Geriatric Assessment
The Comprehensive Geriatric Assessment (CGA) is a systemic, multimodal, inter‐professional approach to a complicated older person with the intent to diagnose geriatric syndromes, develop targeted treatment plans, and improve patient outcomes with a focus on function and quality of life. It typically takes two to three hours to perform and is not practical to be performed by a primary care physician during an office visit. Thus, the Rapid Geriatric Assessment (RGA) was developed to allow primary care physicians to efficiently screen for frailty, sarcopenia, malnutrition/anorexia, cognitive impairment, and advanced directives during the office visit. Based on the results, primary care physicians can develop tailored treatment plans for their patients. Early intervention, when geriatric syndromes are recognized, can decrease disability, hospitalization, and mortality.21
Cognitive screening
Screening for cognitive impairment is part of a CGA and should be done at initial visits for patients in all categories except End of Life, where it should be considered. The Mini‐Mental State examination is a commonly used screening tool but may have limited utility if the cut‐off score is set too high.22 For elderly with high education levels, the Saint Louis University Mental Status (SLUMS) examination or the rapid cognitive screen (RCS), a shorter version, along with other screening tests, may be used.21,23
Depression screening
Depression screening should be carried out at initial visits for patients in all categories. A systemic review concluded that screening for depression can improve outcomes, particularly when screening is coupled with systemic changes that help ensure adequate treatment and follow‐up.24 Screening for depression is part of the RGA. The PHQ‐2 and PHQ‐9 are currently recommended over the Geriatric Depression Scale (GDS) due to their increased sensitivity for detecting more severe forms of depression.25 Their validity is not maintained in patients with dementia, and the Cornell scale (a 19‐item clinician‐administered instrument) is recommended.26
Screening for gait and balance
The evidence to screen for gait and balance problems at initial visits in all categories except End of Life is based on the fact that falls are associated with decreased function, increased nursing home admission, and increased morbidity and mortality in populations similar to patients in these categories. One of the best screeners for gait and balance problems is to ask patients if they have fallen. The ‘Get Up and Go Test’ may quantify functional mobility in addition to testing balance and may also be useful in following clinical change over time.27,28
Advance directives
Although the evidence is not strong that advance directives make a difference in outcomes (e.g. one study showed that systematic implementation of a programme to increase the use of advance directives reduced the utilization of healthcare services without affecting satisfaction or mortality),29 there are ways to increase discussions and completions of advance directives.21,30 Clinicians should take care to ensure that underlying depression does not underlie patient preferences or decisions.
Advance directives are especially important for patients in the Frail, Moderately Demented, and End of Life categories.
Influenza vaccine
This should be done yearly for patients in all categories. More than 90% of the deaths attributed to pneumonia and influenza during epidemics occurred among people aged 65 and older. Influenza vaccination in the elderly has been shown to reduce hospitalization rates, be cost‐effective, and reduce influenza‐associated mortality. In the nursing home, although vaccination is only 40% effective in preventing clinical illness, it is more effective in preventing pneumonia, hospitalization, and death. Vaccinating more than 80% of nursing home residents has been shown to prevent influenza outbreaks.31,32
Pneumococcal vaccine
The recommendations for pneumococcal vaccines are based on evidence and probable life expectancy in various categories. Although the pneumococcal vaccine is less effective in producing protective antibody levels in older adults than young adults, it’s still effective in reducing the incidence of pneumococcal bacteremia in high‐risk patients.
Currently, most organizations recommend one dose of Prevnar 13 followed by one dose of 23 valent pneumococcal vaccine one year apart, after age 65. If the patient has had a prior 23 valent pneumococcal vaccine, only Prevnar 13 should be given. There are no recommendations about re‐immunization.33
Tetanus
Recommendations regarding adult tetanus/diphtheria vaccination do not vary for adult people versus younger adults. Over half the cases of tetanus occurred in people 60 or older. All adults should complete a primary series of tetanus/diphtheria toxoid (TD). If an individual had an incomplete series of uncertain history, it is recommended that the entire primary series be given. The primary series for adults consists of 0.5 ml TD intramuscularly as an initial dose and two and six months later. Booster doses need to be given every 10 years.33 At least one booster dose should be given as a Tdap if not previously received.
Zostavax and Shingrix
Reactivation of latent varicella zoster virus results in a localized eruption known as herpes zoster (shingles). Its incidence increases with age, occurring in up to half of individuals 85 or older. Postherpetic neuralgia is a potentially devastating complication, occurring in more than 40% of individuals older than 60.33 In 2006, the FDA approved the use of Zostavax, which is only 30% protective. In 2016, the FDA approved Shingrix, which is 90% protective. The Advisory Committee on Immunization Practices (ACIP) recommends a one‐time dose of Shingrix to be given as a series of two injections to individuals 50 or older. Individuals who previously received Zostavax should receive Shingrix. All individuals 50 or older should receive varicella zoster vaccination regardless of a prior history of chicken pox.33
Hepatitis C
Patients infected with the hepatitis C virus (HCV) face significant hepatitis C–associated morbidity and mortality related to complications from chronic liver disease and cirrhosis. 75% of patients with hepatitis C were born during 1945–1965. Up to 85% of them are asymptomatic, and at least 50% of them have normal liver function tests. Newer therapies can halt disease progression and cure most patients infected with hepatitis C. The CDC recommends that all adults born during 1945–1965 receive one‐time testing for the hepatitis C anti‐HCV antibody for screening.34
Breast cancer screening
There is no recommendation for or against the clinician recommending self‐examination or breast‐self‐awareness or the clinician doing the clinical breast examination.35‐37 The National Comprehensive Cancer Network (NCCN) recommends both.2 The American Cancer Society (ACS) recommends breast self‐awareness if the woman is interested, and the United States Preventive Services Task Force (USPSTF) recommends against both self‐awareness and clinical examinations.35,37 Breast self‐awareness may allow women to detect lesions or breast cancers not seen on mammography or those that develop between mammograms.35,36
Mammography is the mainstay of breast cancer screening. Research has shown mammography to be effective up to age 84.36 There is a lack of agreement among organizations regarding screening intervals for mammography or when to stop mammography. The ACS recommends annual mammography for women 55 and older, or they may transition to biennial mammography. Women should continue mammography if their overall health is good and life expectancy is 10 or more years. The NCCN recommends annual mammography without guidelines for stopping.36 Few studies describe women’s decision‐making to stop mammography.36