Health Maintenance, Age 66 Years Case File

Health Maintenance, Age 66 Years Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 29

A 66-year-old woman comes in for a routine physical examination. Her menopause occurred at age 51 years, and she is currently taking an estrogen pill along with a progestin pill each day. The past medical history is unremarkable. Her family history includes one maternal cousin with ovarian cancer. On examination, she is found to have a blood pressure o 120/70 mm Hg, a heart rate o 70 beats per minute, and a temperature of 98°F (36.6°C). She weighs 140 lb and is 5 feet 4 in tall. The thyroid is normal to palpation. Examination of her breasts reveals no masses or discharge. The abdominal, cardiac, and lung evaluations are within normal limits. The pelvic examination shows a normal, multiparous cervix, a normal-sized uterus, and no adnexal masses. She had undergone mammography 3 months previously.

» What is your next step?

» What would be the most common cause of mortality for this patient?

ANSWER TO CASE 29:

Health Maintenance, Age 66 Years                                           

Summary: A 66-year-old woman comes for health maintenance. A mammogram has been performed 3 months previously.

• Next step: Each of the following should be performed: Calculate the body mass index, send stool for occult blood, colonoscopy, pneumococcal vaccine, influenza vaccine, tetanus and diphtheria vaccines (if not performed within the past 10 years), herpes zoster vaccine, lipid profile, fasting blood glucose, thyroid function tests, bone mineral density screening, and urinalysis.
• Most common cause of mortality: Cardiovascular disease.

ANALYSIS

Objectives

1. Understand which health maintenance studies should be performed for a 66-year-old woman.
2. Know the most common cause of mortality for a woman in this age group.
3. Understand that preventive maintenance consists of cancer screening, immunizations, and screening for common diseases.

Considerations

The approach to health maintenance includes three parts: (1) cancer screening, (2) immunizations, and (3) addressing common diseases for the particular patient group. For a 66-year-old woman, this includes annual mammography for breast cancer screening, colon cancer screening (annual stool test for occult blood and either intermittent colonoscopy or air contrast barium enema), tetanus, and diphtheria booster every 10 years, the pneumococcal vaccine, annual influenza immunization, and herpes zoster vaccine. She should undergo a lipid profile every 5 years up to the age of 75 years, thyroid function testing every 5 years, and fasting blood glucose levels every 3 years. Because urosepsis is common in geriatric patients, a urinalysis is also usually performed. Osteoporosis screening is indicated for women of age 65 and over. Finally, the most common cause of mortality in a woman in this age group is cardiovascular disease.

APPROACH TO:

Health Maintenance in Older Women                                         

DEFINITIONS

SCREENING TEST: A study used to identify asymptomatic disease in the hope that early detection will lead to an improved outcome. An optimal screening test has high sensitivity and specificity, is inexpensive, and is easy to perform.

PRIMARY PREVENTION: Identifying and modifying risk factors in people who have never had the disease of concern.

SECONDARY PREVENTION: Actions taken to reduce morbidity or mortality once a disease has been diagnosed.

COST EFFECTIVENESS: A comparison of resources expended (dollars) in an intervention versus the benefit, which may be measured in life years or quality adjusted life years.

CLINICAL APPROACH

In each age group, particular screening tests are recommended (Table 29– 1).

Rationale

When the patient does not have any apparent disease or complaint, the goal of medical intervention is disease prevention. One method of targeting diseases is by using the patient’s age. For example, the most common cause of death for a 16-year-old person is a motor vehicle accident; hence, the teenage patient would be well served by the physician encouraging him or her to wear seat belts and to avoid alcohol intoxication when driving. In contrast, a 56-year-old woman will most likely die of cardiovascular disease, so the physician should focus on exercise, weight loss, and screening for hyperlipidemia. In a woman beyond 65 years of age, if prior Pap smears have been normal, cervical cancer screening is not cost-effective. Patients who have had a total hysterectomy (removal of uterine corpus and cervix) do not require vaginal cytology (Pap smears) as long as the patient had no history of cervical dysplasia. (See Table 29– 2 for cervical cytology screening guidelines).

Tobacco Cessation

The most important modifiable factor contributing to mortality is tobacco use. Thus, it is crucial that every patient be identified as to whether they are a smoker. Each patient who is a smoker should be approached on whether they are willing to stop, and if so, then one of the major effective interventions (bupropion, nicotine gum, nicotine inhaler, nicotine nasal spray, or nicotine patch) can be offered. Those unwilling to quit should be given a brief intervention based on the 5 R’s:

• Relevance—indicate why quitting is personally relevant.
• Risks—help patient to identify negative consequences of smoking.
• Rewards—ask the patient to identify benefits of stopping tobacco use.
• Roadblocks—identify barriers to quitting.
• Repetition—motivational intervention should be repeated.

aSome experts recommend mammography beginning at age 40 yr whereas others question its ef cacy in decreasing mortality.

bAdminister Meningococcus vaccine to students, ages 19-21, who are in rst year of college or who live in residence halls.

(Data rom ACOG Committee Opinion No. 534, 2012. Washington, DC: American College o Obstetricians and Gynecologists; 2012 [Reaf rmed 2014].)

Screening in HIV-Positive Women

HIV-positive women have specific screening. There is a greater prevalence of abnormal pap smears and increased risk of progression to high grade disease or cancer, especially with a lower CD4 count. Pap smears twice in the first year after diagnosis or entry into care, and if normal, then annually; there does not seem to be a role for human papillomavirus (HPV) testing in this population. There is no data for when to discontinue (ie, perhaps continue cytology even after hysterectomy or after age 65). Although lung cancers occur more often in HIV-infected individuals, there is likely no utility for chest x-ray or sputum screening. There is a higher incidence of anal cancers in these individuals, and some experts recommend anal cytology, although there is no consensus. They should receive the usual immunizations except varicella zoster which is usually withheld. They should also receive the pneumococcal 13-valent vaccine, and if the vaccine is given when the CD4 count is below 200 cells/mm3, it should be repeated.

Controversies

Recently, several clinical trials have refuted the clinical utility of the internal pelvic examination (bimanual examination) for low-risk and asymptomatic women. The American College of Physicians issued guidelines in 2014 recommending against performing screening speculum/ bimanual pelvic examination in asymptomatic, nonpregnant adult women. There is poor sensitivity of the bimanual examination to detecting adnexal masses. The American College of Obstetricians and Gynecologists recommends annual pelvic examinations and advises that the physician should discuss the complete (internal speculum and/ or bimanual) examination with the patient. Women with symptoms such as vaginal discharge, pelvic pain, urinary incontinence, or pelvic pressure should have a complete examination.

COMPREHENSION QUESTIONS

29.1 A 59-year-old woman is being seen for a health maintenance appointment. She has not seen a doctor for over 10 years. She had undergone a total hysterectomy for uterine fibroids 12 years ago. The patient takes supplemental calcium. The physician orders a fasting glucose level, lipid panel, mammogram, colonoscopy, and a Pap smear of the vaginal cuff. Which of the following statements is most accurate regarding the screening for this patient?

A. The Pap smear of the vaginal cuff is unnecessary.

B. In general, colon cancer screening should be initiated at age 50 but this patient has very sporadic care, therefore colonoscopy is reasonable.

C. Because the patient takes supplemental calcium, a DEXA scan is not needed.

D. Pneumococcal vaccination should be recommended.

29.2 A 63-year-old woman has had annual health maintenance appointments and has followed all the recommendations offered by her physician. The physician counsels her about varicella zoster vaccine. Which of the following is the most accurate statement about this vaccine?

A. This vaccine is recommended for patients who are aged 50 and older.

B. This vaccine is not recommended if a patient has already developed shingles.

C. This vaccine is a live-attenuated immunization.

D. This vaccine has some cross-reactivity with herpes simplex virus and offers some protection against HSV.

29.3 An 18-year-old adolescent female is being seen for a health maintenance appointment. She has not had a Pap smear previously. She currently takes oral contraceptive pills. She began sexual intercourse 1 year previously. Which of the following statements is most accurate regarding health maintenance for this individual?

A. A Pap smear should not be performed in this patient at this time.

B. The HPV vaccine should be administered only if she has a history of genital warts.

C. The most common cause of mortality for this patient would be suicide.

D. Hepatitis C vaccination should be offered to this patient.

29.4 A 39-year-old G1P1 woman who is HIV positive is being seen for a well woman examination. The CD4 count is 600 cells/mm3. She had a mammogram and cervical cytology 1 year ago which were both negative. Which of the following is most appropriate at this time?

A. Chest x-ray

B. Colonoscopy

C. Mammography

D. Cervical cytology

E. Pelvic ultrasound for ovarian cancer screening

ANSWERS

29.1 A. Cervical cytology of the vaginal cuff is unnecessary when the hysterectomy was for benign indications (not cervical dysplasia or cervical cancer) and when there is no history of abnormal Pap smears. Colon cancer screening is generally started at age 50. DEXA scan for osteoporosis screening should be considered in any postmenopausal woman at risk, such as having an osteoporosis- related fracture, a family history, or being thin and Caucasian. Pneumococcal vaccine is generally given at age 65.

29.2 C. The varicella zoster vaccine is a live-attenuated vaccine, recommended for individuals aged 60 and above, and has been shown to greatly reduce the incidence of herpes zoster (shingles), and the severity and likelihood of postherpetic neuralgia. It has no efficacy in preventing HSV.

29.3 A. Cervical cytology should be deferred until age 21. Adolescents frequently clear the HPV infection and allow an abnormal Pap smear to return to normal. Smoking inhibits the ability to clear HPV. The delayed screening prevents unnecessary and costly diagnostic procedures. The HPV vaccine should be recommended to all females between the ages of 9 and 26 regardless of exposure. The most common cause of mortality for adolescent females is motor vehicle accidents. The hepatitis C vaccine is undergoing testing for safety and efficacy and is not currently available.

29.4 D. Annual cervical cytology is indicated for HIV-infected women, and usually without HPV cotesting, since the prevalence is so high that there is little differentiation on triaging based on the result. There is no definite end date (age) to cervical cancer screening in these patients. Mammography and colon cancer screening is the same as HIV-negative patients.

    CLINICAL PEARLS    

» The basic approach to health maintenance is three old: (1) cancer screening, (2) age-appropriate immunizations, and (3) screening or common diseases. » The most common cause o mortality in a woman younger than 20 years is motor vehicle accidents. » The most common cause o mortality o a woman older than 39 years is cardiovascular disease. » Major conditions in women aged 65 years and older include osteoporosis, heart disease, breast cancer, and depression. » Cervical cytology screening does not appear to be cost-effective in women older than age 65 when prior Pap smears have been normal. » Tobacco use is the single most important modifiable risk actor contributing to mortality.

REFERENCES

American College of Obstetricians and Gynecologists. Low bone mass (osteopenia) and fracture risk. ACOG Committee Opinion 407. Washington, DC; 2008. 

American College of Obstetricians and Gynecologists. Well-women visit. ACOG Committee Opinion 534. Washington, DC; 2012. (Reaffirmed 2014.) 

American College of Obstetricians and Gynecologists. Primary and preventive care: periodic assessments. ACOG Committee Opinion 483. Washington, DC; 2011. 

Centers for Disease Control. Immunization schedule for adults, 2015. www.cdc.gov/ vaccines/ recs/ schedules/ adult-schedule.htm#everyone. Accessed 25.08.2015. 

Centers for Disease Control. Immunization schedule for persons 7 through 18 yrs, 2015. www.cdc.gov/ vaccines/ recs/ schedules/ downloads/ child/ 7-18 yrs-schedule-pr.pdf. Accessed 25.08.2015. 

Qaseem A, Humphrey LL, Harris R, et al. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161 (1):67-71.

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