should also be based on coexisting disease, social and economic considerations, and functional age. There is no upper limit for age of screening and treatment for lipid disorders in the elderly. The recommendations for the frequency of screening are not known.46
Thyroid‐stimulating hormone (TSH)
The USPSTF does not currently recommend TSH screening of all older adults on the basis of lack of data. However, they recommend targeted TSH screening for symptomatic patients and those with certain risk factors for thyroid disease. The ACP suggests office screening of women older than 50 may be indicated. However, the evidence for treating subclinical thyroid dysfunction is inconclusive. The American Thyroid Association (ATA) issued guidelines that recommend measuring TSH levels starting at age 35 and every five years thereafter. The American Academy of Clinical Endocrinology (AACE) recommends routine TSH screening in older adults without specifying the age to start screening.47 Hypothyroidism may not be associated with adverse outcomes in the oldest individuals when detected by screening alone. A prospective study involving individuals 85 or older did not show an association of elevated TSH levels with reduction in cognitive function, mood, or performance of ADLs. Higher TSH levels were associated with lower all‐cause and cardiovascular mortality.48 Many geriatricians advocate screening high‐risk patients such as the nursing home population, frail elderly, and patients with dementia.49 The sensitive TSH assay is probably the screening test of choice
Diabetes mellitus
This recommendation is based on organizational recommendations only. The American Association of Clinical Endocrinologists recommends screening asymptomatic individuals if risk factors are present. The American Diabetes Association recommends screening asymptomatic adults with a body mass index greater than 25 kg/m2 or or more additional risk factors. The Canadian Task Force on Preventative Health Care recommends screening individuals at high risk for diabetes only every one to three years with a haemoglobin A1c. The US Preventative Services Task Force recommends screening all adults 40–70 who are overweight or obese. The diagnosis of diabetes can be made with a fasting blood sugar of 126 or greater, an A1c of 6.5% or greater, a random glucose level of 200 or greater, or an 85 g two‐hour glucose tolerance test with a plasma glucose level of 200 or greater.50
Sleep apnoea
Because of the low cost of screening (in the form of asking about symptoms of sleep apnoea during the routine history and physical or using a screening questionnaire tool such as the Epworth Sleepiness Scale)51 and the potential to miss this diagnosis among older patients, it is recommended for Robust and Frail elderly. Studies have shown some benefit of treating sleep apnoea in patients with heart failure and stroke.51,52
Abdominal aortic aneurysm
Performing a one‐time screening for abdominal aortic aneurysm (AAA) with abdominal ultrasound has been shown to reduce mortality in adults. The USPSTF recommends one‐time sonography in males between the ages of 65 and 75 who have ever smoked. The American College of Cardiology (ACC) also recommend screening male ever‐smokers ages 65–75 as well as men over 60 who are siblings or children of individuals diagnosed with an AAA. In addition, the Society of Vascular Surgery (SVS) recommends screening all men 65 or above, men 55 or older with a family history of AAA, and women 65 or above with a family history of AAA or past or present smoking use. The Canadian Cardiovascular Society has similar recommendations but recommends screening adults 50 or older with a family history of AAA.53
Key points
Health promotion and preventive medicine are key to good outcomes.
Older people with different levels of function require different approaches.
Vaccinations remain important in older people.
References
1 1. Gillick M. Choosing Medical Care in Old Age: What Kind, How Much, When to Stop. 1st ed. Harvard University Press; 1994.
2 2. Murphy D. Honest Medicine: Shattering the Myths of Aging and Healthcare. 1st ed. Atlantic Press; 1995.
3 3. Flaherty JH, Morley JE, Murphy DJ, Wasserman MR. The development of outpatient Clinical Glidepaths. J Am Geriatr Soc. 2002; 50:1886–901.
4 4. Byrd JB, Brook RD. In the clinic: hypertension. Annals of Internal Medicine. 2019:ITC65–85.
5 5. Rubenfire M. 2017 American College of Cardiology guideline for high blood pressure in adults. 2017;1–7.
6 6. Paul PA, Oparil S, et al. Evidence‐based guideline for the management of high blood pressure in adults. Report from the panel members appointed to the eighth Joint National Committee (JNC8) JAMA. 2014; 311(5):507–520.
7 7. Gammack JK, Sanford AM. Caloric supplements for the elderly. Current Opinion in Clinical Nutrition and Metabolic Care. 2015; 18:32–36.
8 8. Garry P, Vellas B. Practical and validated use of the Mini Nutritional Assessment in geriatric evaluation. Nutr Clin Care. 1999; 2:146–54.
9 9. Bennani L, Allali F, Rostom S, et al. Relationship between historic height loss and vertrebral fractures in postmenopausal women. Clin Rheumatol. 2009; 28:1283–9.
10 10. Cervo FA, Bruchenthal P, Chen JJ, et al. Pain assessment in nursing home residents with dementia: psychometric properties and clinical utility of the CNA Pain Assessment Tool (CPAT). J Am Med Dir Assoc. 2009; 10:505–10.
11 11. Schuler MS, Becker S, Kaspar, R, et al. Psychometric properties of the German ‘Pain Assessment in Advanced Dementia Scale’ (PAINAD‐G) in nursing home residents. J Am Med Dir Assoc. 2007; 8:388–95.
12 12. Nolan L, O’Malley K. Prescribing for the elderly: Part 1. Sensitivity of the elderly to adverse drug reactions. J Am Geriatr Soc. 1998; 36:142–9.
13 13. Flaherty JH, Perry HM III, Lynchard GS, Morley JE. Polypharmacy and hospitalization among older home care patients. J Gerontol A Biol Sci Med Sci. 2000; 55A: M554–9.
14 14. Fraser GE, Shavlik DJ. Risk factors for all‐cause and coronary heart disease mortality in the oldest‐old. The Adventist Health Study. Arch Intern Med. 1997; 157:2249–58.
15 15. Whitlock EP, Polen MR, Green CA, et al. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventative Services Task Force. Ann Intern Med. 2004; 140:557–68.
16 16. Fiellin DA, Reid MC, O’Connor PG, et al. Screening for alcohol problems in primary care. Arch Intern Med. 2000; 160:1977–89.
17 17. Fulmer T, Guadagno L, Bitondo DC, et al. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc. 2004; 52:297–304.
18 18. Joshi S, Flaherty JH. Elder abuse and neglect in long term care. Clin Geriatric Med. 2005; 21:333–354.
19 19. Chou R, Dana T, Bougatsos C, et al. Screening older adults for impaired visual acuity: a review of the evidence for the U.S. Prevention Services Task Force. Ann Intern Med. 2009; 151:44–58.
20 20. Murlow CD. Lichtenstein MJ. Screening of hearing impairment in the elderly. Rationale and strategy. J Gen Intern Med. 1991; 6:249–58.
21 21. Morley JE. Rapid geriatric assessment: secondary prevention to stop age‐associated disability. Clinics of Geriatric Medicine. 2017; 33(3):431–440.
22 22. White N, Scott A, Woods RT, et al. The limited utility of the Mini‐Mental State Examination in screening people over the age of 75 years for dementia in primary care. Br J Gen Pract. 2002; 52:1002–3.
23 23. Cruz‐Oliver DM, Morley JE. Early detection of cognitive impairment: do screening tests help? J Am Med Dir Assoc. 2009; 10;1–6.
24 24. Greenberg PE, Stiglin LE, Finkelstein SN, et al. The economic