Annals of Long Term Care

American Academy of Family Physicians 2009 Scientific Assembly

October 14-17, 2009; Boston, MA

Screening and Preventive Care in the Elderly

Boston, MA—Aubrey L. Knight, MD, FAAFP, presented a session at the American Academy of Family Physicians (AAFP) meeting on screening and preventive care in the elderly. Challenges for clinicians include the fact that most trials exclude patients over age 75, data from trials are not necessarily applicable to individual patients, and trials do not address how individual characteristics affect the benefit versus harm calculation; therefore, there are factors other than age alone that must be considered. The objectives were to develop a systematic way to think about the benefits and harms of screening tests in older adults, understand the importance of patient preferences in screening decisions, learn how to consider life expectancy when making screening recommendations, and discuss preventive strategies likely to provide improved health and function.

In estimating life expectancy it is possible to estimate if a person is likely to live substantially longer or shorter than the average. The clinician should look at the number/severity of comorbid conditions or functional impairments that would result in life expectancy below average (eg, class III or IV heart failure, chronic obstructive pulmonary disease with home oxygen, dementia with Mini-Mental State Examination < 10, dependence in most activities of daily living), or whether there are no comorbid conditions or functional impairments, which would result in life expectancy above average. As a rule of thumb, a life expectancy of greater than 5 years is required in order for a cancer screening test to result in a survival benefit; for some other tests, the lag time may be days to weeks (hearing, vision, depression, falls risk).

Benefits of screening include identifying a disease before it becomes evident, improved function/prevention of functional decline, and improved quality of life (screening for falls, visual impairment, hypertension). Cancer screening is unlikely to benefit if life expectancy is less than 5 years. Harms of screening include false negative leading to false reassurance, false positive leading to unnecessary and potentially harmful tests, identification and treatment of clinically unimportant disease that would not have progressed to symptoms in the patient’s lifetime, no benefit from early detection with the potential for a diversion of resources, and potential harms intrinsic to the screening test. For example, with the prostate-specific antigen test, 50-80% of men have prostate cancer at autopsy, and only 4% of men die from prostate cancer. Treatment of prostate cancer carries great risk of death, impotence, and urinary/fecal incontinence. Dr. Knight also discussed the harms of colorectal cancer screening such as false-positives and complications (higher in frail elders) (Lieberman DA et al, N Engl J Med, 2000) and cervical cancer screening (Sawaya G et al, Ann Intern Med, 2000).

Clinicians should assess how a patient views potential benefits/harm and integrate values/preferences into decisions. This is different from the public health strategy in which experts weigh benefits/risks and decide what is best for a population. Discuss screening as a choice, not an obligation. Inform patients of the impact, and describe screening as a “double-edged sword.” Psychological harm can occur with the emotional pain of a cancer diagnosis in people whose lives were not extended or with the alarm of false-positive results. However, public health trumps preferences when the screening has public health implications, such as screening for tuberculosis prior to nursing home admission.