Geriatric Health Maintenance Case File

Geriatric Health Maintenance Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 18

A 75-year-old white man presents for a health maintenance checkup. The patient has stable hypertension but has not seen a physician in more than 2 years. He denies any particular problem. He lives alone. He takes an aspirin a day and is compliant with his blood pressure medication (hydrochlorothiazide). His son fears that his father is either experiencing a stroke or getting Alzheimer disease because he is having trouble understanding what family members are saying, especially during social events. The son reported no noticeable weakness or gait impairment. On physical examination, the patient's blood pressure was 130/80 mm Hg. Examination of the ears showed no cerumen impaction and normal tympanic membranes. His general examination is normal. Laboratory studies, including thyroid-stimulating hormone (TSH), are normal.

⯈ What is the most likely diagnosis?

⯈ What is the next step?

ANSWER TO CASE 18:

Geriatric Health Maintenance

Summary: A 75-year-old man who presents with loss of speech discrimination and complains of difficulty understanding speech and conversation in noisy areas.

• Most likely diagnosis: Presbycusis.
• Next step: Presbycusis is a diagnosis of exclusion. Hearing aids are underused in presbycusis, but are potentially beneficial for most types of hearing loss, including sensorineural hearing loss. Consequently, referral to an audiologist for testing and consideration of amplification with a hearing aid may be an important next step.

ANALYSIS

Objectives

1. Be familiar with geriatric health maintenance.
2. Be aware of the importance of geriatric screening.

Considerations

The patient described in this case is a 75-year-old man who has difficulty with speech discrimination and complains of difficulty understanding speech and conversation in noisy areas. He most likely has presbycusis, which is an age-related sensorineural hearing loss typically associated with both selective high-frequency loss and difficulty with speech discrimination. Physical examination of the ears in patients with presbycusis is normal. Other conditions in the differential diagnosis include cerumen impaction, otosclerosis, and central auditory processing disorder. Cerumen impaction and otosclerosis can be diagnosed by otoscopy. Central auditory processing disorder is diagnosed when the patient can hear sounds without difficulty, but has difficulty in understanding spoken words.

Approach To:

Health Maintenance in the Elderly

DEFINITIONS

PRESBYCUSIS: An age-related sensorineural hearing loss typically associated with both selective high-frequency loss and difficulty with speech discrimination.

FUNCT IONAL ASSESSMENT: An evaluation process that gauges a patient's ability to manage tasks of self-care, household management, and mobility.

CLINICAL APPROACH

By the year 2030, the number of people aged 65 and older is expected to double from what it was in 1999, increasing from 34 to 69 million. Geriatric health maintenance provides screening and therapy with the goal of enhancing function and preserving health in the elderly. Screening is not indicated unless early therapy for the screened condition is more effective than late therapy or no therapy. Preventive services for the elderly include as goals the optimization of quality of life, satisfaction with life, and maintenance of independence and productivity. Most recommendations for patients older than age 65 overlap with recommendations for the general adult population. Certain categories are unique to older patients, including sensory perception and fall. The primary care physician can perform effective health screening using simple and relatively easily administered assessment tools (Figure 18-1).

Functional Assessment

Functional assessment gauges a patient's ability to manage tasks of self-care, household management, and mobility. Impairment in activities of daily living (ADL) results in an increased risk of falls, hip fracture, depression, and institutionalization. An estimated 25% of patients older than 65 years have impairments in their

Figure 18-1. Approach to geriatric health maintenance. ADL, activities of daily living; DNAR, do not

attempt resuscitation; IADL, instrumental activities of daily living.

instrumental activities of daily living (IADL) or ADL (Table 18-1). Persons who are unable to perform IADL independently are far more likely to have dementia than their independent counterparts.

Vision Screening

Visual impairment is an independent risk factor for falls, which has a significant impact on quality of life. The majority of conditions leading to vision loss in the elderly are presbyopia, macular degeneration, glaucoma, cataract, and diabetic retinopathy. For older patients with risk factors for cataracts and age-related macular degeneration (AMD) including vision changes, smoking, diabetes, steroid use and family history, visual acuity testing with Snellen chart would be of benefit for identifying visual impairment and is a reasonable initial test to do in the primary care setting. However, United States Preventive Services Task Force (USPSTF) has found insufficient evidence regarding beneficial functional outcomes in the elderly who routinely undergo visual acuity testing. Visual acuity testing does not accurately identify ocular diseases that affect the elderly including cataracts, glaucoma and AMD, so routine referrals for ophthalmologic examination should be considered.

The incidence of presbyopia increases with age. Patients have difficulty focusing on near objects while their distant vision remains intact. AMD is the leading cause of severe vision loss in the elderly. AMD is characterized by atrophy of cells in the central macular region of the retinal pigment epithelium, resulting in the loss of central vision. Treatment options for exudative AMD include laser photocoagulation, and intravitreal injections of vascular endothelial growth factor.

Glaucoma is characterized by a group of optic neuropathies that can occur in all ages. Although glaucoma is most often associated with elevated intraocular pressure, it is the optic neuropathy that defines the disease. For patients who are asymptomatic, USPSTF found insufficient evidence to routinely screen for glaucoma. However, for elderly patients with risk factors including increased intraocular pressure, family history, vision changes, or African-American race, screening would be of benefit.

Cataract is any opacification of the lens. Age-related, or senile, cataracts account for 90% of all cataracts. Cataract disease is the most common cause of blindness worldwide. The definitive treatment for cataracts is surgery. Diabetic retinopathy is the leading cause of blindness in working-age adults in the United States. It is important to consider diabetic retinopathy in geriatric vision screening.

Hearing Screening

More than one-third of persons older than age 65 and half of those older than age 85 have some hearing loss. This deficit is correlated with social isolation and depression. The whispered voice test has sensitivities and specificities ranging from 70% to 100%. The initial office screening for general hearing loss can be reliably performed with questionnaire such as the HHIE-S (Hearing Handicap Inventory for the Elderly). Limited office-based pure-tone audiometry is more accurate in identifying patients who would benefit from a more formal audiometry.

The majority of patients with hearing impairment will present with complaints unrelated to their sensory deficit. In a quiet examination room with face-to-face conversation, patients can overcome significant hearing loss and avoid detection from a physician. Family members are often more concerned about the hearing loss than the patient. Common causes of geriatric hearing impairments are presbycusis, noise-induced hearing loss, cerumen impaction, otosclerosis, and central auditory processing disorder. Presbycusis is age-related sensorineural hearing loss usually associated with both selective high-frequency loss and difficulty with speech discrimination. Presbycusis is the most common form of hearing loss in the elderly. Because it often goes unrecognized, exact prevalence data are lacking. Presbycusis is a diagnosis of exclusion. Complete deafness is not an expected end result of presbycusis. Noise-induced hearing loss is essentially a wear and tear phenomenon that can occur with either industrial or recreational noise exposure. Patients will typically present with tinnitus, difficulty with speech discrimination, and problems hearing background noise. Cerumen impaction in the external auditory canal is a common, frequently overlooked problem in the elderly that may produce a transient, mild conductive hearing loss. It is estimated that 25% to 35% of institutionalized or hospitalized elderly are affected by impacted cerumen. Otosclerosis is an autosomal dominant disorder of the bones in the inner ear. It results in progressive conductive hearing loss with onset most commonly in the late twenties to the early forties. Speech discrimination is typically preserved. Geriatric patients with hearing loss may have otosclerosis complicating their presentation. Central auditory processing disorder (CAPD) is the general term for conditions involving hearing impairment that results from central nervous system (CNS) dysfunction. The patient with CAPD will have difficulty understanding spoken language, but may be able to hear sounds well.

Just as with visual acuity testing, USPSTF did not find sufficient evidence to justify the use of routine screening tests for hearing loss in the elderly. Since the last recommendation, evidence of routine screening has become available that shows that the widespread use of hearing aids after objective hearing loss was identified via in-office tests did not benefit those who did not self-report hearing loss. In other words, only those who had subjective hearing loss seemed to benefit from hearing aids, therefore raising the question of the benefit of routine hearing loss screening in a population in which this problem is so prevalent secondary to the natural process of aging. However, this recommendation does not apply to elderly patients with symptoms of hearing loss, cognitive impairment, or psychosocial complaints indicating other diagnoses.

Fall Assessment

Falls are the leading cause of nonfatal injuries in the elderly. The associated complications are the leading cause of death from injury in those older than age 65. Hip fractures are common precursors to functional impairment and nursing home placement. Approximately 30% of the noninstitutionalized elderly fall each year. The annual incidence of falls approaches 50% in patients older than 80 years. Factors contributing to falls include age-related postural changes, alterations in visual ability, certain medications, and diseases affecting muscle strength and coordination. Due to the far-reaching consequences that falls have on both the patient and the health-care system, the American Geriatric Society recommends that physicians ask their elderly patients about history of falls and balance problems. Additionally, USPSTF recommends incorporation of exercise and physical therapy, including aerobic and strength training, as well as vitamin D supplementation to prevent falls.

Cognitive Screening

The prevalence of dementia doubles every 5 years after age 60, so that by age 85 approximately 30% to 50% of individuals have some degree of impairment. Patients with mild or early dementia frequently remain undiagnosed because their social graces are retained. The combination of the "clock draw" and the "three-item recall" is a rapid and fairly reliable office-based screening for dementia. When patients fail either of these screening tests, further testing with the Folstein Mini-Mental State questionnaire should be performed.

Incontinence Screening

Incontinence in the elderly is common. Incontinence is estimated to affect 11 % to 34% of elderly men and 17% to 55% of elderly women. Continence problems are frequently treatable, have major social and emotional consequences, but are often not raised by patients as a concern.

Depression Screening

Depressive symptoms are more common in the elderly despite major depressive disorder being slightly lower in prevalence when compared with younger populations. Unlike dementia, depression is usually treatable. Depression significantly increases morbidity and mortality, and is often overlooked by physicians. A simple two-question screen (Have you felt down/depressed/hopeless in the last 2 weeks? and Have you felt little interest or pleasure in doing things?) shows high sensitivity. Positive responses can be followed up with a Geriatric Depression Scale, a 30-question instrument that is sensitive, specific, and reliable for the diagnosis of depression in the elderly.

Nutrition Screening

Approximately 15% of older outpatients and half of the hospitalized elderly are malnourished. A combination of serial weight measurements obtained in the office and inquiry about changing appetite is likely the most useful method of assessing nutritional status in the elderly. Adequate calcium intake for women is advised. Supplementation with a multivitamin formulated at about 100% daily value can decrease the prevalence of suboptimal vitamin status in older adults and improve their micronutrient status to levels associated with reduced risk for several chronic diseases. Malnutrition is common in nursing homes, and protein undernutrition has a prevalence of 17% to 56% in this setting. Protein undernutrition is associated with an increased risk of infections, anemia, orthostatic hypotension, and decubitus ulcers.

Hypertension Screening

Treatment of hypertension is of substantial benefit in the elderly. Heart disease and cerebrovascular disease are leading causes of death in the elderly. Treatment of hypertension has contributed to a reduction in mortality from both stroke and coronary artery disease. Lifestyle modifications are recommended for all hypertensive patients. Thiazides are the drugs of choice unless a comorbid condition makes another choice preferable.

Stroke Prevention

The incidence of stroke in older adults roughly doubles with each 10 years of age. The greatest risk factor is hypertension followed by atrial fibrillation. Anticoagulation with warfarin or newer agents, including dabigatran and apixaban, reduces the risk of strokes in people with atrial fibrillation. However, many elderly patients are not anticoagulated because of the fear of injuries from falls. In most instances, the benefits of anticoagulation are likely to outweigh the increased risk of fall-related bleeding, unless the patient has multiple falls, high-risk falls, or a very low risk of stroke. Aspirin use in women between the ages of 55 and 79 is recommended to decrease risk of ischemic stroke in a patient with no preexisting risk factors for gastrointestinal bleeding (USPSTF recommendation, Level A).

Cancer Screening

Screening elderly men for prostate cancer is not routinely recommended, as it has not been definitively shown to prolong life and because of the risk of incontinence or erectile dysfunction caused by the treatments. An older woman should undergo annual mammography until her life expectancy falls below 5 to 10 years, although the USPSTF states that there is insufficient evidence for or against screening in women over the age of 75. Screening for colon cancer is not generally recommended after the age of 75 although there may be some cases where it is appropriate (Level C) and is not recommended after the age of 85 (Level D). Screening for cervical cancer can be stopped in women older than 65 who have had adequate prior screening and are not at high risk for cervical cancer.

Osteoporosis Screening

The prevalence of low bone mineral density in the elderly is high, with osteopenia found in 37% of postmenopausal women. Primary prevention of osteoporosis begins with identification of risk factors (older age, female gender, white or Asian race, low calcium intake, smoking, excessive alcohol use, and chronic glucocorticoid use). Calcium carbonate (500 mg three times daily) and vitamin D (400-800 IU Id) reduce the risk of osteoporotic fractures in both men and women. Bone mineral density testing using dual-energy x-ray absorptiometry (DEXA) of patients with multiple risk factors may uncover asymptomatic osteoporosis. USPSTF recommends osteoporosis screening for women of 65 years and older and those younger than 65 years with risk for fracture equal to or greater than a 65-year-old Caucasian woman with no risk factors besides age.

Immunizations

Everyone over the age of 6 months should receive annual influenza vaccination. Persons older than age 65 should receive at least one pneumococcal immunization and a single booster dose of tetanus, diphtheria, and pertussis vaccine. The herpes zoster vaccine carries a Food and Drug Administration (FDA) indication for use starting at the age of 50, but the Advisory Committee on Immunization Practices recommends one dose of herpes zoster vaccine at age 60 or older.

END-OF-LIFE ISSUES

Advance Directives

Well-informed, competent adults have a right to refuse medical intervention, even if refusal is likely to result in death. To further patient autonomy, physicians are obligated to inform patients about the risks, benefits, alternatives, and expected outcomes of end-of-life medical interventions such as cardiopulmonary resuscitation, intubation and mechanical ventilation, vasopressor medication, hospitalization and intensive care unit (ICU) care, and artificial nutrition and hydration. Advance directives are oral or written statements made by patients when they are competent that are intended to guide care should they become incompetent. Advance directives allow patients to project their autonomy. Although oral statements about these matters are ethically binding, they are not legally binding in all states. Written advance directives are essential so as to give effect to the patient's wishes in these matters.

Durable Power of Attorney for Health Care

A durable power of attorney for health care (DPOA-HC) allows the patient to designate a surrogate decision maker. The responsibility of the surrogate is to provide "substituted judgment" to decide as the patient would, not as the surrogate wants. In the absence of a designated surrogate, physicians turn to family members or next of kin, under the assumption that they know the patient's wishes.

Do Not Attempt Resuscitation Orders

Physicians should encourage patients to express their preferences for the use of cardiopulmonary resuscitation (CPR). Despite the favorable portrayal of CPR in the media, only approximately 15% of all patients who undergo CPR in the hospital survive to hospital discharge. DNAR ("do not attempt resuscitation") is the preferred term over DNR ("do not resuscitate") to emphasize the low likelihood of successful resuscitation. In addition to mortality statistics, patients deciding about CPR preferences should also be informed about the possible consequences of surviving a CPR attempt. CPR may result in fractured ribs, lacerated internal organs, and neurologic disability. There is also a high likelihood of requiring other aggressive interventions if CPR is successful. For some patients at the end of life, decisions about CPR may not be about whether they will live but about how they will die.

CASE CORRELATION

• See also Cases 1 (Health Maintenance, Adult Male) and 11 (Health Maintenance, Adult Female).

COMPREHENSION QUESTIONS

18.1 A third-year medical student is researching various recommendations for the care of the geriatric patient. Which of the following statements is most accurate?

A. USPSTF recommends routine screening for colorectal cancer in all adults starting at the age of 50.

B. USPSTF recommends stopping screening for cervical cancer with Pap smear in all women past the age of 65.

C. The USPSTF recommends that all men should be screened for prostate cancer with prostate-specific antigen (PSA) testing annually starting at the age of 50.

D. Herpes zoster vaccination is recommended for all adults over the age of 50.

18.2 A 70-year-old man is having difficulty hearing his family members' conversations. He is diagnosed with presbycusis. Which of the following statements regarding his condition is most accurate?

A. Presbycusis does not respond to hearing aid use.

B. Presbycusis is usually caused by a conductive disorder.

C. Presbycusis usually results in loss of speech discrimination.

D. Presbycusis usually results in unilateral hearing loss.

E. Presbycusis usually results in low-frequency hearing loss.

18.3 Which one of the following recommendations is accurate regarding the current USPSTF recommendation for osteoporosis screening in the elderly?

A. All women with strong risk factors, regardless of age, should be screened for osteoporosis.

B. Only women above the age of 65 should be screened for osteoporosis.

C. Men and women above the age of 65 should be screened for osteoporosis.

D. African-American race is an independent risk factor for osteoporosis and should warrant screening regardless of other risk factors.

ANSWERS

18.1 A. The only accurate answer among the choices is that regarding colorectal screening. There is no recommendation for annual routine PSA testing for prostate cancer screening. Pap smears can be safely discontinued in women over the age of 65 who have had adequate prior screening. The herpes zoster vaccine is recommended for routine use at age 60 or older.

18.2 C. Up to one-third of people older than age 65 suffer from hearing loss. Presbycusis typically presents with symmetric high-frequency hearing loss. There is loss of speech discrimination, so that patients complain of difficulty understanding rapid speech, foreign accents, and conversation in noisy areas. The mechanism is sensorineural rather than a conductive problem.

18.3 A. USPSTF recommends screening for osteoporosis in women above 65 years and younger than 65 years with risk factors. Therefore, considering age as a risk factor, essentially all women with risk factors must be screened for osteoporosis with bone mineral density test or DEXA scan. The current recommendation applies only to women, as there is insufficient evidence to support screening in men, and the race mostly at risk is Caucasian.

CLINICAL PEARLS

⯈ Protein undernutrition is associated with an increased risk of infections, anemia, orthostatic hypotension, and decubitus ulcers.

⯈ Smoking is associated with osteoporosis.

⯈ lf"osteoporotic"fractures, such as vertebral compression fractures, occur in conjunction with osteopenia on x-ray, the diagnosis of osteoporosis is almost certain.

⯈ Hearing loss and sensory impairments, in general, can be confused with cognitive impairment or an affective disorder.

⯈ Presbyopia, macular degeneration, glaucoma, cataracts, and diabetic retinopathy account for the majority of conditions leading to vision loss in the elderly.

REFERENCES

Centers for Disease Control. Recommended adult immunization schedule, United States-2015. Available at: http:/ /www.cdc.gov/vaccines/ schedules/ downloads/ adult/ adult-combined-schedule.pd£ Accessed April 19, 2015. 

Harper G, Johnston C, Landefeld C, et al. Geriatric disorders. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment. New York, NY : McGraw-Hill; 2014. Available at: http://accessmedicine.mhmedical.com. Accessed May 24, 2015. 

Kudrimoti AM, Perman SE. Hearing and vision impairment in the elderly. In: South-Paul JE, Matheny SC, Lewis EL, et al., eds. Current Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY: McGraw-Hill; 2015. Available at: http://accessmedicine.mhmedical.com. Accessed May 24, 2015. 

Rabow MW, Pantilat SZ. Palliative care and pain management. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment. New York, NY : McGraw-Hill; 2014. Available at: http://accessmedicine.mhmedical.com. Accessed May 24, 2015 

Rosenfeld KE, Wenger NS, Kagawa-Singer M, et al. End-of-life decision making: a qualitative study of elderly individuals.] Gen Intern Med. 2000;15:620. 

Spalding MC, Sebesta SC. Geriatic screening and preventive care. Am Fam Physician. 2008 Jul 15;78(2):206-215. 

State-specific advance directives forms. Available at: http://www.caringinfo.org/stateaddownload. Accessed April 19, 2015. 

Tulsky JA, Fischer GS, Rose MR, et al. Opening the black box: how do physicians communicate about advance directivesr Ann Intern Med. 1998:129:441. 

United States Preventive Services Task Force Published Guidelines. Available at www.uspreventiveservicestaskforce. org/Browse. Accessed April 19, 2015.

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