Screening Issues for the Geriatric Population
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 8–1.Steps to individualize decision making for screening tests. |Favorite Table|Download (.pdf) Table 8–1. Steps to individualize decision making for screening tests.
Estimate the individual’s life expectancy.
Estimate the risk of dying from the condition.
Determine the potential benefit of screening.
Weigh the direct and indirect harms of screening.
Assess the patient’s values and preferences.
Life expectancy quartiles by age. (Reproduced with permission from Walter LC, Covinsky KE: Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750-2756.)
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.