Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + DEMENTIA Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ ICSI 2014, USPSTF 2014 ++ –Insufficient evidence to recommend for or against routine screening for cognitive impairment or dementia. ++ CTFPHC 2016 ++ –Do not screen asymptomatic adults for cognitive impairment. ++ Sources ++ –ICSI. Preventive Services for Adults. 20th ed. 2014. –CMAJ. 2016;188(1):37-46. –Ann Intern Med. 2014;160(11):791-797. +++ Comments ++ False-positive rate for screening is high, and treatment interventions do not show consistent benefits. Early recognition of cognitive impairment allows clinicians to anticipate problems that patients may have in understanding and adhering to recommended therapy, and help patients and their caregivers anticipate and plan for future problems related to progressive cognitive decline. + FALLS IN THE ELDERLY Download Section PDF Listen +++ +++ Population ++ –All older persons. +++ Recommendation ++ NICE 2013, AAOS 2001, AGS 2010, British Geriatrics Society 2001 ++ –Ask at least yearly about falls. ++ Sources ++ –NICE. Falls: Assessment and Prevention of Falls in Older People. London (UK): National Institute for Health and Care Excellence (NICE); 2013. 33 p. (Clinical guideline; no. 161) –2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons: http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf +++ Population ++ –Community-dwelling older adults without known osteoporosis or vitamin D deficiency. +++ Recommendations ++ USPSTF 2018 ++ –Do not use vitamin D supplementation to prevent falls (Grade D). –Encourage exercise interventions to prevent falls in older adults at increased risk for falls (Grade B). –Selectively offer multifactorial interventions to prevent falls in older adults at increased risk for falls (Grade C). ++ Sources ++ –JAMA. 2018:319(15):1592-1599. –JAMA. Published online April 17, 2018. doi:10.1001/jama.2017.21962. +++ Comments ++ Individuals are at increased risk if they report at least 2 falls in the previous year, or 1 fall with injury. Risk factors: Intrinsic: lower-extremity weakness, poor grip strength, balance disorders, functional and cognitive impairment, visual deficits. Extrinsic: polypharmacy (≥4 prescription medications), environment (poor lighting, loose carpets, lack of bathroom safety equipment). A fall prevention clinic appears to reduce the number of falls among the elderly. (Am J Phys Med Rehabil. 2006;85:882) Effective exercise interventions include supervised individual and group classes and physical therapy. Multifactorial interventions include initial assessment of modifiable fall risk factors (balance, vision, postural blood pressure, gait, medication, environment, cognition, psychological health) and interventions (nurses, clinicians, physical/occupational therapy, dietitian/nutritionist, CBT, education, medication management, urinary incontinence management, environmental modification, social/community resources, referral to specialist “ophthalmologist, neurologist, etc.”). All who report a single fall should be observed as they stand up from a chair without using their arms, walk several paces, and return (see Appendix II). Those demonstrating no difficulty or unsteadiness need no further assessment. Those who have difficulty or demonstrate unsteadiness, have ≥1 fall, or present for medical attention after a fall should have a fall evaluation. Free “Tip Sheet” for patients from AGS (http://www.healthinaging.org/public_education/falls_tips.php). Of US adults age ≥65 y, 15.9% fell in the preceding 3 mo; of these, 31.3% sustained an injury that resulted in a doctor visit or restricted activity for at least 1 d. (MMWR Morb Mortal Wkly Rep. 2008;57(9):225) See also page 126 for Fall Prevention and Appendix II. + FAMILY VIOLENCE AND ABUSE Download Section PDF Listen +++ +++ Population ++ –Older adults. +++ Recommendation ++ USPSTF 2013 ++ –Insufficient evidence to recommend for or against routine screening of older adults or their caregivers for elder abuse. ++ Sources ++ –USPSTF. Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: Screening. 2013. –USPSTF. Child Maltreatment: Primary Care Interventions. 2013. +++ Comments ++ All providers should be aware of physical and behavioral signs and symptoms associated with abuse and neglect, including burns, bruises, and repeated suspect trauma. CDC publishes a toolkit of assessment instruments: https://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf + OSTEOPOROSIS Download Section PDF Listen +++ +++ Population ++ –Women age ≥65 y, and younger women at increased risk. +++ Recommendation ++ USPSTF 2011, ACPM 2009, ACOG 2012, ISCI 2014, NAMS 2010 ++ –Screen routinely using either dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine, or quantitative ultrasonography of the calcaneus. ++ Sources ++ –USPSTF. Osteoporosis: Screening. 2011. –Osteoporosis. Washington (DC): ACOG; 2012. (ACOG practice bulletin; no. 129). –Menopause. 2010;17(1):23. –ICSI. Preventive Services for Adults. 20th ed. 2014. –Am J Prev Med. 2009;36(4):366-375. +++ Comments ++ USPSTF specifically defines “increased risk” as having a fracture risk equivalent to that of a 65-y-old white woman. The optimal screening interval is unclear. Screening should not be performed more frequently than every 2 y. ACOG: If FRAX score does not suggest treatment, DEXA should be repeated every 15 y if T-score ≥1.5, every 5 y if T-score is −1.5 to −1.99, and annually if T-score is −2.0 to −2.49. Ten-year risk for osteoporotic fractures can be calculated for individuals by using the FRAX tool (http://www.shef.ac.uk/FRAX/). Quantitative ultrasonography of the calcaneus predicts fractures of the femoral neck, hip, and spine as effectively as does DXA. The criteria for treatment of osteoporosis rely on DXA measurements. +++ Population ++ Older men. +++ Recommendations ++ USPSTF 2011 ++ –Insufficient evidence to recommend for or against routine osteoporosis screening. ++ NOF 2014, ACPM 2009 ++ –Recommend routine screening over age 70 y via bone mineral density (BMD). –Consider screening men age 50–69 with risk factors. ++ Sources ++ –USPSTF. Osteoporosis: Screening. 2011. –Am J Prev Med. 2009;36(4). –Osteoporos Int. 2014; 25(10): 2359–2381. +++ Comment ++ Repeat every 3–5 y if “normal” baseline score; if high risk, then every 1–2 y. + VISUAL IMPAIRMENT, GLAUCOMA, OR CATARACT Download Section PDF Listen +++ +++ Population ++ –Older adults. +++ Recommendations ++ USPSTF 2013, 2016 ++ –Insufficient evidence to recommend for or against visual acuity screening or glaucoma screening in older adults. ++ Sources ++ –JAMA. 2016;315(9):908-914. –USPSTF. Glaucoma: Screening. 2013. ++ ICSI 2014 ++ –Objective vision testing (Snellen chart) recommended for adults age ≥65 y. ++ Source ++ –ICSI. Preventive Services for Adults. 20th ed. 2014.