8: Prevention & Health Promotion

Even in the very elderly, preventive interventions can limit disease and disability. The heterogeneity of the older population in terms of medical conditions, life expectancy, and goals of treatment, however, requires a more thoughtful and individualized application of prevention guidelines rather than a one-size-fits-all approach based solely on age.

Since the 1980s, the U.S. Preventive Services Task Force (USPSTF) has provided evidence-based scientific reviews of preventive health services to guide primary care decision making. The fundamental standard applied by the task force is whether the intervention leads to improved health outcomes (eg, reduced disease-specific morbidity and mortality). In 1998, the Assessing Care of Vulnerable Elders project began developing quality indicators specific for vulnerable older persons (defined as age >65 years and life expectancy <2 years). This project concluded that high-quality evidence about benefits and harms is often limited for interventions in older adult populations. In addition, trials generally show the average effectiveness of an intervention, so it is always necessary to incorporate individual characteristics (eg, life expectancy, goals of care, function, and comorbidities) into screening decisions because such characteristics may change the likelihood that a person will receive benefit versus harm from a preventive intervention.

The framework for individualized decision making (Table 8–1) is anchored by considering an individual’s life expectancy. Rather than using the average life expectancy for a given age, the person’s health status should be incorporated into preventive decisions (Figure 8–1). Persons with several comorbid medical conditions or functional impairments likely have a life expectancy that is lower than average for their age, whereas those without any significant medical conditions or functional impairment likely will live longer than average (see Chapter 3, “Goals of Care & Consideration of Prognosis”). The risk of experiencing the adverse effects of a condition and the potential benefit from early detection should be considered in the context of a person’s estimated life expectancy. The last component of the framework is to assess how individuals view these potential harms and benefits, and integrate their values and preferences into screening decisions.

Table 8–2 summarizes conditions for which screening or other prevention interventions have been shown to result in net benefit for some older people based on USPSTF and geriatrics-focused guidelines. The table also provides general guidance for individualized recommendations by incorporating a person’s function, health, life expectancy, and goals of care. Screening for some conditions is not recommended when potential harms of screening (and the procedures that emanate from screening) outweigh potential benefits based on an individual’s characteristics.

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.

Falls

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.

Depression

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%):

• 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?

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.

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.

Nutrition

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.

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.

Vision

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.

Hearing

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.

Cognitive Impairment

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.

Elder Abuse

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.

Exercise

The benefits of as little as 30 minutes per day of walking on most days of the week to prevent coronary artery disease (CAD), hypertension, diabetes, obesity, and osteoporosis are well established. A Cochrane Review of progressive resistance strength training in older adults, including persons who were healthy, frail, or institutionalized, found it improved strength and performance (gait speed and transfer from chair). Resistance training and exercises such as tai chi, dance, and yoga also have been shown to improve balance. Although the USPSTF does not make a recommendation to counsel on exercise, the review does recognize that multicomponent interventions, including goal setting, written exercise prescriptions, and follow-up, may help increase physical activity. Exercise prescriptions include frequency, intensity, type, timing, and progression of exercise.

Substance Abuse

Tobacco, alcohol, and drug use have adverse impacts on health and are prevalent in older persons, as well as in younger persons. There is good evidence that even older smokers derive benefit from quitting tobacco, including decreased cardiovascular events. The USPSTF recommends asking all adults about tobacco use and providing tobacco cessation interventions if they screen positive. Issues specific to older adults include different pharmacokinetics with aging that may require gentle initiation of pharmacotherapy and inclusion of caregivers in counseling as they may be the source of tobacco.

Screening for alcohol use is also recommended by USPSTF, with a similar recommendation for behavioral counseling if the person screens positive for alcohol overuse. Although the prevalence of alcohol use decreases with age, an estimated 38% of people older than age 65 years drink alcohol, of whom 7.6% drink 5 or more servings a day. Unlike tobacco, there are safe amounts of alcohol consumption. Low-risk consumption is no more than 1 standard drink/day in people age 65 years and older, although in an individual with cognitive impairment, history of falls, liver disease, or a pattern of substance abuse, there may not be a safe amount. There is also controversy around the potential health benefits (reduction in heart disease, stroke, and possibly dementia) from moderate alcohol intake. Screening tests (such as CAGE [cutting, annoyance, guilt, eye-opener], Michigan Alcoholism Screening Test–Geriatric Version, and Alcohol Use Disorders Identification Test) have been validated in primary care settings, but primarily in younger populations. There also is growing interest in using a new single screening question: “In the past year, have you had any times when you had 4 or more drinks at 1 sitting?” (sensitivity 74.3%, specificity 95.6% among people age 65 years and older). The recommended follow-up to a positive screen is counseling and referral to therapy (treatment locator can be found at www.samhsa.gov).

Illicit substance use is a growing problem in the United States, although its prevalence remains lower in older adults than in younger adults (12.9% among ages 30–34 years vs. 1.1% among ages 65 years and older). The question, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?,” was highly sensitive and specific for detection of a drug use disorder in 1 study that included participants up to age 82 years.

Sexual Health

The USPSTF recommends counseling to reduce sexually transmitted infections (STIs) in adults at increased sexual risk, meaning history of any STI in the past year or multiple sexual partners. STIs among older people are on the rise, including HIV, and assessing a person’s sexual behaviors and attitudes is a way to better direct counseling. Assessing sexual health also may reveal psychosocial issues and medication side effects that may have otherwise been missed.

Several vaccinations are widely recommended because they result in net benefit for the majority of older adults. Although vaccination of older adults with moderate or severe acute illness should generally be deferred until the acute illness has improved or resolved, vaccination should not be delayed because of mild respiratory illnesses (with or without fever).

Influenza Vaccine

The effectiveness of the influenza vaccination depends on the recipient’s age and immunocompetence. Among community-dwelling adults older than age 60 years, the vaccine has been 56% effective in reducing influenza-related illness. Among older long-term care residents, vaccine effectiveness in preventing influenza may only be 30% to 40%; however, it may be 50% to 60% effective in preventing pneumonia and hospitalization, and 80% effective in preventing deaths. Seasonal trivalent inactivated influenza vaccine (“flu shot”), either standard-dose or high-dose formulation, is recommended annually for adults age 65 years and older starting in late summer or early fall—as soon as the vaccine is available. Live, attenuated influenza vaccine (“nasal spray”) is not recommended for adults older than age 49 years. Flu shot side effects are typically minor and last less than 3 days. Because the vaccine comes from highly purified inactivated flu virus grown in eggs, influenza vaccination is contraindicated in persons with severe egg allergy.

Pneumococcal Vaccine

The 23-valent pneumococcal vaccine represents 85% to 90% of the serotypes that cause invasive disease in the United States and has been shown to be 56% to 81% effective in preventing invasive disease. The Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal immunization once for all adults age 65 years and older. A one-time pneumococcal revaccination is recommended for those age 65 years and older who received their initial vaccination before age 65. The vaccine has rarely been associated with major side effects, although up to half of vaccine recipients will have a mild local reaction that usually persists for less than 48 hours.

Tetanus/Diphtheria and Tetanus/Diphtheria/Pertussis Vaccines

Cases of tetanus and diptheria in the United States are rare and mostly occur in unvaccinated people. Pertussis is an acute infectious cough illness that remains endemic in the United States. ACIP recommends a booster dose of tetanus-diphtheria toxoid (Td) vaccine every 10 years. For adults age 65 years and older who anticipate contact with an infant, a one-time booster of Tdap (tetanus, diphtheria, and acellular pertussis) vaccine should be given in place of the Td booster. Tdap vaccine can be administered regardless of the interval since the most recent Td vaccine. If an adult has never been vaccinated against tetanus, diptheria, or pertussis, then 3 doses are required (Tdap followed by Td ≥4 weeks later and another dose of Td 6–12 months later). Local reactions are common after these vaccines and a nodule may be palpable at the injection site for several weeks.

Herpes Zoster (Shingles) Vaccine

Zoster is a localized painful cutaneous eruption that is caused by reactivation of latent varicella zoster virus (VZV), often decades after initial varicella infection (“chicken pox”). Zoster vaccine is partially efficacious at preventing zoster, at reducing the severity and duration of pain, and at preventing postherpetic neuralgia. ACIP recommends a one-time herpes zoster (shingles) immunization for immunocompetent adults who are age 60 years and older. Shingles vaccine is a live, attenuated strain of VZV, the same strain used in varicella vaccines, but the shingles vaccine is much more potent. Persons with a history of zoster can be vaccinated. The few adults older than age 65 years who have received the varicella vaccine (began in the United States in 1995) do not need shingles vaccination. Injection site adverse effects may occur in up to half of vaccine recipients, although varicella-like rashes are rare. Shingles vaccination is contraindicated in persons with serious allergies to gelatin or neomycin.

Diabetes Mellitus

The USPSTF recommends screening for diabetes mellitus in adults with hypertension or hyperlipidemia because treatment goals for those conditions might be altered with this additional diagnosis. Other organizations also recommend using HbA1c (glycosylated hemoglobin) ≥6.5% as a threshold for a diagnosis of diabetes, but this is controversial, especially among frail elders (eg, life expectancy <5 years and limited function) for whom HbA1c treatment goal of <8% has been suggested to balance risks of hypoglycemia. Clinical trials to prevent microvascular complications of diabetes have shown that approximately 8 years of treatment are needed to benefit. For individuals whose life expectancy is less than that, benefits of lowering HbA1c are uncertain. Treatment carries the risk of hypoglycemia and burden of injection. For some persons, quality of life may outweigh any potential benefit of treating asymptomatic diabetes.

Thyroid Disorders

The USPSTF concludes there is insufficient data to recommend for or against screening for thyroid disorders in asymptomatic people. Many older adults, however, may have symptoms suggestive of hypothyroidism such as constipation, fatigue, depression, or weight gain. For adults with these symptoms, the preferred diagnostic test is a thyroid-stimulating hormone (TSH) level. In cases of normal free thyroxine (T₄) despite elevated TSH, subclinical hypothyroidism is suspected. A 2009 review found that for subclinical hypothyroidism, replacement therapy with levothyroxine neither improves survival nor quality life; treatment also does not decrease cardiovascular morbidity and has a small risk of harm (eg, unintended weight loss).

Osteoporosis

USPSTF recommends screening with a dual-energy x-ray absorptiometry (DXA) scan of hip and lumbar spine in women age 65 years and older, with at least a 2-year gap between repeat DXA scans. Although USPSTF makes no recommendations on testing in men, other organizations have recommended DXA in men based on individual risk assessment or age >70 years. Osteoporosis will affect as many as 1 in 2 women and 1 in 5 men. As women age, the number needed to treat to prevent 1 fracture over 5 years decreases to as low as 43 by ages 75–79. The FRAX score can further predict individual fracture risk. All guidelines emphasize that decisions to treat should be individualized because all current therapies, even calcium supplementation, although effective, do carry some potential risks.

CAD has remained the leading cause of death in the United States over the last 75 years. To date, using laboratory biomarkers and resting electrocardiograph as screening tests in asymptomatic people has not been shown to be beneficial. Rather, screening should focus on modifiable risk factors for cardiovascular disease, including hyperlipidemia, hypertension, tobacco use, diabetes, obesity, and physical inactivity.

Hyperlipidemia

The USPSTF recommends continued screening for hyperlipidemia in persons older than age 65 years with incorporation of some assessment of overall CAD risk (eg, Framingham or Adult Treatment Panel [ATP] III risk models). The Framingham equation, however, only includes ages up to 79 years, and it is unclear if risk should be extrapolated to older adults (eg, add additional points for each 5-year category thereafter).

In people with known CAD, excellent evidence supports screening and treating hyperlipidemia even up to age 80 years to reduce risk of myocardial infarction, stroke, and mortality. Systematic reviews of treating hyperlipidemia in elders with CAD have shown 25% to 30% reductions in 5-year coronary disease outcomes. Updated in 2004, the Third Report of the National Cholesterol Education Program (ATP III) recommends the low-density lipoprotein (LDL) cholesterol target should be <100 mg/dL for persons with CAD, and an expert-opinion-based recommendation suggests an LDL target <70 mg/dL for those at very high risk for vascular events (known CAD with comorbid diabetes, metabolic syndrome, or continued smoking). For very elderly individuals, clinicians will need to carefully weigh life expectancy, goals of care, and potential side effects from therapies (eg, undernutrition from diet restrictions, myalgias from statins, and drug–drug interactions).

In people up to age 80 years without known CAD, there is 1 randomized control trial (Anglo-Scandinavian Cardiac Outcomes Trial [ASCOT]) that provided some evidence for hyperlipidemia screening and treatment (average LDL approximately 80 mg/dL postintervention). Specific treatment targets in older adults without CAD, however, are uncertain. Incorporation of a CAD risk score should guide application of ATP III guidelines. Although USPSTF recommends repeat screening every 5 years, guidelines recognize lipid levels are less likely to rise after age 65 years. In general, 3–5 years of treatment are required to derive benefit from lipid-lowering therapies, suggesting that for individuals with life expectancy less than 3–5 years, screening is likely to cause more harm than benefit.

Hypertension

The definition for hypertension among older adults remains unclear. Report 7 of the Joint National Commission on Detection, Evaluation and Treatment (JNC7) defines hypertension as >140/90 mm Hg regardless of age. Based on this definition, the USPSTF recommends screening for hypertension in all adults older than age 18 years, with no special recommendations for those older than age 65 years. Most guidelines recommend at least 2–3 different office measures taken on at least 2 different office visits to define hypertension. Frequency of screening is also guided by JNC7 guidelines, recommending intervals of 1–2 years depending on severity of hypertension.

The JNC7 guidelines, however, may be too stringent for older people without CAD. Sclerotic arteries can cause elevations in systolic blood pressure, causing “pseudohypertension,” and at least 1 study among men age 85 years and older found a higher systolic blood pressure (SBP) (>180 mm Hg) was associated with greater survival compared to those who had a SBP <130 mm Hg. The landmark Hypertension in the Very Elderly Trial (HYVET) randomized controlled trial, however, demonstrated benefits of treating hypertension to prevent stroke, death, and CAD in generally healthy asymptomatic people age 60 years and older. This study treated to targets of SBP <150 mm Hg and diastolic blood pressure (DBP) <80 mm Hg. One stroke resulting in death or disease was prevented for every 50 people treated over 4.5 years. Death or disease from coronary heart disease was also reduced (number needed to treat = 100 over 4.5 years). Among the very old (age >80 years), the numbers were similar for stroke (absolute risk reduction of 1.8%, with number needed to treat of 56 over 2.2 years), with no decrease in coronary heart disease.

There is clear benefit in treating hypertension among those with CAD or equivalents regardless of age. The time of 3–5 years to these end points of decreased CAD and cardiovascular accident (CVA), coupled with potential side effects of treatment (fall, bradycardia, electrolyte abnormalities depending on the drug chosen) suggests that in those with limited life expectancy, risks may outweigh the benefit of screening and treatment. If treatment is considered, a higher target blood pressure should be considered.

Abdominal Aortic Aneurysm

In men age 65–75 years with a history of tobacco use, the USPSTF recommends a one-time screening for abdominal aortic aneurysm by ultrasound to allow early detection and elective repair. An abdominal aortic aneurysm diameter of 5.5 cm or more is associated with increased risk of rupture and interventional management is generally recommended. Both endovascular and open repair carry risks for mortality and may require substantial recovery time. Therefore, in individuals with multiple comorbidities or limited life expectancy, the risk of screening and intervention may outweigh the benefits of early detection.

Aspirin

Aspirin for prophylaxis in persons without cardiovascular disease has been proposed to reduce the risk of several diseases: CVA, CAD, and colorectal cancer. The USPSTF weighed the reduced incidence of colorectal cancer against the increased risk of gastrointestinal bleed and hemorrhagic stroke from aspirin 325 mg and recommended against taking aspirin for colorectal cancer prevention.

Also, the benefits of aspirin in reducing the risk of CVA and CAD vary by sex: aspirin decreases CVA in women and decreases CAD in men. USPSTF recommends initiation of low-dose aspirin (75 mg/day was as effective as 325 mg/day in persons without cardiovascular disease) when the benefit (eg, Framingham calculators for CAD or CVA) outweighs the risk for gastrointestinal bleed. Concurrent use of nonsteroidal antiinflammatory drugs triples to quadruples the rate of gastrointestinal bleed from aspirin. Duration of aspirin therapy in trials has ranged from 3–10 years, and the USPSTF recommends reassessment of aspirin risks and benefits every 5 years. There is insufficient evidence to make recommendations for people >80 years old. Also, older individuals with less than a 5-year life expectancy or multiple comorbidities that place them at increased risk of gastrointestinal bleed are likely to experience net harm from initiating aspirin.

Breast Cancer

The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women age 75 years and older because older women were not included in mammography trials. However, indirect evidence suggests mammography every 2 years is likely to result in net benefit for some older women in good health. For example, older women have a higher absolute risk of dying of breast cancer, mammography is more accurate in older women, and there is no evidence that the benefit of screening ceases at a specific age. Therefore, decisions to stop screening should be individualized based on whether a woman has comorbidities that limit her life expectancy to less than 5 years and her values and preferences regarding the potential benefits and harms of screening. Women with limited life expectancy are at risk for harms that happen around the time of screening while they have no chance for potential survival benefit, which only happens several years after the actual screening test. Harms of screening include false-positive results that may lead to a cascade of medical testing and psychological distress, as well as the overdetection and overtreatment of inconsequential disease that would never have come to clinical attention had the woman not been screened. Therefore, a screening mammography is likely to cause net harm in women with limited life expectancy and in those who place high importance on avoiding the harms of screening.

For all age groups, current evidence is insufficient to assess the additional benefits and harms of magnetic resonance imaging or clinical breast examination beyond mammography for breast cancer screening. In addition, teaching women to perform breast self-examination has been shown to cause net harm and is not recommended at any age. Of course, women should be encouraged to report breast changes or abnormalities they discover to their clinician.

Colorectal Cancer

The USPSTF recommends colorectal cancer screening in adults age 50 through 75 years; recommends individualized decision making for adults age 76 through 85 years; and recommends against screening adults older than age 85 years. These cutoffs are based on average life expectancy at each age and should be used as general guides rather than applied rigidly. For example, screening is not recommended for persons of any age who have a life expectancy less than 5 years, and screening may be appropriate for a very healthy 88-year-old person who has never been screened. Advancing age increases the absolute risk of dying of colorectal cancer.

There are multiple acceptable measures of colorectal cancer screening. These tests include high sensitivity gFOBT (guaiac-based fecal occult blood testing) or iFOBT (immunologic fecal occult blood test)/FIT (fecal immunochemical test) annually, or sigmoidoscopy every 5 years, or colonoscopy every 10 years. Older adults are more likely to have cancer in the right half of the colon, decreasing the sensitivity of sigmoidoscopy, which examines only the left half of the colon. Also, choice of screening test should consider availability and individual preferences. gFOBT requires dietary and medication restrictions 7 days prior to screening, whereas iFOBT/FIT eliminates the need for these restrictions. Bowel preparations are required prior to sigmoidoscopy and colonoscopy. The standard follow-up of any positive test is a diagnostic colonoscopy, such that people who would never accept or tolerate colonoscopy should not be screened. Risks of colonoscopy increase with age and comorbidity burden. It is estimated that perforation, hemorrhage, or cardiovascular/pulmonary events occur in 26 per 1000 colonoscopies for adults age 65 years and older and in approximately 35 per 1000 colonoscopies for adults age 85 and older.

For all ages there is insufficient evidence to weigh the potential benefits of computer tomographic colonography against the likely harms of the test. Barium enema is the least-sensitive screening test for colorectal cancer and is no longer recommended for screening.

Cervical Cancer

The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer (such as women with history of a high-grade precancerous lesion or cervical cancer, in utero exposure to diethylstilbestrol, or who are immunocompromised). Older women with adequate prior screening are at extremely low risk for developing cervical cancer, even if they have substantial life expectancy or a new sexual partner. Adequate prior screening is defined as 3 consecutive negative cytology results or 2 consecutive negative HPV (human papillomavirus) results within 10 years before cessation of screening, with the most recent test occuring within 5 years. Women older than age 65 years who have an inadequate screening history or those who have never been screened should receive screening with cytology (Papanicolaou smear) every 2 to 5 years, ending at age 70 to 75. Women at any age who have had a hysterectomy with removal of the cervix for a benign condition are not at risk for cervical cancer and should not be screened. Harms of cervical cancer screening include false-positive results. Mucosal atrophy, which is common after menopause, may predispose older women to false-positive cytology and lead to additional testing and invasive diagnostic procedures, such as colposcopy and cervical biopsy, as well as psychological distress. In addition, many precancerous cervical lesions (such as CIN2) will spontaneously regress such that screening may cause harm through the identification and treatment of inconsequential disease.

For all ages there is limited evidence on the benefits and harms of HPV testing alone as a screening strategy. HPV testing combined with cytology every 5 years may be a reasonable alternative in younger women who want to lengthen the screening interval.

Prostate Cancer

There is considerable controversy surrounding prostate-specific antigen (PSA) screening for men of all ages because of the lack of conclusive evidence that screening reduces mortality from prostate cancer. All guidelines, however, agree that screening men with a life expectancy less than 10 years is not recommended because they have little chance for any potential survival benefit. The USPSTF recommends against PSA screening in all men, whereas other organizations suggest screening might be warranted in men in good health who value the small or uncertain benefits of screening over the substantial known harms. Guidelines generally agree that among men with long life expectancy the decision to undergo PSA screening is a preference-sensitive decision that should be informed. Clinicians should inform men of the potential benefits, limits/gaps in current evidence, and known harms of screening. Harms include false-positive results that may lead to additional testing and prostate biopsies, as well as overdetection and overtreatment of clinically inconsequential prostate cancers that would never have progressed to cause illness in a man’s lifetime. In addition, treatment of prostate cancer often results in serious adverse effects in older men (such as incontinence, impotence, radiation proctitis or hip fractures).

For all age groups digital rectal examination is not recommended for prostate cancer screening. Also, there is no evidence that the use of free PSA or PSA density, velocity, or doubling time improves health outcomes and some of these strategies may increase harm.

Other Cancers

The USPSTF recommends against routine screening for pancreatic or ovarian cancer for persons of all ages. There is no evidence that screening for pancreatic cancer (using abdominal palpation, ultrasonography, or serologic markers) or ovarian cancer (using CA-125 or transvaginal ultrasonography) is effective in reducing mortality, and there is potential for significant harm because of the limited accuracy of available screening tests, invasive nature of diagnostic tests, and the poor outcomes of treatment.

The USPSTF concludes that there is insufficient evidence to assess the balance of benefits and harms of screening for lung or skin cancer for persons of all ages. One randomized trial has shown low-dose computed tomography screening can reduce lung cancer mortality in current or former smokers age 55 to 74 years. However, the harms were substantial, including complications from invasive diagnostic procedures, such as bronchoscopy or lung biopsy, which may be greater in older adults. Therefore, lung cancer prevention efforts should still focus on encouraging older smokers to quit. Also, although there is no evidence to support total body skin examinations clinicians should remain alert for skin lesions with malignant features (eg, rapidly changing lesions and those with asymmetry, border irregularity, or color variability).