Preventive health care for older women

Primary preventive measures for women must be
accomplished early in life to make an impact later in
life. Prevention for the older person includes maintaining
quality of life, preserving function, preventing
collapse of family support systems, and maintaining
independence in the community.
Primary preventive measures are optimally accomplished
early in life to make an impact later in life.
Goals of preventive care
for the older woman
1. The percentage of US adults older than age 65
years is growing rapidly and is expected to almost
double between 1995 and 2030 (12.8% to 20%).1
2. Life expectancy for women is longer than that of
men, at all ages older than 65 years. By age 85,
only 45 men will be alive for every 100 women.2
This significantly changes the social environment
in which older women live. Understanding the
specific needs and circumstances of an individual
woman helps to guide preventive health decisions.
3. The annual physical examination encompasses
screening and preventive counseling. Both
primary preventive measures (i.e. interventions
targeted at preventing specific conditions in
asymptomatic persons) and secondary preventive
measures (i.e. screening for early detection and
treatment of modifiable risk factors or preclinical
disease) are described.
General assessment
Well-being/living situation/independence
1. Health status assessment and primary and
secondary prevention encompass more than a
periodic physical examination. A
multidimensional assessment focusing on mental
health, physical health, basic functioning, social
functioning, and economic well-being provides a
complete picture of the older woman (Table 2.1).
2. Early in the evaluation, establishing the older
woman’s marital status, her current living
arrangements and household partners, and whether
she has experienced the loss of a spouse or long-time
friend is important. Is she currently working or
active in group activities outside the home?
3. The accuracy of the history depends on adequate
mental and affective functioning of the patient.
The accuracy of historical information gathered
from the older woman, family member or friend,
and the consistency of the information between
sources, provide clues regarding the older
woman’s cognitive function and whether she can
remain independent.
Caregiver responsibilities
1. Older women often have substantial
responsibilities caring for spouses, siblings,
children, and grandchildren. More than 15 million
adults currently provide care to relatives.3 Of all
caregivers for disabled elders, 70% are women and
30% of these are older than age 74 years.4
2. Caregiving taxes physical, social, emotional, and
financial resources, and can significantly affect
the health and functional status of the caregiver.
The combination of loss, prolonged distress and
the physical demands of caregiving increase the
caregiver’s risk for physical and emotional health
problems.3
3. Caregivers who provide support to their spouses
and report caregiving strain are 63% more likely to die within four years than
non-caregivers.3
4. Significant levels of depression are seen in
caregivers of Alzheimer’s patients. Assistance is
available through support groups and information
accessible through the Internet: www.alz.org and
www.alzheimers.com.
5. Reducing caregiving demands by providing respite
care or other relief for the caregiver may mitigate
the strain so that the caregiver and cared for family
member can remain independent longer.
Caregiving taxes physical, social, emotional,
and financial resources, and can significantly
affect the health and functional status of the
caregiver.
Presence of chronic disease
1. With aging, the older woman becomes more
susceptible to chronic illness and disease. For
example, the incidence of degenerative joint
disease is increased in older women. This causes an
increased incidence of knee pain, which is
associated with diminished quality of life.5
2. There is a higher incidence of all chronic diseases,
especially diabetes mellitus and hypertension, in
minority groups.6
3. The presence of common chronic health problems
is associated with lower levels of cancer
screening – presumably because of the time
commitment required by the clinician to care for these chronic illnesses, negatively impacting on
preventive services.7 Access to care
Insurance coverage/underinsurance
1. In the USA, underinsurance is the inability to
pay out-of-pocket expenses despite having
insurance, and usually implies inability to
use preventive services also. Medicare-eligible
citizens may be unable to afford medical
expenses not covered by Medicare. Many elderly
recently joined Medicare Health Maintenance
Organizations (HMOs) to obtain added benefits,
including prescription benefits, and have been
confused and abandoned by the failure and
break-up of these Medicare HMOs.
2. The underinsured category also includes
unemployed persons age 55 to 64 and those not
provided with coverage through their jobs.
They are not yet eligible for Medicare and
must pay high individual health premiums
when they can obtain some form of group
coverage. Women are more likely to be
underinsured because they are more likely to
be divorced and no longer covered by a
husband’s insurance, or underemployed in a
part-time job that does not provide medical
insurance. Lack of health insurance is associated
with delayed health care and increased mortality.
3. Underinsurance may also result in adverse health
consequences.8 There is a dose-response
relationship between the level of insurance
coverage and receipt of preventive services.
4. Women access the health care system more
frequently than do men. They receive more health
services and prescriptions, undergo more
examinations, laboratory tests, and blood pressure
checks than men.
5. However, when US physicians were surveyed
recently regarding making the diagnosis
of coronary artery disease and recommending
coronary angiography and/or revascularization
procedures, they were significantly less likely to
make these recommendations for women and
minority groups.9
Lack of health insurance is associated with
delayed health care and increased mortality.
Mobility
1. Those women most likely to get screening and
preventive services have a usual source of care and
no limitations on mobility.10
2. This is evident in the higher risk for delayed
diagnosis of breast and cervical cancer in disabled
women.11
Those women most likely to get screening and
preventive services have a usual source of care
and no limitations in mobility.
Language/acculturation
1. A low level of acculturation results in a lower
likelihood of receipt of preventive services.12 Cultural
explanatory models are important in describing the
woman’s willingness to receive care. Eliciting this
information is easierwhen the clinician and the older
woman have a comfortable relationship. Otherwise,
the clinician may be unaware of why therapies
prescribed are unsuccessful or why the woman fails
to follow advice.
2. Religion is a significant part of the culture of
racial and ethnic communities representing a
range of socioeconomic status. Physical health,
depressive symptoms, and hypertension
improved, and tobacco and alcohol use decreased
as a woman’s religious involvement increased in
ethnic communities.13
Emotional/mental status/cognitive
functioning
1. Depression
Depression is the most commonly diagnosed
mental illness in older adults in the primary
care setting, although it often goes unnoticed.14
Major depression is seen in 1–5% and
significant depressive symptoms in up to 25%
of community-dwelling older people. Older
women receive more antidepressants every year
than men, though this difference decreases as
they get older.15
a. Older adults with major depression who are
seeing primary care physicians have
significantly higher medical costs (reflecting
more outpatient visits, laboratory tests, X-rays,
inpatient days, and specialty medical visits) than controls matched for age, gender, and
chronic mental illness.16
b. Older caregivers demonstrate significantly
higher levels of depressive symptoms, anxiety,
and lower levels of perceived health than do
their non-caregiving counterparts.16
c. In addition to depression, stress-related
symptoms are common in older adults. Lower
stress levels are evident in retirees comparedwith
those approaching retirement,17 or working.
2. Cognitive dysfunction
a. Cognitive decline in the very old has been
underestimated and must be assessed
carefully and regularly (Table 2.2).18
b. A complete mental status examination
includes an evaluation of level of
consciousness, attention, language
capabilities, memory, proverb interpretation,
comparisons, calculations, writing, and
constructional ability.
Older adults with major depression who are
seeing primary care physicians have significantly
higher medical costs.
c. Condensed mental status screening tools can
substitute for the complete mental status
examination and detect cognitive deficits that
are often seen in dementia syndromes.
d. Deficits often occur without a change in level
of consciousness, are significantly different
from the patient’s baseline results, and always
result in some impairment of function.19
e. The average age of onset of dementia is 69
years (Figure 2.1).
f. Dementia imposes heavy responsibilities on
family and resources and must be
distinguished from delirium (reversible
cognitive deficits).
g. Brief mental status tests may evaluate
intellectual functioning only or also include a
functional assessment. Two commonly used
tests are the Pfeiffer Short Portable Mental
Status Questionnaire and the Folstein Mini
Mental State Examination.20 None of these
tools has complete diagnostic accuracy and
they may fail to identify subtle changes in
highly functioning elderly. Basic testing is
included in Table 2.1.
h. When there are negative results in both the
metabolic work-up and the mental status
examination for patients with functional
impairment, formal neuropsychological
testing is necessary. The results can also assist
in care coordination by suggesting beneficial
environmental adaptations.
Dementia imposes heavy responsibilities on
family and resources and must be distinguished
from delirium.
3. Family support
a. The caregiving ability and availability of
family and friends must be determined to
identify who could help the elder in the event
of an illness, accident, or other acute event
that would limit self-care ability.
b. Caregivers can also provide valuable
information regarding subtle changes in
functioning or cognition. Social network
The older woman’s involvement in the community
reflects her ability to make and sustain relationships
and also defines a support system outside the
family. The active woman is unlikely to be severely
handicapped by mental and emotional conditions.
5. Religious involvement
a. After adjusting for physical and mental health
conditions, social connections, and health
practices, older women who attend church at
least once weekly had a better chance of
survival.21
b. The positive effects of religion have been seen
in all age groups. Fewer depressive symptoms
occur in women who have a denominational
affiliation, whereas women with no or low
frequency of church attendance have more
current smoking and daily drinking.13
c. Religious participation has short- and long-term
influence on functioning in the elderly, especially
those who are disabled, including the following.
i. Attendance at services is a strong
predictor of better functioning.
ii. Health practices, social ties, and indicators
of well-being reduce, but do not eliminate,
these effects; disability has minimal effects
on subsequent attendance.
d. Older adults who reside in deteriorated
neighborhoods experience more physical
health problems than older people who dwell
in more favorable living environments.22
Data from a nationwide longitudinal survey
of older people suggest that the noxious
impact of living in a dilapidated
neighborhood on changes in self-rated health
over time is offset completely for older adults
who are deeply religious.
6. Sexuality
a. Like younger adults, older adults are sexual
beings. Assumptions of sexual activities or lack
thereof based upon age alone are unwarranted.
Even in the presence of significant ongoing
health problems, appropriate sexual history
questioning of all older women is helpful.
Older women who attend church at least
once weekly had a better chance of survival.
b. Issues include lack of availability of partners
(widows or spouses with significant health
problems), physiological changes associated
with age (mucosal dryness in postmenopausal
women) and changes in relationships with
aging. As with younger patients, discussions
of sexual activity include inquiries and
education on risky sexual behaviors.
Older adults who reside in deteriorated
neighborhoods experience more physical
health problems than do older people who
dwell in more favorable living environments.
Functional assessment
Activities of daily living/instrumental
activities of daily living
1. Periodic health examination provides an
opportunity to detect functional problems that
can decrease life expectancy. Classifying the older
woman by functional ability is more helpful than
classifying her by age (Table 2.3).
2. Instrumental activities of daily living (IADLs) are
those that require the patient to use integrative
thought processes and complex musculoskeletal
coordination to perform the necessary daily
tasks of life (e.g. working, shopping, cooking,
managing money, driving or arranging
transportation, using the telephone) (Table 2.4).
3. Basic activities of daily living (ADLs) are those
that are necessary to maintain personal care
(e.g. bathing, dressing, maintaining continence,
transferring or walking, toileting, eating).
4. Multiple instruments exist for research and social
service purposes, but the most commonly used
clinical instrument is the Katz Index of Activities
of Daily Living.23
Ambulation/activity patterns
1. More than 40% of women older than age 65 report
a sedentary lifestyle that is associated with many
chronic illnesses.24 Maintenance of regular
leisure-time activity results in lower lipid levels,
coronary artery disease, diabetes mellitus, and
hypertension.
2. Regular exercise improves neurobehavioral
function.25 3. Strength training is important for maintenance of
strength, physical function, bone integrity and
psychosocial health.26
Diet/nutrition
1. Approximately 21–45% of women between ages
65 and 74 years are overweight.31 Diet affects the
development of most chronic diseases that are also
impacted by exercise patterns. In addition, stroke,
constipation, and diverticular and dental disease
are all influenced by diet.
2. This may be the appropriate time in the history to
ask about the use of vitamins and nutritional
supplements. They serve as a potential source of
symptoms and drug interactions.
3. Accurate weights at the clinical visit are
important, rather than relying on the stated
weight. Unfortunately the national norms do not
include data on older people.
4. Significant weight loss (1–2% of body weight in
one week, 5% in one month, or 10% in six
months) may reflect many diseases (Table 2.5),
poor dentition, cognitive impairment, respiratory
dysfunction, poor hand-to-mouth coordination,
a need for assistance in purchasing or preparing
foods or other factors affecting the amount of
food consumed (such as elder abuse).
Risk assessment
Risk of elder abuse
1. As many as 2.5 million older adult persons are
abused each year and the number of cases is likely
to increase as this population grows. Elder abuse exists in many forms: physical, emotional,
financial, and sexual; neglect and self-neglect.
2. Most states have mandatory reporting; however,
this may infringe on the autonomy of competent
geriatric individuals. Supportive assessment and management focuses on both the patient and the
caregiver for problem solving.
3. Physicians infrequently report elder abuse. This
may be caused by unfamiliarity with reporting
laws, fear of offending patients, concern about
time limitations, and the belief that they do not
have appropriate evaluation skills. In the USA,
reporting suspected abuse directly to the
appropriate state agency facilitates the
coordination of thorough long-term assessment
and management.
4. Older women and men have similar abuse rates.
Abuse is best correlated with the emotional and
financial dependence of the caregivers on the
geriatric victims. Relatives, usually spouses, most
commonly abuse older patients.
5. No specific screening tools have been found to be
clearly effective in identifying elder abuse victims.
A few direct questions in the course of routine
history taking may provide the physician with
insight into those patients at risk (US Preventive
Services Task Force (USPSTF) class C). Helpful
questions include, “Are you afraid of anyone at
home?”, “Have you been struck, slapped, or
kicked?” or “Do you ever feel alone?”28
Elder abuse is best correlated with the emotional
and financial dependence of the caregivers on
the geriatric victims, and relatives, usually spouses,
most commonly abuse older patients.
Risk for substance abuse
1. Substance abuse, including alcohol and tobacco
abuse, afflicts the older patient as well as the young.
The periodic examination is the logical time to
screen for substance abuse and provide
appropriate counseling. Emphasizing the
relatively short-term rewards of smoking
cessation, such as decreasing the risk of stroke,
can be persuasive for the older person
struggling with tobacco abuse.
2. Referral to a specific program is more helpful for
the patient than merely suggesting she discontinue
tobacco use. However, more women and more
elderly quit smoking “cold-turkey” and on their
own than using a program. The multiple ways
other than cigarettes (snuff, pipes, etc.) that an
older woman can use tobacco should be
recognized.
3. The four-question CAGE instrument
(see Chapter 27) can be very helpful in
identifying alcohol abuse or dependence. It is
less sensitive for early problem drinking, heavy
drinking or drinking in any woman or the
elderly than it is with men.
More women and more elderly quit smoking
“cold-turkey” and on their own than using a
program.
Risk of injury
1. Safety belts
Older adult persons are less likely to be involved
in a motor vehicle accident (caused by decreased
driving distances and lower speeds). Older women
and their passengers still benefit fromthe use of lap/
shoulder belts at all times even in the presence of air
bags (USPSTF class A).29 For some small, frail
women, air bags can pose a potential risk of injury.
2. Falls
Falling is a common, serious problem in older
individuals. Falls are the leading cause of non-fatal
injuries and unintentional injury deaths in older
persons in the USA. Screening for falls may include
asking the patient whether she has fallen in the
past year or whether she is afraid of falling. Gait
assessment and rehabilitation can be offered to such
women. These measures have been shownto reduce
the risk of falling and subsequent injuries.28
Periodic medical care
Examination frequency
All elders benefit from a periodic examination that
focuses on prevention. However, with accurate record
keeping, this evaluation can be accomplished through
serial visits as the older woman is monitored for
chronic diseases. This approach is consistent with
the current USPSTF guidelines (Table 2.6).
Immunizations
1. Older adults are often inadequately immunized.
Formal documentation of remote vaccine history
is often unavailable. A review of immunization
history and documentation can be performed
during the periodic examination 2. Influenza vaccine
Annual influenza vaccine is recommended for all
older adults, particularly those who are chronically
ill or at high risk of contracting influenza, such as
those patients in institutions (assisted living centers,
nursing homes, boarding and daycare homes)
(USPSTF class B). The vaccine is effective in
reducing hospitalizations, deaths, associated
complications and health care costs from influenza 3. Pneumococcal polysaccharide vaccine
A single immunization is recommended for all
immunocompetent adults age 65 years and older
(USPSTF class B). Universal revaccination is
unnecessary as the protection afforded by the
vaccine persists for up to nine years or more. The
American College of Physicians does recommend
revaccination for patients who have received the
vaccine before age 65 years and for whom more
than six years have passed since the initial vaccine.
4. Tetanus
Although tetanus is an uncommon disease in
developed nations, more than 60% of cases occur
in patients older than 60 years. The standard
recommendation is a combined tetanus-diphtheria
(Td) given every 10 years for all patients (USPSTF
class A).
A single Td booster at age 65 years may be a
cost-effective alternative, given current compliance
with the 10-year guideline. A complete primary
series of three toxoid doses over 6 to 12 months is
necessary for those patients who have never been
vaccinated. Adacel vaccine, similar to DTaP but
with reduced quantities of d and detoxified PT,
provides active booster immunization for the
prevention of tetanus, diphtheria and pertussis
as a one-time shot to patients up to 64 years.
Screening (Table 2.8)
1. Hypertension
a. Impact
Elevated blood pressure occurs in 60% of non-
Hispanicwhites, 71%of non-Hispanic African-
Americans, and 61% of Mexican-Americans
older than age 60 years. There is a 90% lifetime
risk of becoming hypertensive in normotensive
population at 55 years of age. Prehypertensive
individuals (systolic BP 120–139 mmHg or
diastolic BP 80–89 mmHg) require lifestyle
modifications to prevent the progressive rise
in blood pressure and cardiovascular disease.
b. Systolic rather than diastolic blood pressure is
a better predictor of coronary artery disease,
cardiovascular disease, heart failure, stroke,
end-stage renal disease, and all-cause mortality
than diastolic blood pressure in the elderly.
Primary hypertension is the most common
form of hypertension in older persons.30
c. Blood pressure measurements at least every two
years for adults with diastolic blood pressures
less than 80mmHg and systolic blood pressures
below 120 mmHg are recommended.30
d. Annual blood pressure managements are
recommended for persons with diastolic
blood pressures 80 to 89 mmHg or systolic
blood pressures 120 to 139 mmHg. Persons
with higher blood pressure require more
frequent measurements.
e. Older individuals are more likely than
younger individuals to exhibit an orthostatic
fall in blood pressure and hypotension.
Therefore, blood pressure should be
measured in both the standing and sitting
positions in older individuals.
Systolic rather than diastolic blood pressure is
a better predictor of coronary artery disease,
cardiovascular disease, heart failure, stroke,
end-stage renal disease, and all-cause mortality
than diastolic blood pressure in the elderly.
f. Treating hypertensionin the elderly is important
and does decrease their risk ofmorbidity and
mortality. Effects of non-pharmacological
first-line therapy (i.e. weight reduction,
increased physical activity, sodium restriction,
decreased alcohol intake) on cardiovascular
morbidity and mortality are less well studied.29
g. For individuals 40–70 years of age with BP in
the range of 115/75 to 185/115 mmHg, each
increase of 20 mmHg in systolic BP or 10
mmHg in diastolic BP, doubles the risk of
cardiovascular disease. The benefit of
treatment of hypertension was demonstrated
even in patients aged above 80.29
Treating hypertension in the elderly is
important and does decrease their risk of
morbidity and mortality.
2. Breast cancer
a. The USPSTF recommends routine screening
every 1–2 years with mammography and
annual clinical breast examination (CBE) for
women aged 50 to 69 years.29
b. There is insufficient evidence to recommend
for or against routine mammography and CBE for women age 70 years or older, although
recommendations for healthy women older
than age 70 may be made on other grounds
(e.g. those with a past history of malignancy).
Women who have had one mammogram after
age 70 years are much less likely to die of breast
cancer. With higher risk of breast cancer,
women older than 70 years of age, whose life
expectancy is not compromised by other
co-morbidities (i.e. dementia, life expectancy
less than five years) may benefit from routine
mammography as younger women do.31,32,33
c. Older women with low bone mineral density
have a lower risk of breast cancer (presumably
caused by decreased exposure to estrogen) and
may benefit less from continued screening.34
d. Data regarding the sensitivity of monthly breast
self-examination (BSE) in detecting breast
cancer are extremely limited. Sensitivity may be
approximately 15%. Sensitivity for detecting
breast cancer rises to 26% if the women are also
screened by CBE and mammography.35
e. Factors that have been associatedwith inadequate
screening are advanced age, poor cognitive
function, and nursing home residence.36
The USPSTF recommends routine screening
every 1–2 years with mammography and
annual clinical breast examination for women
aged 50 to 69 years.
3. Cervical cancer
a. For those older women in whom repeated Pap
smears have been normal, further screening
does not appear to be beneficial. Those women
with no prior screening, previously inadequate screening or for those women engaging in
high-risk sexual behaviors, screening with Pap
smears every 1–3 years is recommended.
b. Women who have undergone hysterectomy
for non-cervical cancer diagnoses, with
complete removal of the cervix do not benefit
from Pap smear screening.29
c. There is insufficient evidence to provide for
or against an upper age limit to Pap smear
screening. The USPSTF and the American
College of Physicians offer guidelines to cease
screenings after age 65 years, while the
Canadian Task Force recommends ceasing
after age 69 if prior screening has been normal
(USPTFP class C).29
For those older women in whom repeated
Pap smears have been normal, further
screening does not appear to be beneficial.
4. Colon cancer
a. Colon cancer is the second most common
form of cancer in the USA and the second
highest cause of cancer mortality. Although its
peak incidence is between ages 70 and 80 years,
none of the available studies focuses on the
geriatric population.
b. Digital rectal examination (DRE) is of little
value in screening for colon cancer, since fewer
than 10% of colorectal cancers can be palpated.
c. Annual fecal occult blood testing (FOBT) in
asymptomatic patients has a high rate of
false-positives. The positive predictive value is
only 2–11% for carcinomas and 20–30% for
adenomas in patients older than age 50 years.
The predictive value may be higher in older
patients caused by the higher prevalence of
colorectal cancers in these age groups. Two
recent studies have shown reductions in
mortality in patients offered FOBT every one
to two years.37 Traditional three-card FOBT is
more sensitive than office fecal occult after
DRE.33 All positive results need to be further
evaluated with appropriate testing
(colonoscopy, air contrast barium enema).
d. Screening with sigmoidoscopy, with or without
FOBT, is recommended every three to five years
by most authorities, although intervals of 10
years may also be adequate (USPSTF class B).29
e. Sigmoidoscopy with longer (60 cm) flexible
sigmoidoscopes has been shown to have
greater sensitivity and is better tolerated by
the patient than rigid sigmoidoscopy.
f. The American Cancer Society recommended
colonoscopy every 10 years as one way of
screening for colon cancer. One study showed
that colonoscopy is slightly more sensitive at
screening and follow up of the rate of polyp
progression.33 But it also has more serious
complications compared to other screening
methods.
Screeningforcoloncancerwithsigmoidoscopy,
with or without fecal occult blood testing, is
recommended every three to five years.
5. Depression/cognitive impairment
a. The ideal depression-screening tool for older
persons is both accurate and easy to
administer. The original 30-item Geriatric
Depression Scale (GDS) was developed by
Brink and Yesavage in 1982 and condensed
to a 15-item version by Sheikh in 1986 with
improved efficiency and no loss of
accuracy.38 Most recently, a five-item version
of GDS has been developed, resulting in a
marked reduction in administration time
(Table 2.9).39
b. Education and cultural background
moderate Mini Mental Status Examination
(MMSE) results. College-educated women
perform better on these examinations and
racial and ethnic minorities do more poorly,
almost entirely related to lower
socioeconomic status and poorer educational
attainment.40
6. Hyperlipidemias
a. Current recommendations for screening of
asymptomatic women older than age 65 years
are conflicting. Although hyperlipidemia is
strongly associated with atherosclerotic heart
disease, little correlation has been shown
between elevated total or low-density
lipoprotein (LDL) cholesterol and long-term
heart disease risk or mortality in women older
than age 65 years.
b. Currently the American College of Physicians
and USPSTF do not recommend cholesterol screening in asymptomatic women older than
age 65. Individualized screening of otherwise
healthy women with major risk factors for
CHD (smoking, hypertension, and diabetes)
is a class C recommendation.29 Screening with
fasting or non-fasting samples is appropriate.
The ratio of total to high density lipoprotein
(HDL) cholesterol appears to be the best
predictor of coronary risk in older patients.41
Data showed that lipid lowering is as or more
effective in older patients than in younger
ones, and with the higher risk of CHD events
in older patients,42 the decision of screening
of cholesterol and appropriate treatment
needs to be made based on each case. Patients
with life expectancy sufficient to benefit from
treatment may benefit from screening.
The ratio of total to high density lipoprotein
cholesterol appears to be the best predictor
of coronary risk in older patients.
7. Thyroid disease
a. Although there is a high prevalence of thyroid
disorders in older patients, especially women,
no benefits of thyroid screenings have been
shown in clinical trials.
b. Asymptomatic elevations in thyroidstimulating
hormone (TSH) or low thyroxine
(T4) levels have been found in up to 15% of
women older than age 60 years.43 Subclinical
thyroid disease is also described, especially in
patients with cognitive and affective deficits.
c. With reasonable assay costs, screening for
mild thyroid failure at the periodic health
examination may be cost effective. The US
and Canadian Task Forces agreed that it
might be reasonable to test high risk patients,
especially women, and those with possible
symptoms (class C recommendation).29
d. A TSH assay alone is a reasonable test, with a
subsequent follow-up of abnormal values.
e. Screening every five years has been suggested
as an appropriate interval.
8. Incontinence
a. Urinary incontinence is a common,
disruptive, and potentially disabling
condition. Women, more commonly than
men, experience urinary incontinence with
increasing frequency with age and level of
institutionalized care. Significant problems
with incontinence may lead to social isolation,
with resultant decline in physical well-being
and quality of life (see Chapter 18).
b. Simply, direct questioning in the routine
history taking will often reveal symptomatic
urinary incontinence. Because urinary
incontinence is curable or treatable in many
elderly women, it is essential that specific
questions be included in the periodic
examination 9. Osteoporosis
(see also Chapter 28)
a. Approximately 1.3 million osteoporosisrelated
fractures occur each year in the USA.
Seventy percent of fractures in those 45 years
or older are types related to osteoporosis.
b. Osteoporosis is defined as a bone mineral
density 2.5 standard deviations (SD) below
the normal mean.44 However, it is not
necessary to obtain such measurements in
order to initiate treatment (see Chapter 28).
c. Dual-energy X-ray absorptiometry (DEXA)
is recognized as the safest, most accurate, and
more precise modality for measuring bone
density in the clinical setting and is the gold
standard. If the patient already has evidence of
vertebral fracture, the diagnosis of osteoporosis
is present and treatment is indicated.
d. Randomized trials show that estrogen and
calcium supplementation is effective in
preserving bone density in postmenopausal
women. Postmenopausal women who have
discontinued HRT within the past five years
have a risk for hip fracture that is at least as high
as that in women who have never used HRT.45
e. Benefits of hormonal prophylaxis on bone
mass and fracture risk appear greatest when
treatment is begun close to menopause
(before the period of rapid bone loss) and
continued for longer periods (more than five
years) (Table 2.10).29 But the use of HRT has
decreased due to the increased risks of breast
cancer, ovarian cancer, strokes and CHD.
f. Prevention, diagnosis and screening methods
are listed in Table 2.11.
10. Sensory impairment
a. Hearing loss
Hearing impairment occurs with increasing
prevalence as patients age. Presbycusis is the
most common cause, with approximately
33% of patients aged 65 years and older
suffering objective hearing loss. Periodic
questioning about potential hearing loss is
a rapid and inexpensive screen for hearing
impairment. Handheld devices (audioscopes)
may be more sensitive but there is
inconclusive evidence to support routine
audiometry testing (USPSTF class B).29
b. Vision loss
Visual impairment is a common problem
among older patients, with potentially
serious complications in general health
and quality of life. Presbyopia, cataracts,
age-related macular degeneration (ARMD)
and glaucoma are the most common causes
of visual impairment. Routine screening with
Snellen acuity testing is recommended for
older women (USPSTF class B).29 Screening
asymptomatic patients with ophthalmoscopy
by the primary care physician is a class C29
recommendation. No specific frequency for
screening is recommended.
11. Polypharmacy
a. Polypharmacy is the rule rather than the
exception for older patients. Multiple
chronic illnesses, self-medication, and the
physiopharmocological changes with aging
can lead to adverse reactions and drug
interactions that may go unrecognized in
the older patient.
b. Incorporating a medication review into the
periodic health examination and then again
frequently in follow-up visits can help to
avoid adverse drug reactions. Inquiring about all medications taken, including
over-the-counter medications, vitamins,
herbals and alternative/complementary
therapies is helpful. Asking the patient to
bring in the entire content of her medicine
cabinet can be illuminating. Expired drugs,
medications for illnesses no longer requiring
treatment and prescriptions from multiple
providers are frequently noted.
c. Encouraging the patient to use a pharmacy
with database capability can help to reduce
the likelihood of drug–drug interactions or
adverse effects of multiple drug regimens.
A good relationship between the physician
and pharmacist can also be beneficial in
avoiding adverse reactions or drug–drug
interactions.
12. Abdominal aortic aneurysm (AAA)
a. An AAA is present when the infrarenal aortic
diameter exceeds 3 cm. USPSTF
recommends one-time US screening of
AAA in men with risk factors: age (being
65 or older), male sex, a history of ever
smoking (at least 100 cigarettes lifetime),
and a first-degree family history of AAA.46,47
b. USPSTF recommends against routine
screening of AAA in women (class D). This is
based on the lower prevalence of AAA in
women (about 15% of that in men) and late
onset in the 80s. But certain risk groups in
female patients may also benefit from AAA
screening.46,47
c. The Society for Vascular Surgery and the
Society for Vascular Medicine and Biology
recommend screening all men aged 60 to 85,
women aged 60 to 85 with cardiovascular risk
factors, and men and women aged 50 and
older with a family history of AAA.
d. Beginning in January 2007, Medicare will
provide coverage for a one-time
ultrasonography screen for AAA in men with
risk factors, and in men and women 65 to
74 years of age with a family history of AAA.
Chemoprophylaxis
Aspirin
Aspirin prophylaxis for stroke and myocardial
infarction prevention has been well studied in men.
There is, as yet, inconclusive evidence to recommend
for or against aspirin prophylaxis in older women.
Individual patients may benefit from such intervention
but potential risks (gastrointestinal bleeding or
cerebral hemorrhage) must be weighed (USPSTF
class C)

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