. The condition screened for must have a significant effect on health.
   
   
2. Acceptable methods of preventive intervention or treatment must be available for the condition.
   
   
3. For primary preventive services (counseling, chemoprevention, immunizations), the intervention must be effective in preserving health.
   
   
4. For other preventive services or interventions:
   
   (a) There must be a period before the individual (or his or her caretaker) is aware of the condition, or of its seriousness or implications, during which it can reliably be detected by providers;
   
   (b) Tests used to identify the condition must be able to reliably discriminate between cases and non-cases of the condition; and
   
   (c) Preventive services or treatment during this "pre-awareness" period must have greater effectiveness than care or treatment delayed until the individual or caretaker brings it to a provider's attention.
   
   
5. For individuals who are cared for by caregivers, the benefit offered by the preventive service must outweigh any negative effects on the quality of life of caregivers.
   
   
6. The relative value of the preventive service or intervention must be determined by a comparison of its costs with its expected health benefits.[2]

Using data from the U.S. Preventive Services Task Force and the above criteria, it is possible to provide successful, cost-effective, and appropriate preventive services to older patients as part of their primary care.

Mrs. S. is a healthy 83-year-old African American woman who presents for a well patient visit. She has mild hypertension controlled with 12.5 mg of hydrochlorothiazide, hypothyroidism with normal TSH and Free T4 levels on .075 mg of levothyroxine replacement therapy and moderate degenerative joint disease for which she uses meloxicam 15 mg once a day. As she is active and healthy, she wants to make sure her gynecological cancer screening is up to date. There is no history of breast cancer or other gynecologic cancer in her family. She has not had a hysterectomy. She went through menopause at the age of 56. She had routine pap and pelvic examinations through the age of 70, but has avoided them in recent years as they are uncomfortable. She is a widow and has not been sexually active for more than ten years. She has had mammography in the past, but is unable to recall exact dates. She does not perform monthly breast self-examination.