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Common geriatric conditions (called syndromes to reflect the multifactorial etiologies) include falls, poor nutrition, vision and hearing loss, and cognitive impairment. These conditions are often underrecognized despite causing significant burdens to quality of life and function. Therefore, detection of these conditions is recommended to evaluate the etiology of functional limitations in frail elders. USPSTF and Assessing Care of Vulnerable Elders (ACOVE)-3 guidelines are discussed here; see Chapter 6, “Geriatric Assessment,” for a more detailed discussion of geriatric syndromes.
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The USPSTF concludes that there is strong evidence that several types of primary care-relevant interventions (eg, comprehensive multifactorial assessment and management, exercise/physical therapy interventions, and vitamin D supplementation) reduce falls among older adults at high risk for falling. Components most commonly included in effective multifactorial trials, and thus recommended, are home safety modifications; balance, gait and strength training; and withdrawal or minimization of psychoactive and other medications. Harms of these interventions appear minimal. The most frequently recommended screening test for falls is the Get Up and Go Test, which takes less than 1 minute. Any unsafe movement during the test suggests an increased risk of falling and should prompt the provider to refer the patient to physical therapy for complete evaluation. The American Geriatric Society has also published guidelines on falls and recommends asking older people annually if they have fallen in the past year.
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Michael
YL, Whitlock
EP, Lin
JS, Fu
R, O’Connor
EA, Gold
R; US Preventive Services Task Force.. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force.
Ann Intern Med. 2010;153(12):815-–825.
CrossRef
[PubMed: 21173416]
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Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons.
J Am Geriatr Soc. 2011;59(1):148-–157.
CrossRef
[PubMed: 21226685]
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Depression is not a normal part of aging. It is associated with decreased quality of life, function, and higher mortality. The USPSTF recommendation is to screen if a system to support treatment of depression exists (eg, mental health treatment or care coordination). The Patient Health Questionnaire 2 (PHQ-2) is a screening tool that has been validated in adults age 65 years and older (sensitivity 100% and specificity 77%):
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Over the past month, have you often had little interest or pleasure in doing things?
Over the past month, have you often been bothered by feeling down, depressed, or hopeless?
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If the person answers yes to either of these questions, then a more detailed assessment (ie, PHQ-9) along with consideration of other medical explanations (ie, hypothyroidism, medication side effect, or substance use) is required.
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Depression causes high morbidity, especially at the end of life, and a range of effective therapies exist. Treatments, including antidepressants and psychotherapy, are effective in older adults, and in contrast to young adults, antidepressants reduce suicidal behaviors. Supportive counseling and psychotherapy, when available, should be offered. When adding antidepressants, providers should consider pharmacokinetics in older adults and start with a lower dose, choose agents to minimize anticholinergic side effects, and weigh the time to benefit (usually 4–6 weeks) against a person’s goals and prognosis.
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O’Connor
EA, Whitlock
EP, Beil
TL, Gaynes
BN Screening for depression in adult patients in primary care settings: a systematic evidence review.
Ann Intern Med. 2009;151(11):793-–803.
CrossRef
[PubMed: 19949145]
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For the general population, the USPSTF recommends dietary counseling to reduce fats and salt and to increase fruits, vegetables, and grain products containing fiber because these diets are associated with better health outcomes. Counseling can improve dietary behaviors, including reduction in dietary fat and salt and increases in fruit and vegetable intake. None of the studies, however, were designed to assess the adverse effects of dietary counseling, especially in chronically ill older adults for whom protein-calorie malnutrition becomes an important concern. For older adults at risk for malnutrition or weight loss, restrictive diets should be avoided. ACOVE-3 recommends assessing weight at each visit for frail elders to identify undernourishment.
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Suboptimal levels of vitamins may be risk factors for chronic disease such as cardiovascular disease, cancer, and osteoporosis. For most individuals, a single multivitamin should provide adequate levels. Because the recommended intake of vitamins B12 and D is closer to twice the recommended daily intake, it is reasonable to recommend multivitamin supplements with additional vitamin D and B12.
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Lin
JS, O’Connor
E, Whitlock
EP
et al Behavioral Counseling to Promote Physical Activity and a Healthful Diet to Prevent Cardiovascular Disease in Adults: Update of the Evidence for the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2010. (Evidence Syntheses, No. 79.)
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Reuben
DB Quality indicators for the care of undernutrition in vulnerable elders.
J Am Geriatr Soc. 2007;55 Suppl 2:S438-–S442.
CrossRef
[PubMed: 17910568]
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Up to 50% of older adults have undetected vision impairment. ACOVE-3 recommends a comprehensive eye exam (including acuity, dilation of pupil, intraocular pressure measurement, and retina) every 2 years. There is little evidence, however, that screening for vision loss improves functional outcomes or quality of life, and some treatments carry a small risk for serious complications, including acute vision loss. In most primary care clinics, routine screening is completed with the Snellen eye chart, which can identify impaired visual acuity (defined as best corrected vision worse than 20/50), but does not screen for macular degeneration, cataracts, or glaucoma. There is insufficient evidence for or against screening for these problems, given little evidence that early treatment improves vision-related function. Therefore, in clinical settings, screening for visual problems is a preference-sensitive decision.
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Rowe
S, MacLean
CH Quality indicators for the care of vision impairment in vulnerable elders.
J Am Geriatr Soc. 2007;55 Suppl 2:S450-–S456.
CrossRef
[PubMed: 17910570]
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U.S. Preventive Services Task Force. Screening for impaired visual acuity in older adults: U.S. Preventive Services Task Force recommendation statement.
Ann Intern Med. 2009;151(1):37-–43.
CrossRef
[PubMed: 19581645]
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ACOVE-3 recommends screening for hearing loss in vulnerable adults during initial evaluation with no specific recommendation on repeat screening. The USPSTF evidence review did find good evidence screening detects hearing loss, but only 1 good-quality randomized trial showing benefit on quality of life with immediate hearing aids. Screening for hearing loss carries little risk, and hearing impairment is a prevalent problem in older persons. Examples of screening include a brief question (“Would you say you have any difficulty hearing?”), finger rub (failure to identify rub in ≥2 of 6 trials), or audiometric testing. If a patient wants to pursue amplification there are effective treatments (hearing aids); therefore, screening for hearing loss is a preference-sensitive decision.
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Chou
R, Dana
T, Bougatsos
C, Fleming
C, Beil
T Screening adults aged 50 years or older for hearing loss: a systematic evidence review for the U.S. Preventive Services Task Force.
Ann Intern Med. 2011;154(5):347-–355.
CrossRef
[PubMed: 21357912]
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The USPSTF gives no formal recommendation for routine screening of dementia. Although some screening tests have good sensitivity to detect cognitive impairment (eg, Minicog, Mini Mental State Examination [MMSE], and Montreal Cognitive Assessment [MOCA]), the limited efficacy of therapies (both pharmacologic and behavioral) and the potential distress of being labeled with dementia in face of limited treatment options have to be considered. ACOVE-3 recommends an initial cognitive assessment to allow for early implementation of nonpharmacologic interventions and earlier advanced planning, while also recognizing the lack of evidence. Given the risk of harm, the decision to screen an asymptomatic person should be preference-specific and may include discussion with a caregiver to determine if this is desired by the person. If memory has been raised as a concern by the person or caregiver, then the above tests can be performed as part of an initial diagnostic workup.
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Feil
DG, MacLean
C, Sultzer
D Quality indicators for the care of dementia in vulnerable elders.
J Am Geriatr Soc. 2007;55 Suppl 2: S293-–S301.
CrossRef
[PubMed: 17910550]
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Elder Abuse is not addressed by USPSTF, but it is estimated to have a prevalence of 2% to 10%, even with underreporting. The definition of abuse includes both intentional actions that cause or increase risk of harm and failure to satisfy an elder’s needs or protect the elder from harm. Although there is no formal recommendation for screening, there is a need for health care providers to be vigilant to the signs and symptoms of abuse.