CPM18th Care of Older Persons
CPM18th Care of Older Persons
CPM18th Care of Older Persons
Physicians Consensus
Statements on Wellness:
Care of Older Persons
Care of Older
Persons
53
Initiate wellness
program.
Follow up.
54
A wellness program should include health promotion The older person is at risk for the following diseases:
such as nutrition and fitness program, specific disease influenza, pneumonia, herpes zoster, tetanus and
protection such as immunization and disease prevention diphtheria. Immunization aims to induce an immune
which include the screening tests. The older patient and response that will protect against later exposure to the
their families should be given anticipatory guidance pathogen. The estimated average annual disease burden
on this. The Philippine Academy of Family Physicians was from high to low: pneumococcal disease (37,223
launched its Family Wellness Program through its DALYs/year), influenza (7941 DALYs/year), herpes zoster
advocacy project “Kalusugan ng Pamilya Mo, Aalagaan (942 DALYs/year), and pertussis (812 DALYs/year). The
Ko” with the primary objective of promoting wellness. adaptation of models and parameters specifically for the
elderly resulted in a higher disease burden compared to
The Consensus Statements Technical Working Groups the use of general population models.
(TWG) on Wellness for Older Persons held several
meetings among themselves and consultative meetings Pneumococcal Vaccine
with the PAFP Committee on Quality Assurance and Statement 1. PCV13 vaccination is recommended to
stakeholders to discuss each of the statements that 65 years or older who have not previously received a
will be considered and recommended. Topics on the pneumococcal vaccine or whose previous vaccination
components of wellness include health promotion such history is unknown. A dose of the 23-valent pneumococcal
as proper nutrition, exercise and counseling; specific polysaccharide vaccine (PPSV23) for these patients
protection such as immunization; chemoprophylaxis should be given 1 year after PCV13 vaccination.
and screening for risk factors. Based from these topics, (Moderate grade, Strongly recommended)
the group formulated research questions that will guide
in the search for literature and appraisal of evidences. Statement 2. If a patient 65 or older has not previously
Appraised articles were presented amongst the members received the PCV13 vaccine but has received one or
of the TWG and formulation of statements followed. more doses of PPSV23, that patient should receive a
dose of PCV13 at least one year after administration
Assessment of the level of quality of evidences utilized of the most recent dose of PPSV23. (Moderate grade,
the GRADE (Grading of Recommendations, Assessment, Moderately recommended)
Development and Evaluation) approach. A high grade
level of evidence connoted that the members were Summary of Evidences.
confident that the true effect lies close to that of the Both PCV 13 and PPSV23 is recommended for older
estimate of the effect. A moderate grade level describes person (Tomczyk, 2014 ). They have to be administered in
a moderate confidence in the effect estimate the true sequential series. Reverse cumulative distribution curves
effect is likely to be close to the estimate but there is a of the population antipneumococcal OPA responses
possibility that it is substantially different. A low grade for the vaccination sequences PCV13/PCV13, PCV13/
level means that confidence in the effect estimate is PPSV23, and PPSV23/PCV13 were compared. As seen
limited and the true effect may be substantially different. when comparing OPA GMTs, population responses were
A fourth measurement (very low grade) was not included generally greater, depending on serotype, following
in this process. administration of PPSV23 given after PCV13 compared
with responses following administration of PCV13 given
The draft statements were then presented in a consensus after PPSV23. Responses following two administrations
conference attended by the current board of directors of PCV13, given 1 year apart, were also generally greater
of PAFP, representatives of local PAFP chapters and than responses following the sequence of PPSV23/
family medicine residency training programs, and other PCV13. However, responses after the PCV13/PCV13
stakeholders that included representatives from the Food sequence were similar or lower (with the exception of
and Nutrition Research Institute, Philippine College of serotypes 6A, 6B, and 23F) than responses following
Geriatric Medicine, among others. PCV13/PPSV23 (Greenberg 2013, Jackson 2013).
55
Influenza Vaccine age and older previously vaccinated with 23-valent pneumococcal
polysaccharide vaccine. Vaccine 2013;31:3585–93
Statement 3. Annual vaccination with Influenza 4. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal
vaccine is recommended for 65 years old and above. conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine
(Moderate grade, Strongly recommended) among adults aged ≥65 years: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Morb Mortal
Wkly Rep 2014;63:822–5.
Summary of Evidences. 5. Rivetti, D. et al. Vaccines for preventing influenza in the elderly.
Sixty-four studies were included in the efficacy / [Cochrane Database Syst Rev. 2010]
effectiveness assessment, resulting in 96 data sets. In 6. Schmader, KE. Effect of a Zoster Vaccine on Herpes Zoster-Related
Interference with Functional Status and Health-Related Quality of Life
homes for elderly individuals (with good vaccine match and Measures in Older Adults. J Am Geriatr Soc. 2010 September ; 58(9):
high viral circulation) the effectiveness of vaccines against 1634–1641.
ILI was 23% (6% to 36%) and non-significant against 7. Tseng, HF. Herpes Zoster Vaccine in Older Adults and the Risk of
influenza (RR 1.04: 95% CI 0.43 to 2.51). Well matched Subsequent Herpes Zoster Disease. JAMA, January 12, 2011—Vol
305, No. 2
vaccines prevented pneumonia (VE 46%; 30% to 58%), 8. Yao, C. et al. The Immunogenicity and safety of zoster vaccine in
hospital admission (VE 45%; 16% to 64%) and deaths Taiwanese adults. Vaccine 33 (2015) 1515–1517
from influenza or pneumonia (VE 42%, 17% to 59%). 9. Acosta A. Cost-effectiveness of Tdap substitution for Td in prevention
of pertussis in adults 65 years and older. Presented to the Advisory
Committee on Immunization Practices (ACIP), February 22, 2012.
In elderly individuals living in the community, well matched Atlanta, GA: US Department of Health and Human Services, CDC;
vaccines prevented hospital admission for influenza and 2012.
pneumonia (VE 26%; 12% to 38%) and all-cause mortality 10. Krishnarajah G. Cost-effectiveness analysis of Boostrix (tetanus toxoid,
reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed)
(VE 42%; 24% to 55%). After adjustment for confounders, among individuals ≥65 years of age in prevention of pertussis.
vaccine performance was improved for admissions to Presented to the Advisory Committee on Immunization Practices (ACIP),
hospital for influenza or pneumonia (VE* 27%; 21% to February 22, 2012. Atlanta, GA: US Department of Health and Human
Services, CDC; 2012.
33%), respiratory diseases (VE* 22%; 15% to 28%) and 11. Moro, P. et al. Adverse events after Tetanus Toxoid, Reduced Diphtheria
cardiac disease (VE* 24%; 18% to 30%); and for all-cause Toxoid and Acellular Pertussis (Tdap) Vaccine administered to adults 65
mortality (VE* 47%; 39% to 54%). years of age and older reported to the Vaccine Adverse Event Reporting
System (VAERS), 2005–2010 . Vaccine 29 (2011) 9404–9408
12. Weston, WM. Vaccination of adults 65 years of age and older with
The public health safety profiles of the vaccines tetanus toxoid, reduced diphtheria toxoid and acellular pertussis
appear to be acceptable. (Rivetti et al, 2010, Cochrane vaccine (Boostrix(®)): results of two randomized trials. Vaccine. 2012
collaboration). Feb 21;30(9):1721-8
can take a high personal toll on older people: falls and substantiate the use of Vitamin B12, Vitamin C and Zinc
fractures, disabilities, loss of independence, and death as supplements. Current recommendations on vitamin
(Pedersen and Cederholm, 2013). B12 intake vary from 1.4 to 3.0 μg per day and are based
on the amount needed for maintenance of hematologic
One epidemiological study showed a positive association status or on the amount needed to compensate obligatory
between higher dietary protein intake and fewer health losses. A systematic review was done to evaluate
problems in older women. With data from the Health, whether the relation between vitamin B12 intake and
Aging, and Body Composition (Health ABC) Study, cognitive function should be considered for underpinning
Houston et al, were able to assess the association vitamin B12 recommendations in the future. The study
between dietary protein intake and changes in lean concluded that current evidence on the relation between
body mass (LBM) over a 3-year period in healthy, older vitamin B12 intake or status and cognitive function is not
adults (n = 2066). sufficient for consideration in the development of vitamin
B12 recommendations. (Pedersen, 2013 and Houston,
However, based on the recent Food and Nutrition 2014)
Research Institute National survey in 2015, the
recommended protein intake remains the same among Estimated average requirement for ascorbic acid is
adults and older persons (65-72 g/day). They did not around 40-60 mg day (Bauer, Biolo, et al., 2013). This
recommend a higher protein intake and advised that level is enough to meet the needs of an older person
protein requirement remain unchanged among 20 years 60 years old and above (Food and Nutrition Research
old and above (FNRI National Survey, 2015). This Institute Seminar Series, July 2015).
recommendation was based on a national survey and
did not take into account the other metabolic needs of The findings of the ZENITH study showed that between the
an older person brought about by aging. ages of 55–70 years old, healthy individuals experience
significant alterations in immune function. Such changes,
In view of this Technical Working Group, this recom however, are largely sex-specific. It is unclear what the
mendation is too low for older persons. Recent long-term impact of suboptimal Zinc intakes may be on
researches also suggest other specific nutritional immune function. Zinc is known to be essential for optimal
strategies to promote protein absorption and its efficient immune function and our findings suggest that serum Zinc
use in older people; such strategies deal with protein concentration is negatively correlated with age; thus, it is
source, timing of intake, and specific amino acid content possible that maintaining optimal Zinc status during late-
or supplementation (Bauer, Biolo, et al., 2013) middle age will be advantageous to health and successful
ageing, potentially mitigating against age-related changes
Statement 7. Calcium plus Vitamin D supplementation in immune function. Clearly, further research is needed
is recommended for older persons to prevent fracture to explore the effect of improved Zinc status on emerging
risk. (Moderate grade, Strongly recommended) immune deficiencies in cell-mediated immunity in healthy
55–70 years old. (Coudray, 2005)
Summary of evidences
Several high quality studies showed consistent results that References:
1. Pedersen and Cederholm , Evidence Based Recommendation for
Calcium + Vitamin D supplements can reduce fracture risk Dietary Protein Intake in Older Persons, 2013
in both community-dwelling and institutionalized middle- 2. Houston,et al. Health, Aging and Body Composition (Healh ABC) Study,
aged to older adults. In a review of eight Randomized 2014
3. Food and Nutrition Research Institute National Survey, 2015
Controlled Trials, it has been shown that Calcium + Vit 4. Bauer, Biolo, et al, Evidence- Based Protein Recommendations for
D supplementation produced as significant 15% reduced Optimal Dietary Protein Intake in Older People: A Position Paper from
risk of total fractures (SRRE 0.85, 95%CI 0.73-0.98) PROT-AGE Study Group, 2013
and a 30% reduced risk of hip fractures (SSRE, 0.70; 5. Weaver, Alexander et al, 2015, Calcium plus vitamin D supplementation
and risk of fractures: an updated meta-analysis from the National
95% CI, 0.56-0.87). The risk of osteoporotic fractures Osteoporosis Foundation, Osteoporosis Int, (2016) 27: 367-376
increases with age among individuals aged >50 years. 6. Li-Yu J, NNHeS. Prevalence of osteoporosis and fractures among
Calcium plus vitamin D supplementation has been widely Filipino adults. Phil J Int Med, 2007; 45:57-63
7. Doets, van Wiljgarden et al. Vitamin B12 intake and status and cognitive
recommended for the prevention of osteoporosis and function in elderly people. Epidemiol Rev. 2013;35:2-21. doi: 10.1093/
subsequent fractures (Houston, et al., 2014). epirev/mxs003. Epub 2012 Dec 5.
8. Zhaoli Dai, Woon-Puay Koh. B-Vitamins and Bone Health–A Review
Several meta-analyses showed statistically significant of the Current Evidence. Nutrients. 2015 May; 7(5): 3322–3346.
9. Dullemeijer, Souverein et al. Systematic review with dose-response
reductions in risk for both total and hip fractures, meta-analyses between vitamin B-12 intake and European Micronutrient
which supports the use of calcium plus vitamin D Recommendations Aligned’s prioritized biomarkers of vitamin B-12
supplementation to reduce fracture risk. Identification including randomized controlled trials and observational studies in
adults and elderly persons. Am J Clin Nutr. 2013 Feb;97(2):390-402.
of strategies to reduce fracture risk is important, given doi: 10.3945/ajcn.112.033951. Epub 2012 Dec 26.
that osteoporosis and low bone mass is at 19.8% 10. Coudray, Connor. Introduction to the ZENITH study and summary of
prevalence in the Philippines, especially among urban baseline results. European Journal of Clinical Nutrition (2005) 59, Suppl
post- menopausal women (FNRI National Survey 2015; 2, S5–S7. doi:10.1038/sj.ejcn.1602304
Bauer, Biolo, et al., 2013).
57
Lack of physical activity has been identified as the fourth where 76% were women) exercise programs designed to
leading risk factor for global mortality (6% of deaths prevent falls in older adults also prevent injuries caused
globally). Moreover, physical inactivity is estimated to be by falls, including or further most serious falls, and falls
the main cause for approximately 21–25% of breast and causing medical injuries (El Khouri et al, 2013). Rather
colon cancers, 27% of diabetes and approximately 30% than rest, frail older people should resume their physical
of ischemic heart disease burden (WHO, 2010). activities after a fall as soon as deemed safe by their
physician.
Statement 9. There is sufficient evidence that
physical activity reduces the risk from mortality from Statement 12. Frail older persons will also benefit
all causes (Moderate grade, strongly recommended) from home aerobic, resistance and balance exercises
with or without machines, standing or chair-based,
Statement 10. There is a dose-response relationship at regular intervals and sustained for long periods.
between level of physical activity and its benefit (Moderate grade, moderately recommended)
(Moderate grade, strongly recommended)
Summary of evidences
Summary of Evidences Frail older people are often unable to do vigorous
A systematic review of 18 prospective studies of 280,000 exercise programs. However, when supervised, and
individuals showed that a standardized dose of walking with consistent engagement, benefits can be accrued
and cycling, when adjusted for other physical activities (Anthony et al, 2013).
reduced risk for death at 10% (95%CI) and 11%
respectively (Kelly, et, al, 2014). The Bambui Health In the systematic review of 9 studies by de Labra et al
and Aging Study (Ramalho et al, 2015) looked at other (2015) which enrolled a pooled 1067 older adults, mean
physical activities and grouped them as light: going up age 82.5 years and 71% women, the effects of physical
the stairs at a normal pace, carrying a load, mopping or therapy interventions of combined aerobics, resistance
scrubbing floors, cleaning windows, rhythmic dancing; and muscle strength training exercises of frail seniors who
moderate: cycling for leisure or to work, painting as a responded to the definition of frailty by Fried. The effects
home repair, volleyball, tennis, basketball, football; and were compared with no activity or previous lifestyle of a
vigorous such as walking fast, brisk walking, aerobics/ control group. After 10-12 weeks, there was a significant
gym workout, running/jogging, gardening, sewing wood increase in knee function in 1 study, reduced falls in
and horseriding. These levels of physical activity were 2 studies, and improved the chair-rising ability. Other
grouped according to the level of energy expenditure studies showed improvement of balance, improvement
of 1 MET equivalent to the oxygen consumption of 3.5 of the frailty status with good nutrition, and improved
mL/kg/min. This prospective cohort study included 1809 the time spent on the Timed Up and Go Test but these
Brazilian residents greater than 60 years old and followed changes were not significant. There were also studies
for 11 years with death as the endpoint. A statistically that did not improve functional ability nor improve the
significant interaction (P<0.03) was found between sex walking speed.
and energy expenditure. Among older men, increases in
levels of physical activity were associated with reduced Chair-based exercises were used by Kevin Anthony
mortality risk. The hazard ratios were 0.59 (95% CI et al (2013) involving 230 pooled subjects from a total
0.43–0.81) and 0.47 (95% CI 0.34–0.66) for the second of eight (8) randomized controlled trials. High-paced
and third tertiles, respectively. Among older women, complex choreographed movements were used in
there was no significant association between physical different studies, another study used moderate intensity
activity and mortality. progressive training exercises using Theraband, and
another study used home-video instruction. All activities
Moving from no activity to higher levels of activity was were supervised by the physical therapist. Although rated
also found to be more beneficial than having no activity as low quality because of differences in methodology,
at all. A systematic review and meta-analysis of 22 improvements were seen in Timed Up and Go tests,
cohort studies and observational studies from Europe, muscle strength, grip strength, muscle power, cadence
North America, East Asia and Australia for an almost one and gait, walking speed and MMSE scores. But the
million general healthy population ages 35-88 showed significant changes were the improvement in chair-rising
the largest benefit was found among the totally inactive ability, heart rate and systolic blood pressure. Further
or no activity at all moving to low levels of activity (RR studies of these natures are recommended therefore to
19%, 95% CI) such as walking alone at a leisurely pace establish the benefits of physical therapy programs for
at 2.5 hrs/week, classified as moderate activity. Still to frail older people.
those already engaged in vigorous activities, increasing
References:
to 7 hrs/week of moderate activity, the risk reduction was 1. World Health Organization, 2010. Global Recommendations on Diet
still better (RR 22% 95% CI) when additional exercises and Physical Activity for Health. Geneva: WHO available at http://www.
were added. (Woodcock, et al, 2010) who.int/dietphysicalactivity/publications/9789241599979/en
2. Kelly P, Kahlmeier S, et al, 2014. Systematic Review and Meta-analysis
of reduction in all-cause mortality from walking and cycling and shape of
Statement 11. Physical activities in a Fall Prevention dose-response relationship. International Journal of Behavioral Nutrition
Program, e.g., yoga and tai chi, and improving protective and Physical Activity 11:132. 1-15.
responses from falls, prevent serious injuries from 3. Ramalho et al, 2015. Physical activity and all-cause mortality among
older Brazilian adults: 11-year follow-up of the Bambui Health and Aging
falls in older people. (High grade, strongly recommended) Study. Clin Interv Aging; 10: 751–758.
4. Woodcock J, et al, 2010. Non-vigorous physical activity and all-cause
Summary of Evidence mortality: systematic review of meta-analysis and cohort studies.
International Journal of Epidemiology 2011. 40:121–138. doi:10.1093/
In a meta-analysis of 17 randomized controlled ije/dyq104
trials using a pooled data of 4305 participants (2195 5. Active Aging Partnership. National blueprint: increasing physical
intervention, and 2110 control; mean age 76.7 years activity among adults aged 50 and older. http://www.agingblueprint.
58
org. Accessed August 17, 2016. be referred for audiometric examination. (Moderate
6. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for
preventing falls in older people living in the community. Cochrane
grade, Strongly recommended)
Database Syst Rev. 2009(2):CD007146.
7. El Khouri, et al, 2013. The effect of fall prevention exercise programs Summary of Evidences
on fall induced injuries in community dwelling older adults: systematic Twenty studies evaluated the diagnostic accuracy of
review and randomized controlled trials. British Medical Journal; 347.
F6234 doi: 10.1136/bmj f6234. 1-13. clinical tests, a single question, a questionnaire, or a
8. Chief Medical Officers (2011). Start Active, Stay Active, A Report handheld audiometric device for identification of hearing
on Physical Activity for Health from the 4 Home Countries. United loss in older adults. For detection of >25 or >30 dB
Kingdom.
9. Stevens JA, 2010. A CDC Compendium of Effective Fall Interventions:
hearing loss, four studies (one good-quality) found that
What Works for Community-Dwelling Older Adults. 2nd ed. Atlanta, GA: the whispered voice test at 2 feet was associated with
Centers for Disease Control and Prevention, National Center for Injury a median positive likelihood ratio (PLR) of 5.1 (range,
Prevention and Control, 2.3 to 7.4) and median negative likelihood ratio (NLR)
10. Anthony K et al, 2013. Chair-based Exercises for Older People: A
Systematic Review. Biomed Research International. 13: Article ID of 0.03 (range, 0.007 to 0.73). For detection of >25 dB
309506, 1-9. hearing loss, six studies (four good-quality) found that
11. de Labra et al, 2015. Effects of Exercises on Frail Older People. BMC a single question was associated with a median PLR of
Geriatrics 15:154
DOI 10.1186/s12877-015-0155-4
3.0 (range, 2.4 to 3.8) and median NLR of 0.40 (range,
0.33 to 0.82), and four good-quality studies found that the
HHIE-S (based on a cutoff score of 8) was associated with
a median PLR of 3.5 (range, 2.4 to 11) and median NLR
SCREENING FOR OLDER PERSONS of 0.52 (range, 0.43 to 0.70). Likelihood ratio estimates
were similar for detection of >40 dB hearing loss. For
Physiologic changes in aging contribute in the increase detection of >40 dB hearing loss, three studies (two
risk of older persons for geriatric syndromes (impairment good-quality) found that the AudioScope (based on ability
of vision and hearing, cognitive impairment, depression), to hear tones between 500 and 4000 Hz at 40 dB) was
or certain diseases like osteoporosis and cancer. It is associated with a median PLR of 3.4 (range, 1.7 to 4.9)
estimated that as many as 1 in 2 women and 1 in 5 men and median NLR of 0.05 (range, 0.03 to 0.08). In direct
are at risk for an osteoporosis-related fracture during comparisons, one good-quality study found that the watch
their lifetime. tick and finger rub tests were associated with similar
NLRs but substantially stronger PLRs compared with
Most common among cancer are the following: breast the whispered voice test or a single screening question.
cancer, prostate cancer and cervical cancer. The Three studies showed a consistent trade-off between
incidence of breast cancer in the Philippines is 18.7% lower sensitivity and higher specificity for the HHIE-S
while cervical cancer is 6.8% and prostate cancer is 4.9%. compared with a single screening question, resulting in
In the US, in 2015, an estimated 232,000 women were somewhat stronger PLRs and weaker NLRs.Two studies
diagnosed with the disease and 40,000 women died of found that the AudioScope was associated with stronger
it. It is most frequently diagnosed among women aged NLRs compared with the HHIE-S, with relatively small
55 to 64 years, and the median age of death from breast differences in PLR estimates.
cancer is 68 years. Colorectal cancer is most frequently
diagnosed among adults aged 65 to 74 years; the median Statement 15. Mini Mental Status Examination (MMSE)
age at death from colorectal cancer is 68 years. Seventy can adequately detect dementia and Mild Cognitive
percent of deaths due to prostate cancer occur after age Impairment (MCI) and is therefore recommended
75 years. for screening asymptomatic elderly in primary care.
(Moderate grade, Strongly recommended)
Statement 13. In the primary care setting, Snellen’s
Visual acuity test is recommended as a screening tool Summary of Evidences
to identify elderly with low vision. (Moderate grade, There were 41 studies that addressed the diagnostic
Strongly recommended) accuracy of very brief and brief screening instruments
that could be administered in primary care and seven
Summary of Evidence studies that addressed instruments that could be self-
Eight cross-sectional studies were identified that administered. The included studies considered a broad
evaluated the diagnostic accuracy of screening for range of participants relevant to older adult primary care
impaired visual acuity in older adult. Four studies found populations and a wide variety of different screening
that screening questions are not accurate for identifying instruments. Overall, study participants were community-
persons with vision impairment compared to the Snellen dwelling older adults selected from the community or
chart. Four studies found that visual acuity testing is not primary care practices. Two studies explicitly included
accurate for identifying the presence of vision conditions people in assisted living or residential care facilities.
compared to a detailed ophthalmologic examination. Almost all studies had a majority of women participants, but
One study found that the Amsler grid is not accurate for studies varied in the mean age (range of means, 69 to 95
identifying the presence of vision conditions compared years) and prevalence of dementia (range of prevalence,
to a detailed ophthalmologic examination. One very 1.2% to 47.1%). Education was not always reported.
small (n=50) study found non-ophthalmologists are as
accurate as ophthalmologists for identifying presence The best-studied instrument remains the MMSE, which
of cataracts. has a relatively long administration time compared with
other screening instruments included in this review. For
Statement 14. It is recommended that the Single the MMSE, the most commonly reported cut-points were
Question “Do you think you have difficulty hearing?” 23/24 and 24/25, although higher and lower cut-points
be used as a screening tool to detect hearing loss were evaluated in various studies. Pooled estimates
in the elderly. Those who respond “yes” should across 14 studies (n=10,185) resulted in 88.3 percent
59
sensitivity (95% CI, 81.3% to 92.9%) and 86.2 percent Statement 17. Screen all elderly women with bone
specificity (95% CI, 81.8% to 89.7%) for a cut-point of mineral denitometry whose 10-year fracture risk is
23/24 or 24/25. Studies in populations with low levels of equal to or greater than that of a 65-year-old woman
education (majority with primary school education or less) who has no additional risk factors (moderate grade,
used lower cut-points. Test performance to detect MCI moderately recommended)
was based on a much smaller body of literature (k=15;
n=5,758). Studies using higher cut-points to detect MCI Summary of evidences
did not have better sensitivity or specificity Measurement of bone density using Dual xray
absorptiometry (DXA) has become the gold standard for
Statement 16. It is recommended that PHQ-2 be used the diagnosis of osteoporosis and for guiding decisions
as an initial step in identifying risk for depression in about which patients to treat. Although DXA is not a
the elderly (using the cut-off 2). Elderly who will be perfect predictor of fractures, DXA of the femoral neck
positively screened should undergo a diagnostic is considered to be the best predictor of hip fracture and
screen using GDS-15. (Moderate grade, Strongly is comparable with DXA measurements of the forearm
recommended). for predicting fractures at other sites. A large prospective
cohort study in the Netherlands that included persons
Summary of Evidences older than 55 years reported the incidence of vertebral
There were 39 studies that addressed the validity of and nonvertebral fractures approximately 6 years after
PHQ-2 in detecting depression. Thirty-three studies were patients obtained baseline DXA measurements of the
excluded, and 6 studies met the inclusion criteria. femoral neck.
Reference
One review of the GDS-15 and GDS-30, published in 1. Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R. Screening for
2010, included a meta-analysis of 17 studies conducted in osteoporosis: an update for the U.S. Preventive Services Task Force.
primary care settings. The principle inclusion criteria were Ann Intern Med. 2010;153:1-14. [PMID: 20621892]
studies that compared the diagnostic validity of the GDS
to that of the semi-structured psychiatric interview for Statement 18. The Technical working group adopts
diagnosing late-life (aged 55 years or older) depression. the (US Preventive Service Task Force) recommenda
Studies evaluating the GDS-15 (k=7) used cut-offs tions on cancer screening.
ranging from 3 to 7, resulting in an adjusted sensitivity of a. Biennial screening with mammography is recom
81.3 percent (95% CI, 77.2 to 85.2) and a specificity of mended for 60-74 years old. (Moderate grade,
78.4 percent (95% CI, 71.2 to 84.8). Studies evaluating moderately recommended)
the GDS-30 (k=10) used cutoffs ranging from 7 to 11, b. Colonoscopy is recommended every 10 years
resulting in an adjusted sensitivity of 77.4% (95% CI, 66.3 for 60-74 years old. (Moderate grade, moderate
to 86.8) and a specificity of 65.4 percent (95% CI, 44.2 to recommendations)
83.8). In order to more fully examine the clinical utility of c. Routine PSA screening for prostate cancer for 60
the GDS, the authors also evaluated general practitioners’ years old and above is not recommended. Digital
ability to detect depression without a screening tool. rectal examination may be done. (Moderate grade,
Using data from six studies, the authors’ reported a moderately recommended)
pooled sensitivity of 56.3 percent (95% CI, 40.0 to 72.0) d. Pap smear is not recommended in women older
and specificity of 73.6 percent (95% CI, 71.7 to 75.5). than age 65 years who have had adequate prior
The authors concluded that the GDS-30 had modest screening and are not otherwise at high risk for
diagnostic success, modest clinical utility, and limited cervical cancer. (Moderate grade, strongly recom
benefit beyond the general practitioners unassisted mended)
clinical skills. The GDS-15, however, was believed to
have adequate diagnostic value with significantly greater Summary of evidences
accuracy than the GDS-30 and, thus, good clinical utility.
Furthermore, use of the GDS-15 by general practitioners Mammography
has the potential to increase unassisted case detection An updated meta-analysis by Nelson and colleagues
by 8 percent. of RCTs of screening mammography found similar RR
reductions in breast cancer mortality by age group as
References: the previous USPSTF evidence review. The combined
1. Evidence Synthesis Number 127 Screening for Impaired Visual Acuity in RRs were 0.92 (CI, 0.75 to 1.02) for women aged 39 to
Older Adults: A Systematic Review to Update the 2009 U.S. Preventive
Services Task Force Recommendation. Roger Chou, MD Tracy Dana, 49 years, 0.86 (CI, 0.68 to 0.97) for women aged 50 to
MLS Christina Bougatsos, MPH Sara Grusing, BS Ian Blazina, MPH. 59 years, 0.67 (CI, 0.54 to 0.83) for women aged 60 to
AHRQ Publication No. 14-05209-EF-1 July 2015 69 years, and 0.80 (CI, 0.51 to 1.28) for women aged
2. Evidence Synthesis 83. Screening for Hearing Loss in Adults Ages 50
Years and Older: A Review of the Evidence for the U.S. Preventive 70 to 74 years. Updated decision models performed by
Services Task Force. Roger Chou, MD Tracy Dana, MLS Christina CISNET yielded somewhat higher estimates in lifetime
Bougatsos, BS Craig Fleming, MD Tracy Beil, MS AHRQ. AHRQ relative breast cancer mortality reductions with biennial
Publication No. 11-05153-EF-1 March 2011 mammography screening in women aged 50 to 74 years
3. Screening for Cognitive Impairment in Older Adults: An Evidence Update
for the U.S. Preventive Services Task Force. Investigators: Jennifer S. compared with previous analyses (median reduction,
Lin, MD, MCR Elizabeth O’Connor, PhD Rebecca C. Rossom, MD, MSCR 25.8% vs. 21.5%; range across models, 24.1% to 31.8%
Leslie A. Perdue, MPH Brittany U. Burda, MPH Matthew Thompson, vs. 20.0% to 28.0%, respectively). Since its previous
MD, MPH, DPhil Elizabeth Eckstrom, MD, MPH. AHRQ Publication No.
14-05198-EF-1 November 2013 analysis, CISNET has revised the inputs of each of its
4. Screening for Depression in Adults: An Updated Systematic Evidence 6 models (for example, portraying distinct molecular
Review for the U.S. Preventive Services Task Force. Elizabeth O’Connor, subtypes and including digital mammography), which
PhD Rebecca C. Rossom, MD, MSCR Michelle Henninger, PhD Holly C.
Groom, MPH Brittany U. Burda, MPH Jillian T. Henderson, PhD Keshia
may account for some of the difference. The updated
D. Bigler, BS Evelyn P. Whitlock, MD, MPH. AHRQ Publication No. 14- estimate of the mortality benefit of mammography is also
05208-EF-1 July 2015 higher than that obtained via meta-analysis of randomized
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trials for a similar age group (24.1% to 31.8% for women COUNSELING FOR OLDER PERSONS
aged 50 to 74 years in decision models vs. 19% to 22%
for women aged 50 to 69 years in RCTs). In the recent FNRI National Health Survey, older persons
are prone to tobacco addiction and alcohol misuse.
Colonoscopy 23.9% of the young old and 17.9% of the middle to old
A prospective cohort study found an association old are current smokers. 56.2 of the young old (60-69)
between patients who self-reported being screened with and 39.9% of the middle to old old (70 and above) are
colonoscopy and a lower colorectal cancer mortality current drinkers. 51% of the young old are binge drinkers
rate. while 35.1% of the old old are binge drinkers.
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