INTRODUCTION — The profile of aging in the United States has changed dramatically over the last century. The average life expectancy at birth has increased from 47 years in 1900 to nearly 79 years in 2014. By 2030, the percentage of the population over 65 years of age will exceed 20 percent, or over 70 million people [1]. Worldwide, the number of adults over 60 years of age will top two billion by 2050 and will constitute over 20 percent of the world's population [2].
Definitions of health and wellbeing in late life have changed with the increase in life expectancy. Heart disease, cancer, and stroke have become the leading causes of death among older adults, while deaths due to infection have decreased. Adults surviving into late life suffer from high rates of chronic illness; 80 percent have at least one and 50 percent have at least two chronic conditions [1]. There is a strong association between the presence of geriatric syndromes (cognitive impairment, falls, incontinence, vision or hearing impairment, low body mass index [BMI], dizziness) and dependency in activities of daily living [3].
Decline in function and loss of independence are not an inevitable consequence of aging. Given the high prevalence and impact of chronic health problems among older patients, evidence-based interventions to address these problems become increasingly important to maximize both the quantity and quality of life for older adults.
This topic offers a brief discussion of office-based assessments to identify and address common problems that are amenable to prevention or amelioration in older adults. An overview of preventive medicine for the general population is presented separately. (See "Overview of preventive care in adults".)
GOALS OF CARE FOR OLDER ADULTS — Physiologic and functional status vary greatly among older adults. This wide heterogeneity means that treatment decisions, both preventive and therapeutic, should be considered based on individual needs. Age alone should not be the sole determinant for many interventions, and all treatments should aim to preserve function and maximize quality of life.
For decisions related to screening and other preventive interventions, the concept of lag time to benefit is relevant [4]. If a screening intervention, such as screening for colorectal cancer with fecal occult blood testing, has a lag time of 10 years for a risk reduction of one death per 1000 persons screened, and an individual has a predicted life expectancy of five years, then such screening would not be likely to provide benefit for that individual. Studies suggest that many older patients in the United States, and women in particular, are over-screened for certain conditions and under-screened or undertreated (eg, immunizations and counseling) for others [5,6].
A proposed framework for primary care for older individuals that defines short-term, mid-range, and long-term goals may help providers more appropriately and effectively prioritize issues in this population [7].
Short-term issues: Focus on immediate needs to maintain or restore current health status; may be the sole focus for patients at the end of life.
●Symptom management
●Care coordination
●Personal safety
●Evaluate the living situation
Mid-range issues: Address needs over the subsequent one to five years.
●Preventive care
●Disease management
●Psychological issues
●Coping strategies
Long-term issues: For older adults who are currently healthy and high-functioning.
●Plans to be implemented at the time of eventual decline
Approximations of life expectancy based on health and function can help providers, patients, and caregivers in prioritizing issues and making decisions. Evidence-based tools available online at eprognosis.ucsf.edu can help generate estimates of survival for older adults with different conditions and in different settings.
Providers are encouraged to consider the individual patient’s health status, preferences, and priorities in management of the issues discussed below. This review serves as a guide for discussions and decisions regarding use of preventive services among older adults, and also provides descriptions and tools useful in performing the assessments contained in the Medicare Initial Preventive Physical Examination (IPPE). (See 'Medicare and preventive visits' below.)
OVERVIEW OF PREVENTION FOR OLDER ADULTS — A comprehensive summary of recommendations for screening and prevention for specific conditions is presented in a table (table 1).
Healthy lifestyle — Encouraging older adults to adopt a healthy lifestyle may lower their risk of developing disability. In one cohort of individuals aged 65 and older who were without disability at baseline and followed for 12 years, the risk of developing moderate to severe disability was greater for individuals who had only low or intermediate levels of physical activity (hazard ratio [HR] 1.72, 95% CI 1.48-2.00), ate less than one serving of fruit or vegetable daily (1.24, CI 1.10-1.41), or were current or recent smokers (HR 1.26, CI 1.05-1.50) [8].
Physical activity — Exercise benefits people of all ages and may decrease all-cause morbidity and increase lifespan [9,10].
All older adults, including the very old, those with multiple morbidities, or those who are in chronic care facilities, can benefit from physical activity. Participation in any amount of physical activity will result in some health benefit. Specific benefits among older adults include reduction in falls and fall-related injuries, and maintenance of physical function [11]. A description of the benefits of exercise and a full discussion of exercise recommendations for older adults are presented separately. (See "The benefits and risks of aerobic exercise" and "Physical activity and exercise in older adults".)
The American Heart Association (AHA) and the American College of Sport Medicine (ACSM) provide recommendations for adults over age 65 years for various types of activity and guides for implementing such programs [12]. Specific exercises fall into four categories: aerobic, muscle strengthening, flexibility, and balance.
●For aerobic activity, guidelines suggest a minimum of 30 minutes of moderate-intensity exercise on five days each week, or a minimum of 20 minutes of vigorous-intensity activity on three days each week, or some combination of the two [12]. Definitions for moderate and vigorous activity depend on the person's baseline conditioning.
●Exercises to maintain and increase muscle strength include weight training, weightbearing calisthenics, or resistance training.
●Evidence supporting flexibility activities is less rigorous, but most experts recommend 10 minutes of some static stretching of major muscle groups on days when aerobic or muscle strengthening exercise is performed, to maintain range of motion.
●Balance training exercises are recommended to improve stability and prevent falls and injuries related to falls. Static balance training involves learning to recover balance on a tilting balance platform. Dynamic balance training that does not require special equipment, such as Tai Chi, may be more readily available outside of a formal supervised setting [13-15].
The AHA/ACSM guidelines emphasize a graduated or stepwise introduction of physical activity to improve safety and adherence. An individualized "activity plan" should recommend levels of physical activity and define how the individual will meet them. Developing an activity plan, particularly for older adults with chronic conditions, may warrant input from physical therapists/exercise physiologists or referral to specialty programs (eg, cardiac or pulmonary rehabilitation). Routine electrocardiogram (EKG) or cardiac exercise testing are not indicated for asymptomatic patients who are preparing to undergo an exercise program. The Medicare Initial Preventive Physical Examination (IPPE), however, does provide coverage for an initial 12-lead EKG and its interpretation as part of the introductory visit. (See 'Medicare and preventive visits' below and "Physical activity and exercise in older adults", section on 'Benefits of physical activity in older adults' and "Screening for coronary heart disease".)
Tobacco use — Older adults should be questioned about smoking and counseled on how to quit smoking if they currently smoke. Rates of smoking and tobacco use are lower for adults over age 65 than for younger individuals [16]. Nonetheless, the older generation has a long history of high rates of smoking and excess smoking-related mortality from lung cancer, cardiovascular disease, and chronic obstructive pulmonary disease [17].
High-quality evidence demonstrates that smoking cessation significantly reduces the risk for coronary heart disease, various cancers, and chronic obstructive pulmonary disease [18]. One study addressed smoking cessation in older community-dwelling adults and found that, within five years of stopping smoking, the relative risk for all-cause mortality fell below that for current smokers [19]. A meta-analysis found that the mortality benefits of smoking cessation were demonstrable at all ages, including in subjects age 80 years and older [20]. (See "Benefits and consequences of smoking cessation", section on 'All-cause mortality'.)
Ongoing regular counseling for smoking cessation for all patients who use tobacco products is recommended by the US Preventive Services Task Force (USPSTF). (See "Behavioral approaches to smoking cessation".)
Nicotine replacement therapy, although not specifically studied in older individuals, has been shown to be effective as an adjunct for selected patients [21]. Other options, including bupropion and varenicline, may also be reasonable choices for older patients [22]. (See "Pharmacotherapy for smoking cessation in adults" and "Overview of smoking cessation management in adults".)
Alcohol — The American Geriatrics Society guidelines suggest specific questioning regarding the frequency and quantity of alcohol use, followed by asking the CAGE questions (Cut down, Annoyed, Guilty, Eye-opener) to identify patients with alcohol-related problems [23]. (See "Screening for unhealthy use of alcohol and other drugs in primary care", section on 'CAGE questions'.)
Nearly 50 percent of adults over age 65 years consume alcohol. Among these, 14.5 percent drink more than the recommended weekly allowance (>7 drinks per week) or drink in binges. When accounting for concurrent medical problems, a survey classified 53 percent of older drinkers as having harmful or hazardous patterns of alcohol consumption [24]. Alcohol use in older adults is associated with increased risk of falls and may negatively impact function and cognition, as well as general health [25].
Risk factors for alcohol abuse among older adults include bereavement, depression, anxiety, pain, disability, and a prior history of alcohol use. A variety of screening tools are effective for identifying alcohol misuse in older patients [25]. (See "Screening for unhealthy use of alcohol and other drugs in primary care", section on 'Older adults'.)
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has developed an excellent clinician tool for helping patients who consume alcohol to excess [26]. Clinician recommendations and advice may be as effective as more detailed behavioral counseling programs at reducing alcohol use [25].
Limited role for aspirin in primary prevention — Although aspirin may have the potential to decrease the risk of incident cardiovascular disease and cancer in some patient populations, it also increases the risk of bleeding, particularly among older adults. The 2022 USPSTF statement recommends against initiating low-dose aspirin for primary prevention in adults 60 years or older [27]. For older adults already taking aspirin and who have no history of cardiovascular events, clinicians and patients should consider stopping it, particularly in those over age 75. This is discussed in detail separately. (See "Aspirin in the primary prevention of cardiovascular disease and cancer".)
Proton pump inhibitor (PPI) use may reduce gastrointestinal bleeding in higher-risk patients [28]. Guidelines from the American College of Cardiology/American College of Gastroenterology/AHA suggest that all patients who are over 60 years of age and who have one additional risk factor (corticosteroid use, dyspepsia, or gastroesophageal reflux disease [GERD] symptoms) should use a PPI if they are maintained on chronic aspirin therapy [29]. (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity".)
Immunizations — A summary of recommended immunizations for adults from the US Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) is shown in a Table (figure 1 and figure 2).
COVID-19 — Vaccines to prevent SARS-CoV-2 infection are highly effective in preventing serious illness and death. Older adults are at increased risk of morbidity and mortality, and we encourage all older adults to receive vaccination, as recommended by the CDC [30]. The epidemiology and clinical characteristics of coronavirus disease 2019 (COVID-19), including the impact of older age, are discussed elsewhere. (See "COVID-19: Clinical features".)
Detailed information on the available vaccines is presented in a separate topic review. (See "COVID-19: Vaccines".)
Tetanus or pertussis with tetanus vaccine — Clinical tetanus, though rare in the United States, occurs predominantly in unvaccinated or under-immunized older adults. Patients older than 60 years account for approximately 60 percent of all cases of tetanus in the United States [31].
The ACIP recommends booster doses of adult-type tetanus and diphtheria toxoid (Td or Tdap) every 10 years.
Vaccination against pertussis is important for adults who have close contact with infants aged younger than one year (such as grandparents, child care providers, and health care providers) [32]. The only available adult vaccine against pertussis is the Tdap vaccine. Tdap should be administered regardless of the interval since the last dose of Td.
Studies of the Td vaccine have demonstrated the efficacy and cost-effectiveness of a single booster in producing sustained immunity to both tetanus and diphtheria among older patients (aged 50 to 70) who had received a primary booster series [33-35]. The ACIP still recommends a booster every 10 years, while the American College of Physicians (ACP) and the ACOVE authors support a single Td booster in later life (age >50 years) in patients who have completed the primary series and have not had a booster within the last 10 years. (See "Tetanus-diphtheria toxoid vaccination in adults".)
Influenza vaccine — More than 90 percent of influenza-related deaths occur among people age 60 and over [36]. Older adults also experience significantly increased morbidity from the disease.
Annual influenza immunization for all adults is recommended by the CDC [37]. Efficacy, choice of vaccine formulation, and adverse effects are discussed in detail separately. (See "Seasonal influenza vaccination in adults", section on 'Choice of vaccine formulation' and "Seasonal influenza vaccination in adults".)
Pneumococcal vaccine — Pneumococcal disease is a significant cause of morbidity and mortality in older adults. Both the incidence of pneumococcal disease and the mortality rate increase after age 50 and more sharply after age 65 [38].
UpToDate recommendations for pneumococcal vaccination in immunocompetent older adults are provided separately. (See "Pneumococcal vaccination in adults" and "Pneumococcal vaccination in adults", section on 'Approach to healthy older adults and those with predisposing medical conditions'.)
Herpes zoster vaccine — Vaccinations to prevent herpes zoster are recommended for most older adults and are now updated to include a the more effective recombinant, adjuvanted vaccine. Specifics of vaccine formulations for herpes zoster, including indications, contraindications, and administration, are described in detail separately. (See "Vaccination for the prevention of shingles (herpes zoster)".)
Herpes zoster or shingles, due to reactivation of latent varicella zoster virus, causes a painful localized rash. Sequelae, including postherpetic neuralgia, encephalitis, myelitis, and palsies of cranial and peripheral nerves, are more common in older patients. Herpes zoster affects about 30 percent of individuals over their lifetime, with a substantial increase in risk (8- to 10-fold) in late life [39]. Vaccine to prevent herpes zoster should not be used for the treatment of zoster or postherpetic neuralgia.
Cancer screening — Screening asymptomatic older adults for selected cancers has the potential to allow more effective treatment through early detection. However, both screening tests and disease treatment have been less rigorously evaluated in older adults, leading to more uncertainty about the benefit of screening among older patients compared with younger individuals [40,41]. Additionally, comorbid illness and frailty alter the risk-benefit ratio for screening in this group [42]. A modeling study estimated harms and benefits in individuals with varying degrees of comorbidities related to regular screening starting at age 50 with mammography, prostate-specific antigen testing, and fecal immunochemical testing [43]. The harms and benefits of screening for individuals age 76 with no comorbid conditions were equivalent to those age 74 with mild comorbidity, age 72 with moderate comorbidity, and age 66 with severe comorbidity.
The decision to offer cancer screening to the older patient presents a clinical challenge. Clinicians should assess the benefits and risks of screening for older adults on an individual basis, considering the patient's estimated remaining life expectancy, and help patients make decisions based on personal values and preferences [4,40,44,45].
Primary care providers and patients report uncertainty and discomfort with the idea of discussing stopping cancer screening, particularly mammography. Provider scripts and strategies about stopping cancer screening in patients over 75 have been developed, with the goal of increasing provider ability to engage patients in an informed shared-decision-making process [46]. These scripts provide specific language to concisely and clearly explain key issues including: guideline-based recommendations for stopping screening, the delay in benefit of up to 10 years, the problems of false positives and overdiagnosis, and how to engage patients in discussions ahead of screening about the risks and benefits of possible cancer treatments.
Prostate cancer screening — The USPSTF updated its recommendations in 2018 [47] to recommend individual discussion of the risks and benefits of prostate cancer screening and suggest that men between the ages of 50 to 69 years are most likely to benefit from screening. The decision to screen for prostate cancer should be based on individual discussions, involving patient preference for specific health outcomes and risks and benefits of screening. Black men, those known or likely to carry BRCA1 or BRCA2 genetic mutations, and those with a positive family history of prostate cancer should be informed of their higher lifetime risk. When a decision is made to screen, UpToDate suggests that screening stop when the patient’s life expectancy is less than 10 years, or if the patient decides against further screening. (See "Screening for prostate cancer".)
Colorectal cancer screening — Screening for colorectal cancer (CRC) can reduce cancer-specific mortality. Available CRC screening tests, their effectiveness and safety, and the frequency of testing recommended for adults who are at average risk for CRC are described in detail elsewhere. (See "Screening for colorectal cancer: Strategies in patients at average risk" and "Tests for screening for colorectal cancer".)
Breast cancer screening — Decisions about screening for breast cancer, especially in older women, should involve discussion of patient values and preferences and the potential benefits and harms of screening. Data from randomized trials of screening mammography demonstrated an approximate 19 to 30 percent reduction in breast cancer mortality among screened versus unscreened women, but these data do not reflect the improvement in outcome with current breast cancer treatment, and enrolled women only up to age 74 [48-50]. Data from modelling studies of screening in older women suggest a mortality benefit for screening when the life expectancy is 10 years or more [51]. A decision aid describing the risks and benefits of mammography screening for women aged 75 and older is available to help these women with decision-making around mammography screening [52]. (See "Screening for breast cancer: Strategies and recommendations".)
For women at average risk who opt to undergo mammography screening for breast cancer, screening biennially will detect nearly as many cancers as annual screening and reduces the risk of false-positive readings [53].
The American Geriatrics Society has identified breast cancer screening as one of its targets for the "Choosing Wisely" campaign and recommends that breast cancer screening should not be undertaken in women with a life expectancy less than 10 years [54]. Screening in women with shorter life expectancy would expose them to potential immediate harm with little chance of benefit.
Cervical cancer screening — Cervical cancer is no more aggressive in older women than younger women, and high-grade lesions are rare among older women who have been previously screened. Nonetheless, a substantial number of cervical cancers occur in older women, many of whom have had inadequate screening [55-59]. In the United States, Medicare began providing reimbursement for Pap smear screening in 1990, motivated by findings that up to 40 percent of older adult women had never had a Pap smear [60-63].
Most major guidelines recommend stopping cervical cancer screening at age 65 for women who have had adequate recent screening and are not at increased risk for cervical cancer. Adequate screening is defined as:
●Two consecutive negative primary human papillomavirus (HPV) tests within the past 10 years, with the most recent test within the previous five years; or
●Two consecutive negative co-tests (Pap and HPV testing) within the past 10 years, with the most recent test within the previous five years; or
●Three consecutive negative Pap tests within the past 10 years, with the most recent test within the previous three years
However, women who have a new sexual partner or are current or previous smokers generally should continue to be screened if their life expectancy is >10 years. Women who have had a total hysterectomy with removal of the cervix for indications unrelated to cervical cancer should not undergo screening for cervical cancer. (See "Screening for cervical cancer in resource-rich settings", section on 'Age >65 years' and "Screening for cervical cancer in resource-rich settings", section on 'Prior benign hysterectomy'.)
Lung cancer screening — Annual screening by low-dose chest CT scan has been found to reduce mortality in high-risk populations [64]. Considering these findings, the 2021 USPSTF recommendations call for annual low-dose chest CT scan screening for high-risk individuals ages 50 to 80 years. Persons at increased risk are defined as those with at least a 20 pack-year smoking history, and either current smokers or former smokers having quit within the past 15 years. Screening is to be discontinued when a person has not smoked for 15 years or if life expectancy is limited. Multiple other organizations also support lung cancer screening for high-risk older adults (table 2). (See "Screening for lung cancer".)
Cardiovascular screening
Blood pressure screening — Hypertension is highly prevalent among older adults (60 to 80 percent) and remains the leading risk factor for ischemic heart disease and stroke [65]. In this age group, the USPSTF recommends measuring blood pressure annually to screen for hypertension [66]. More frequent measurement may be indicated, depending on the patient's risk factors. This is described separately. (See "Overview of hypertension in adults", section on 'Detection'.)
While blood pressure lowering in hypertensive patients is associated with decreased mortality in many instances, aggressive treatment of hypertension in older adults may have adverse effects. Goal blood pressure and management of hypertension in the older adults are discussed elsewhere. (See "Goal blood pressure in adults with hypertension" and "Treatment of hypertension in older adults, particularly isolated systolic hypertension".)
Lipid screening — The risk of CHD attributable to lipids is similar across age ranges [67]. Older adults have a higher overall annual risk of CHD and stand to benefit from lipid reduction if life expectancy warrants [68]. As such, there is no particular age above which initial screening for lipid abnormalities should not be performed. However, in patients who have had more than one prior normal lipid profile, we suggest stopping screening at age 65. (See "Screening for lipid disorders in adults", section on 'Stopping screening' and "Low-density lipoprotein cholesterol-lowering therapy in the primary prevention of cardiovascular disease" and "Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease".)
The USPSTF has found good evidence that lipid measurement can identify asymptomatic people at increased risk of CHD, and good evidence that lipid-lowering drug therapy decreases the incidence of CHD in people with abnormal lipids and causes few major harms [21]. The USPSTF concludes that the benefits of screening for and treating lipid disorders in older people outweigh harms, but notes that data are limited regarding primary prevention of CHD in older populations. There are no prospective randomized trials of lipid therapy that have included persons 80 years or older at baseline enrollment [69].
Lipid-lowering therapy clearly benefits older adults at high risk of coronary events. The benefit of primary prevention for low-risk older adults remains unclear. For those with an overall risk of CHD exceeding 10 percent over 10 years, screening and treatment appear to be substantiated [67]. However, the decision to initiate lipid-lowering therapy in older adults, and particularly those 80 years and older, should be individualized based on comorbidities and recognition of problems that may arise from polypharmacy in this population. (See "Screening for lipid disorders in adults" and "Drug prescribing for older adults", section on 'Polypharmacy'.)
Abdominal aortic aneurysm — Screening for abdominal aortic aneurysm (AAA) with a one-time abdominal ultrasound examination has been shown to decrease aneurysm-related deaths and all-cause mortality in men [70,71]. Because the prevalence of AAA is lower in women, screening has not been shown to be effective in women [72].
We, along with the USPSTF and the AHA, recommend one-time screening for AAA with abdominal ultrasonography in men ages 65 to 75 who have ever smoked. We also suggest one-time screening with abdominal ultrasonography in men ages 65 to 75 who have a first-degree relative who required AAA repair or died from AAA rupture. We offer screening to women who have a strong family history of either AAA repair or death due to AAA rupture, basing the decision to screen upon their values and preferences. Screening is discussed in more detail separately. (See "Screening for abdominal aortic aneurysm".)
Aneurysmal repair should be considered for asymptomatic aneurysms that are more than twice the size of the normal segment and for aneurysms with enlarging diameter at follow-up. (See "Management of asymptomatic abdominal aortic aneurysm".)
Screening for diabetes — The USPSTF revised its recommendations regarding screening for diabetes mellitus in 2015. Consistent with these recommendations, we suggest screening for diabetes as part of cardiovascular risk assessment in adults aged 40 to 70 years with body mass index (BMI) ≥25 kg/m2 [73]. We also suggest screening individuals with hypertension or hyperlipidemia. Screening may be performed by measuring a fasting plasma glucose or, when obtaining a fasting specimen is inconvenient, ordering an A1C (glycated hemoglobin). Abnormal results require a repeat test to confirm the diagnosis of diabetes. (See "Screening for type 2 diabetes mellitus".)
No specific evidence exists to support screening for diabetes in those over age 70. Decisions should be based on individual risks and life expectancy, as well as accounting for the potential harms of screening such as overtreatment.
Functional and psychosocial evaluation
Functional assessment and geriatric evaluation — Impairment in activities of daily living is associated with an increased risk of falls, depression, institutionalization, and death in the affected older adult [74,75]. Obtaining a history of functional status, with particular attention to activities of daily living (eg, bathing, toileting, grooming, meal preparation) allows the clinician to focus on potential problem areas. Asking questions targeted at specific conditions that impact function and quality of life may well reduce the morbidity related to these problems (table 3). In addition, measurement of gait speed identifies older adults at high risk of functional decline and poor health [76]. A gait speed faster than 1 meter/second suggests better-than-average life expectancy. (See "Office-based assessment of the older adult", section on 'Functional assessment'.)
Comprehensive Geriatric Assessment (CGA) can provide a more formal means of identifying key problems and can inform interventions that result in reduced functional decline and improved quality of life [77,78]. However, CGA can be impractical and time-consuming in the primary care setting. (See "Comprehensive geriatric assessment".)
Cognitive assessment — We suggest that clinicians perform cognitive testing in patients with memory complaints, either self-expressed, or noted by a caregiver or clinician. This is in general agreement with statements from several medical organizations [79-81]. In addition, the National Institute on Aging recommends screening all patients over 80 years old [80] and advocates for the use of structured instruments [82] or algorithms [83] to assist in determining who should be screened. However, we recommend not screening asymptomatic patients, in agreement with the Canadian Task Force on Preventive Health Care [79]. The USPSTF has concluded that there is insufficient evidence to broadly recommend cognitive screening in the general geriatric population [84].
Cognitive testing may allow detection of early or mild dementia when symptoms can be subtle. Detection of early cognitive impairment can be beneficial as it allows for increased awareness of patient safety and behavioral issues and provides an opportunity to implement pharmacologic interventions. In addition, an early diagnosis allows families and loved ones to prepare for caregiving needs and to implement financial and legal planning. Finally, it can facilitate more informed decision-making to optimize quality of life [85].
A number of instruments, including the Mini Mental Status Examination (MMSE), Clock Drawing Test, Mini-Cog, Memory Impairment Screen, Saint Louis University Mental Status (SLUMS) Examination, and Montreal Cognitive Assessment (MOCA) are validated screening tools [85,86]. Validated instruments also exist for collecting data from a relative or caregiver of a patient with cognitive decline [87]. A detailed discussion of mental status scales is provided elsewhere. (See "Mental status scales to evaluate cognition".)
Depression — Late-life depression often goes undetected and has a significant adverse impact on quality of life, outcomes of medical disease, health care utilization, morbidity, and mortality [88]. Suicide rates are almost twice as high in the older adult compared with the general population, with the rate highest for White men over 85 years of age. We suggest screening for depression when staff-assisted depression care supports are in place to ensure appropriate diagnosis, treatment, and follow-up. (See "Diagnosis and management of late-life unipolar depression".)
The majority of older adults with depression initially present to primary care, often with somatic complaints. Among older adults, depression can present atypically with cognitive, functional, or sleep problems, as well as complaints of fatigue or low energy [88,89].
Several short screening instruments have been developed and validated for screening for depression in older adults. (See "Diagnosis and management of late-life unipolar depression", section on 'Screening instruments'.)
The USPSTF recommends screening all adults for depression, although the optimal screening interval is unknown [90,91]. They also emphasize the importance of having systems in place to provide screening results to the clinician, a readily accessible means of making an accurate diagnosis, and a mechanism for providing treatment and careful follow-up.
Osteoporosis — The prevalence of low bone mineral density (BMD) in older adults is high. Osteopenia is found in 37 percent of postmenopausal women, and osteoporosis (bone mineral density or BMD >2.5 SD below the mean for young women) in 7 percent [92]. We suggest BMD assessment for all women 65 years of age and older and men who have either manifestations of low bone mass (low trauma fractures or loss of height) or risks for fracture (eg, glucocorticoid therapy, androgen deprivation therapy, hyperthyroidism, low body weight, hypogonadism, previous fragility fracture). UpToDate authors prefer screening by dual-energy radiographic absorptiometry (DXA) of hip and spine, though hip alone could be sufficient in older individuals. (See "Screening for osteoporosis in postmenopausal women and men".)
UpToDate suggests follow-up DXA as follows:
●In adults with low bone mass (T-score -2.00 to -2.49) at any site or who have risk factors for ongoing bone loss (eg, glucocorticoid use, hyperparathyroidism), follow-up measurements approximately every two years, as long as the risk factor persists.
●In women 65 years of age and older at baseline screening, with low bone mass (T-score -1.50 to -1.99) at any site, and with no risk factors for accelerated bone loss, follow-up DXA in three to five years.
●In women 65 years of age and older with normal or slightly low bone mass (T-score -1.01 to -1.49) at baseline measurement and no risk factors for accelerated bone loss, follow-up DXA in 10 to 15 years [93,94].
The USPSTF recommends that women aged 65 and older be screened routinely for osteoporosis using bone densitometry [95]. The USPSTF also recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures, including those with low body weight. Varying recommendations for screening from several expert groups are presented in a Table (table 4). (See "Screening for osteoporosis in postmenopausal women and men".)
Vision screening — Low vision is reported by 15 percent of adults over 75 and is associated with significant declines in health, function, and quality of life. It has also been linked to increased risk of falls, decline in cognition, and increased rates of depression. The USPSTF reviewed the role of screening for vision loss among older adults and found that the evidence was inconclusive to support routine vision screening [96]. Evidence was inconclusive that early detection of visual impairment improved visual outcomes, functional status, or quality of life. Based on this review, there is no clear indication to perform regularly scheduled screenings among otherwise asymptomatic, average-risk older adults. However, we do advise that a vision assessment be included as part of the routine workup for older adults with recent cognitive decline, functional impairment, or falls. (See "Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis", section on 'Screening'.)
Hearing loss — Hearing loss is the third most common ailment, after hypertension and arthritis, to afflict older adults, and is associated with depression, social isolation, poor self-esteem, increased hospitalization rates, cognitive decline, and functional disability [97-100].
In 2021, the USPSTF concluded that there was insufficient evidence to determine the balance of benefits and harms of screening for hearing loss in asymptomatic older adults aged 50 years or older [101]. Despite the insufficient evidence, we suggest that primary providers screen adults over 65 for hearing loss, and in particular, vulnerable older adults at risk for functional decline, hospitalization, or cognitive problems [98].
Patient inquiry is a rapid and inexpensive way to screen for hearing loss. While pure tone audiometry is the reference standard for screening hearing, a whispered voice test is both sensitive and specific [102]. An evidence review to support a recommendation from the USPSTF found that either the whispered voice test at two feet or a single question regarding perceived hearing loss were nearly as effective as a formal hearing questionnaire or use of a tone-emitting otoscope for the detection of hearing loss [103]. (See "Evaluation of hearing loss in adults", section on 'Office hearing evaluation' and "Presbycusis".)
Nutrition — Many major authorities on health care maintenance, including the Canadian Task Force, the ACP [104], and the American Academy of Family Physicians (AAFP), recommend that clinicians routinely provide nutritional assessment and counseling to their patients.
Approximately 15 percent of older outpatients and half of the hospitalized older adults are malnourished [105]. Despite the clear relationship between undernutrition and increased morbidity and mortality [106], there are no well-validated general laboratory screens for this condition. A combination of serial weight measurements obtained in the office and inquiry about changing appetite are likely the most useful methods of assessing nutritional status in older patients. In addition, a mini-nutritional assessment tool has been developed to help the clinician determine patients who may need nutritional support and counseling (figure 3).
Vulnerable older adults with an involuntary weight loss of 10 percent or more in less than a year should undergo further evaluation for undernutrition, possible medical or medication-related causes, dental status, food security, food-related functional status, appetite and intake, swallow ability, and previous dietary restrictions [107]. (See "Geriatric nutrition: Nutritional issues in older adults".)
Vitamin D — A growing evidence base has identified the high prevalence of vitamin D deficiency (<30 ng/mL) among older adults and important health implications [108]. The role of vitamin D in falls prevention is uncertain, although most experts advise that the daily intake of vitamin D in older adults should be at least 800 international units. However, evidence suggests that high dose intermittent vitamin D (24,000 international units or greater) may increase fall risk [109]. At least 1.2 g of elemental calcium in the diet or as a supplement is also recommended. (See "Calcium and vitamin D supplementation in osteoporosis" and "Falls: Prevention in community-dwelling older persons".)
It appears that vitamin D plus calcium may reduce the risk of hip fracture in older adults. Although the large Women's Health Initiative found that calcium and vitamin D was not effective in reducing fractures in healthy postmenopausal women over a seven-year follow-up [110], two meta-analyses have found that vitamin D and calcium decreased the relative risk of fractures [111,112].
However, in a three-year European trial among 2157 healthy adults aged 70 years or older (DO-HEALTH), treatment with 2000 international units per day of vitamin D3, 1 g per day of EPA/DHA omega-3 fatty acids, or a strength-training exercise program, either alone or in combination, did not improve health outcomes of systolic or diastolic blood pressure, nonvertebral fractures, physical performance, infection rates, or cognitive function [113].
Multivitamins — No prospective randomized data supports an effect of multivitamins on morbidity or mortality. Multivitamin supplementation has the potential to provide benefit for those older individuals whose nutritional intake is insufficient. However, observational studies have suggested that multivitamin supplements do not decrease the risk for cancer or cardiovascular disease, and one large cohort study suggested the possibility of increased mortality in healthy older women who reported taking vitamin supplements [114]. (See "Vitamin intake and disease prevention".)
Falls and mobility — Providers should regularly ask older patients about recent falls and fall risks, because of the high incidence and potential sequelae of falls, including fracture or hospitalization. Methods and specific in-office tests to assess fall risks are described in detail separately. (See "Falls in older persons: Risk factors and patient evaluation", section on 'Evaluation for patients with increased fall risk'.)
For patients who fall or have problems in physical functioning or limited mobility that increase their risk for falls, clinicians should assess for contributory factors, review medications, and ask about home safety. (See "Falls in older persons: Risk factors and patient evaluation".)
Effective interventions for people with a history of falls or risks for falling, including physical therapy, assistive devices, and a supervised exercise program, are discussed in detail separately. (See "Falls: Prevention in community-dwelling older persons".)
Incontinence — Urinary incontinence (UI) causes major social and emotional distress in older adults and is a major factor in nursing home placement. UI is estimated to affect 11 to 34 percent of older men and 17 to 55 percent of older women [115]. Diabetes approximately doubles the risk for severe incontinence in women [116]. Continence problems are potentially treatable [117] but are often not raised by patients as a concern [118].
A targeted history and physical examination can often identify the cause of UI and lead to appropriate intervention. We ask about and document the presence or absence of UI biannually, and determining whether the UI, if present, is bothersome to the patient or caregiver. Appropriate assessment includes questions to determine UI onset (acute versus chronic), type (eg, stress, urge, overflow, mixed), and precipitants (eg, cough, medication use). A targeted physical might include assessment for fluid overload, genital and rectal examination, and neurologic evaluation. Urine and blood tests are indicated to evaluate for infection, metabolic causes, renal dysfunction, and possible vitamin B12 deficiency. Routine urodynamic testing is not recommended. (See "Female urinary incontinence: Evaluation" and "Female urinary incontinence: Treatment" and "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment".)
MEDICATION USE — Problems related to medication use are common in older adults. Adults over age 65 in the United States take an average of three to five medications [119]. Use of multiple medications increases the risk for drug-drug interactions and associated adverse drug events. Altered pharmacokinetics and pharmacodynamics in older adults contribute to adverse drug events, a common cause of hospitalization and morbidity in older patients [120]. (See "Drug prescribing for older adults".)
Evidence-based recommendations on medication management include (table 5) [121]:
●Maintain an up-to-date medication list, including over-the-counters and herbals.
●Comprehensively review medications at least once annually (if not at every visit) and after all hospitalizations. A clear indication for each medication, and documentation of response to therapy (particularly for chronic conditions), should be included.
●Assess for duplication, drug-drug or drug-disease interactions, adherence, and affordability.
●Assess for specific classes of medications commonly associated with adverse events: anticoagulants, analgesics (particularly narcotics and nonsteroidal antiinflammatory drugs [NSAIDs]), antihypertensives (particularly angiotensin-converting enzyme [ACE] inhibitors and diuretics), insulin and hypoglycemic agents, and any psychotropics.
●Minimize or avoid use of anticholinergic medications which present specific risks.
The Beer's Criteria for Potentially Inappropriate Medication Use in Older Adults, updated in 2019, also provides a list of commonly encountered problem medications [122]. (See "Drug prescribing for older adults".)
An approach to deprescribing is discussed in detail elsewhere. (See "Deprescribing".)
HOME SAFETY ASSESSMENT — In 2012 to 2013, over 90,000 older adults in the United States died as a result of unintentional injury [123]. Over one-half these were due to falls and another 14 percent due to motor vehicle accidents. Additional causes included poisoning, fire, and suffocation. Common physical and cognitive problems predispose older adults to higher rates of accidents in the home. After an accident, older adults are less likely to get prompt assistance or needed medical help because of their increased risk of isolation and problems with communication.
Evidence is not robust on how to best reduce risk of injury. Home safety intervention trials have largely focused on fall prevention and have had mixed results, likely due to the multifactorial and personalized nature of assessments and interventions [124]. (See "Falls: Prevention in community-dwelling older persons".)
Nonetheless, several brief self-administered checklists may be provided to patients and families or other household members to help in raising awareness and meeting the Medicare Annual Wellness Visit (AWV) requirement for safety evaluation (A Home Fall Prevention Checklist for Older Adults and Home Safety Tips for Older Adults).
DRIVING — Adults over age 70 suffer more motor vehicle accidents and more fatal driver and pedestrian accidents per one million miles driven than middle-aged drivers. This is likely a result of factors such as a decline in visual acuity, hearing, and psychomotor skills [125]. The American Medical Association (AMA) offers a specific online publication to guide assessment of the older driver [126]. (See "Approach to the evaluation of older drivers".)
Clinicians should discuss driving with all patients diagnosed with dementia, and either recommend stopping driving or refer for formal driving assessment by occupational therapy. A diagnosis of dementia independently increases the risk of a motor vehicle accident (odds ratio [OR] 2.4 to 4.7) [127]. Specific reporting laws vary by state. The American Academy of Neurology has issued guidelines for driving in patients with Alzheimer disease based upon the clinical dementia rating [128]. (See "Management of the patient with dementia".)
FINANCIAL AND SOCIAL SUPPORT — Providers should screen for problems with financial and social resources, as these issues have direct implications for health status and wellbeing. The older adult United States population varies widely in measures of wealth and social support. While the overall rate of poverty among adults over age 65 has declined over the last 50 years, 10 percent of older adults still live at or below the poverty line, with higher rates among Black (18 percent) and Hispanic (17 percent) older adults [129].
Older adults also suffer from social isolation, due to functional limitations, and a lack of relatives, friends, or organizations to provide physical or emotional support needed to maintain independence and wellbeing. Social isolation and poverty are associated with high rates of depression, anxiety, disability, and self-rated poor health [130]. A 2020 report from the National Academy of Sciences documented the substantial health risks of social isolation, including heart disease, dementia, and death, and provided guidance on interventions [131].
Most communities have assistance available through Area Agencies on Aging or other municipal organizations. Information can be gathered online at the Eldercare Locator.
ELDER MISTREATMENT — Elder mistreatment has been reported in 3 to 8 percent of the older adult population in the United States [132]. A variety of forms of neglect or physical abuse (physical, sexual, psychological, financial, neglect) can result in adverse health outcomes for older victims, including increased mortality [133]. (See "Elder abuse, self-neglect, and related phenomena".)
Victims themselves are unlikely to report instances of abuse, making it difficult to address issues in the clinical setting. Older adults who are noted to have contusions, burns, bite marks, genital or rectal trauma, pressure ulcers, or a body mass index (BMI) <17.5 without clinical explanation should be asked about mistreatment or referred to social work services [25]. Available screening tools may also help clinicians discriminate cases of abuse or neglect.
The American Medical Association (AMA) and the US Preventive Services Task Force (USPSTF) recommend that clinicians routinely ask older patients direct, specific questions about abuse [90,134], although the USPSTF finds insufficient evidence to recommend for or against the use of screening instruments [90].
ADVANCE DIRECTIVES AND HEALTH CARE PROXY — A discussion of end-of-life care is well-suited to the health maintenance examination when the focus may be less on specific disease and more on prevention and planning. While addressing these issues can be complex and time-consuming, specific CPT codes to bill for discussions of 30 minutes or more focused on advance care planning (ACP) affords providers in the United States an opportunity to address these vital concerns [135]. Older patients may experience periods of altered sensorium or cognitive impairment and become unable to participate in their financial or health care decisions. Powers of attorney, living wills, advanced directives, and guardianship documents become important in these situations. (See "Advance care planning and advance directives".)
A power of attorney designates a surrogate who is authorized to manage a patient's financial affairs. A health care power of attorney designates a representative to make health care choices for the patients. For patients who have not created a health care power of attorney, the spouse or other first-degree relative typically is the default surrogate decision-maker. The patient's preferences are sometimes detailed in a living will or other more detailed advance directive. Examples include out-of-facility Do Not Resuscitate (DNR) order forms, the Physician Orders for Life-Sustaining Treatment (POLST), Medical Orders for Scope of Treatment (MOST), and Medical Orders for Life-Sustaining Treatment (MOLST) forms. These documents may address situations in which the patient has a terminal illness, persistent vegetative state, or progressive neurologic condition and can include explicit directions for care management including withdrawal or withholding specific measures such as artificial nutrition or hydration. If no surrogate is designated and next-of-kin is not available, guardianship may be obtained. Guardianship is a legal proceeding whereby the court appoints a surrogate decision-maker. (See "Ethical issues in palliative care".)
MEDICARE AND PREVENTIVE VISITS — In 2005, the Medicare Modernization Act (MMA) authorized full payment for an Initial Preventive Physical Examination (IPPE), also known as the "Welcome to Medicare Preventive Visit." This examination is for new Medicare beneficiaries and is focused on identifying and mitigating health risks and educating patients about available preventive services. Updated in 2011, a qualifying IPPE requires performance of seven key components, including:
●Medical and surgical history
●Risk factors for depression or other mood disorders
●Functional ability and safety
●Physical exam to include height, weight, body mass index (BMI), blood pressure, visual acuity, and other relevant elements
●End-of-life planning
●Education, counseling, and referral based on issues identified
●Orientation to available preventive services
As a part of its documentation, the visit results in a written plan shared with patients detailing recommendations and referrals.
A brief written guide to the IPPE is available online from the Centers for Medicare & Medicaid (CMS) at The ABCs of the Initial Preventive Physical Examination (IPPE) [136].
The MMA legislation also provides for a follow-up Annual Wellness Visit (AWV) after each 12-month period to continue to monitor and build upon the plan created as part of the IPPE. A brief written guide to the AWV (“The ABCs of the Annual Wellness Visit (AWV)”) is available online from the Centers for Medicare & Medicaid (CMS).
RESOURCES — For a number of years, the US Preventive Services Task Force (USPSTF) has developed and revised specific clinical recommendations regarding health maintenance for all populations in the United States [90].
Over the last decade, several resources have emerged to define priorities for prevention and promotion specifically among older adults. Healthy People 2030 (HP2030) defines specific targets for the older adult population nationwide [137].
Guidelines with regard to interval screening for specific malignancies are available from the USPSTF, the American Cancer Society (ACS) [40,90], and others. ACS recommendations are generally more supportive of cancer screening programs than are those of other groups.
The American Geriatric Society offers an online archive of information related to geriatric screening and health maintenance issues [138].
The Institute for Healthcare Improvement (IHI), in partnership with the John A Hartford Foundation, has launched the Age-Friendly Health Systems initiative with online guides about improving care of older adults by focusing on the “4Ms” (Mobility, Mentation, Medications, What Matters). Resources are available online [139].
Information on legal issues and the older patient is available from the National Academy of Elder Law Attorneys.
PATIENT RESOURCES — The Agency for Healthcare Research and Quality has prepared a booklet for older adults called "The Pocket Guide to Staying Healthy at 50+." There are separate guides for men and women.
Through its Health in Aging Foundation, the American Geriatrics Society has created an informational website for patients and caregivers.
The National Institute on Aging provides free pamphlets, as part of its AgePage series, on other common issues in older adults.
Information for patients about the Medicare Initial Preventive Physical Examination (IPPE) is available on the Medicare website.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Falls".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Preventive health care for older adults (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Goals of care for older adults – The wide heterogeneity in health states among older adults means that treatment decisions, both preventive and therapeutic, should be based on individual needs. Age alone should not be the sole determinant for many interventions, and all treatments should aim to preserve function and maximize quality of life. (See 'Goals of care for older adults' above.)
•A summary of recommendations for specific conditions is presented in a table (table 1). (See 'Overview of prevention for older adults' above.)
●Healthy lifestyle – Healthy lifestyle measures supported by evidence and current guideline recommendations include a) exercise to include aerobic activity 30 minutes daily for at least five days a week, muscle strengthening, and balance training; b) smoking cessation; and c) limiting alcohol intake. (See 'Healthy lifestyle' above.)
●Immunizations – Immunization schedules should include annual influenza vaccination, pneumococcal vaccination, and herpes zoster vaccine after age 50. We encourage vaccination to prevent coronavirus disease 2019 (COVID-19). Older adults who have not received a Tdap (tetanus, diphtheria, acellular pertussis) should receive a one-time Tdap booster after age 65 as well. (See 'Immunizations' above.)
●Cancer screening – Cancer screening decisions should be based on assessment of risk and benefit as well as individual preference and life expectancy. For women who choose to undergo screening after counseling about harms and benefits, biennial screening mammography may be offered for those with at least 10 years of life expectancy. Screening for colorectal cancer (CRC) is indicated beginning at age 45, using one of the several tests effective for CRC screening, with timing of discontinuation of screening based on health status. (See 'Cancer screening' above.)
●Cardiovascular disease screening
•Screening for hypertension is recommended annually. Screening for hyperlipidemia is most strongly recommended for those with known cardiovascular disease, and certain risk factors make screening for abdominal aortic aneurysm and diabetes appropriate. (See 'Cardiovascular screening' above and 'Screening for diabetes' above.)
●Other screening
•Monitor for symptoms and conditions that often impact health, safety, and quality in late life, including cognitive impairment, depression, gait instability and falls, vision and hearing loss, poor nutrition, weight loss, and functional decline. (See 'Hearing loss' above and 'Vision screening' above and 'Functional and psychosocial evaluation' above.)
•Screen for osteoporosis in all women age 65 or older as well as men with risk factors. (See 'Osteoporosis' above.)
●Medication use – Regularly perform medication reconciliation to include assessment of indications, adverse effects, interactions, and cost of prescription and nonprescription medications and supplements. (See 'Medication use' above.)
●Safety and financial security – Inquire about elder abuse, driving safety, and financial security. (See 'Elder mistreatment' above and 'Driving' above and 'Financial and social support' above.)
●Advance care planning – Establish and maintain advance directives, updating goals and preferences for care as health conditions and life circumstances evolve in late life. (See 'Advance directives and health care proxy' above.)
