Abat wellness in elderly--pims 2020 version 2 -trimmed down
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Wellness assessment in the elderly
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Abat wellness in elderly--pims 2020 version 2 -trimmed down
- 1. • 58 year old successful businessman • (+)Hypertension, controlled by medications • Plays golf 1-2x a month • Healthy eater • Does not smoke • Occasional drinker • Feels sluggish • Not as physically active as he was 20-30 years ago • Feels like “age is catching up on him” I need something more…
- 2. MARC EVANS M. ABAT, MD, FPCP, FPCGM Internal Medicine-Geriatric Medicine Division of Adult Medicine, Department of Medicine, PGH “I wanna be forever young” (Wellness in the Elderly)
- 3. Outline • Concept of Wellness in the Elderly • Approaching Wellness Evaluation in the Elderly • Indicators of Health and Wellness in the Elderly • Multidisciplinary Approach to Good Health and Wellness in the Elderly
- 4. Concept of Wellness in the Elderly
- 5. Aging • accumulation of changes responsible for the sequential alterations that accompany advancing age and the associated progressive increases in the chance of disease and death Harman D, Proc National Academy of Science USA, 1991
- 6. Wellness in the Elderly “The antonym of ILLNESS” “Something much MORE”
- 7. Wellness in the Elderly • a purposeful process of individual growth, integration of experience, and meaningful connection with others, reflecting personally valued goals and strengths, and resulting in being well and living values Nurs Forum. 2012 Jan-Mar; 47(1): 39–51.
- 8. Healthy Aging • The process of developing and maintaining the functional ability that enables well-being in older age WHO. 2015. World report on ageing and health
- 9. Approaching Wellness Evaluation in the Elderly
- 10. Agenda….. Hunzikeret al. BMC Family Practice2011,12:22
- 11. Goal of the Diagnostics Screening Case Finding
- 12. ..difference between screening, i.e., testing large numbers of apparently healthy people to detect unrecognized disease at an earlier stage…… ………and case-finding, i.e., evaluating subgroups of people at increased risk of having a disease to make a diagnosis earlier than would occur by waiting for them to present with symptoms or signs. http://jamanetwork.com/journals/jama/fullarticle/2510889
- 13. The Core • multidimensional, interdisciplinary diagnostic process • develop a coordinated and integrated plan for treatment and long-term follow-up. • emphasizes quality of life and functional status, prognosis, and outcome • employment of interdisciplinary teams and the use of any number of standardized instruments • both a diagnostic and therapeutic process Comprehensive Geriatric Assessment Medical History Physical Functional Behavioral Emotional Environmental Spiritual Social http://journals.sagepub.com/doi/pdf/10.1177/107327480301000603 https://www.uptodate.com/contents/comprehensive-geriatric-assessment https://www.bmj.com/content/343/bmj.d6553
- 14. Guidance on Preventive Services US Preventive Services Task Force (USPSTF) Independent panel of experts in primary care and prevention who systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. These reviews are published as U.S. Preventive Services Task Force recommendations on the Task Force Website and/or in a peer-reviewed journal. https://www.uspreventiveservicestaskforce.org/Page/Name/recommendation s
- 16. Grade A women aged 30 to 65 years, screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (co-testing). 2018 Screening for colorectal cancer starting at age 50 years and continuing until age 75 years. 2016 (being updated) Screening syphilis infection in persons who are at increased risk for infection. 2016 screening for high blood pressure in adults aged 18 years or older 2015 (being updated)
- 17. Grade B Unhealthy Drug Use Screening 2020 Hepatitis C Infection Screening 2020 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked. 2019 assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool; a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. 2019 unhealthy alcohol use in primary care settings, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. 2018
- 18. screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older 2018 screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool 2018 screening for latent tuberculosis infection (LTBI) in populations at increased risk. 2016 screening for depression in the general adult population, 2016 (being updated) biennial screening mammography for women aged 50 to 74 years. 2016
- 19. screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese 2015 screening for chlamydia and gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection 2014 (being updated) screening for hepatitis B virus (HBV) infection in persons at high risk for infection 2014 (being updated) annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years; screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy 2013 (being updated)
- 20. Grade C selectively offer screening for AAA with ultrasonography in men aged 65 to 75 years who have never smoked 2019 men aged 55 to 69 years, the decision to undergo periodic prostate- specific antigen (PSA)-based screening for prostate cancer should be an individual one 2018 screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient's overall health and prior screening history 2016 (being updated)
- 21. Grade D asymptomatic bacteriuria in nonpregnant adults 2019 routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history or ancestry is not associated with potentially harmful BRCA1/2 gene mutations. 2019 screening for pancreatic cancer in asymptomatic adults. 2019 screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and do not have a history of a high-grade precancerous lesion (ie, cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. 2018 screening for cervical cancer in women older than 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer 2018 screening with resting or exercise electrocardiography (ECG) to prevent cardiovascular disease (CVD) events in asymptomatic adults at low risk of CVD events 2018 screening for ovarian cancer in asymptomatic women. 2018 screening for thyroid cancer in asymptomatic adults 2017 against screening for chronic obstructive pulmonary disease (COPD) in asymptomatic adults. 2016 (being updated) against screening for asymptomatic carotid artery stenosis in the general adult population. 2014 (being updated) against screening for testicular cancer in adolescent or adult men 2011
- 22. Grade I Cognitive Impairment in Older Adults 2020 Screening for abuse and neglect in all older or vulnerable adults 2018 screening for atrial fibrillation with electrocardiography (ECG). 2018 (being updated) screening for peripheral artery disease (PAD) and cardiovascular disease (CVD) risk with the ankle-brachial index (ABI) in asymptomatic adults 2018 adding the ankle-brachial index (ABI), high-sensitivity C-reactive protein (hsCRP) level, or coronary artery calcium (CAC) score to traditional risk assessment for cardiovascular disease (CVD) in asymptomatic adults to prevent CVD events. 2018 screening for osteoporosis to prevent osteoporotic fractures in men 2018 screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events 2018 celiac disease in asymptomatic persons. 2017 screening pelvic examinations in asymptomatic women for the early detection and treatment of a range of gynecologic conditions. 2017
- 23. visual skin examination by a clinician to screen for skin cancer in adults. 2016 screening for impaired visual acuity in older adults. 2016 (being updated) digital breast tomosynthesis (DBT) as a primary screening method for breast cancer. 2016 adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram. 2016 screening mammography in women aged 75 years or older 2016 screening for thyroid dysfunction in nonpregnant, asymptomatic adults. 2015 screening for vitamin D deficiency in asymptomatic adults. 2014 (being updated) screening for chlamydia and gonorrhea in men. 2014 (being updated) screening for suicide risk in adolescents, adults, and older adults in primary care 2013 (being updated) screening for oral cancer in asymptomatic adults. 2013 screening for primary open-angle glaucoma (POAG) in adults. 2013 (being updated) screening for hearing loss in asymptomatic adults aged 50 years or older 2012 (being updated) screening for bladder cancer in asymptomatic adults. 2011
- 24. What about procedures that have no clear recommendations? SHARED DECISION MAKING
- 25. Indicators of Health and Wellness in the Elderly
- 26. •International Journal of Environmental Research and Public Health 10(12):6630-44 Healthy Ageing Good quality of life Survivial to specific age in good health Autonomy in ADLs No or few chronic diseases Little or no disability No/mild cognitive or function impairment High social participation Health behavior Culture Gender
- 27. Multidisciplinary Approach to Good Health and Wellness in the Elderly
- 29. What if at the end of the Wellness Check-Up there is really nothing wrong with the older person? Re-evaluate goals Modify plans Revise management Reassure
- 30. Thank you!
Notas do Editor
- Good day. Let me start of by presenting this case. He is a 58 year old successful businessman. Hypertensive, but, controlled by medications. He Plays golf 1-2x a month. He is a Healthy eater, Non-smoker and Occasional drinker However, he Feels sluggish and Not as physically active as he was 20-30 years ago. He Feels like “age is catching up on him” He needs something more
- In the next few minutes we will be discussing some concepts on Wellness in the Older Person. I am Dr. Marc Abat, and thank you for being with us.
- WE will discuss the concept of Wellness in the Elderly, How to approach wellness evaluation for this age group, the indicators of health and wellness in the elderly and briefly touch on the multidisciplinary approach to good health and wellness for the elderly
- We will start with the concept of wellness in the elderly
- Aging is accumulation of changes responsible for the sequential alterations that accompany advancing age and the associated progressive increases in the chance of disease and death Changes happen from the molecular level, in our DNA and genes, up to larger biochemical processes, up to our organs, leading to changes in how we function. All of these contribute to us getting more sick and dying.
- Being well was earlier thought of as just having no disease and not being sick. But throughout the years, this definition has considerably expanded.
- We now acknowledge wellness in the elderly as a purposeful process of individual growth, integration of experience, and meaningful connection with others, reflecting personally valued goals and strengths, and resulting in being well and living values Wellness may thus be different concept and process from person to person, and at each stage of their lives
- There is considerable similarity and overlap with the WHO concept of healthy aging, defined as The process of developing and maintaining the functional ability that enables well-being in older age The intrincic capacity of the older person emanates from his genetics, health characteristics (like age-related traits, health related behaviors, risks factors, diseases and geriatric syndromes), and personal characteristics. The intrinsic capacity interacts with his environment in both directions, leading to his overall functional ability that enables wellbeing.
- So how do we approach wellness evaluation in the elderly?
- We should always recognize that there is a reason for them to undergo these wellness evaluations. It may start out just like any preventive or general exam, but there may more deep-seated concerns like psychosocial concerns, or concerns for particular diseases
- Selection of diagnostics may boil down to whether you are doing the test for screening or case finding
- Screening involves testing large numbers of apparently healthy people to detect unrecognized disease at an earlier stage……versus Case-finding involves evaluating subgroups of people at increased risk of having a disease to make a diagnosis earlier than would occur by waiting for them to present with symptoms or signs.
- The core of doing a wellness evaluation in the elderly still involves doing the Comprehensive Geriatric Assessment. This is a multidimensional, interdisciplinary diagnostic process to develop a coordinated and integrated plan for treatment and long-term follow-up. It employs interdisciplinary teams and the use of any number of standardized instruments. There is emphasizes on quality of life and functional status, prognosis, and outcome. It is both a diagnostic and therapeutic process
- We will base our choices of diagnostics mainly and primarily on evidence-based recommendations. It can be from health authorities or societies involved in these policies. For this talk, we will use the Guidance on Preventive Services of the US Preventive Services Task Force (USPSTF)
- These are the explanations for the grading. Grades A and B should be offered or provided. Grade C services should only be offered for select patients depending on individual circumstances. Grade D services are discouraged. Grade I services have insufficient current evidences, and as such patients should be aware of the uncertainty in harms and benefit
- Grade A recommendations are for cervical cancer screening for women aged 30 to 65 years, Screening for colorectal cancer starting at age 50 years and continuing until age 75 years, Screening syphilis infection in persons who are at increased risk for infection, screening for high blood pressure in adults aged 18 years or older
- Grade B recommendations are for Unhealthy Drug Use Screening, Hepatitis C Infection Screening, 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked, unhealthy alcohol use in primary care settings, women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or with an ancestry associated with (BRCA1/2) gene mutations with an appropriate familial risk assessment tool
- screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older, or in those younger and increased risk of osteoporosis, as determined by a formal clinical risk assessment tool screening for latent tuberculosis infection (LTBI) in populations at increased risk screening for depression biennial screening mammography for women aged 50 to 74 years
- screening for abnormal blood glucose in adults aged 40 to 70 years who are overweight or obese screening for chlamydia and gonorrhea in older women who are at increased risk for infection screening for hepatitis B virus (HBV) infection in persons at high risk for infection annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years
- selectively offer screening for AAA with ultrasonography in men aged 65 to 75 years who have never smoked men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient's overall health and prior screening history
- Notable Grade D recommendations against screening for asymptomatic bateriuria, routine BRCA ½ testings, pancreatic CA testing, cervical Ca screening in those post-hysterectomy and with no high-grade cervical lesions and in those older than 65 but low risk and with adequate previous screening ECG in asymptomatic adults at low risk for CVD Ovarian and thyroid Ca Asymptomatic adults for COPD Asymptomatic carotid artery stenosis
- Grade I is given to screening for cognitive impairment, abuse and neglect, AF with ECG, PAD and CVD risk with ankle brachial index in asymptomatic adults, adding parameters like ABI or hsCRP to traditional CVD risk assessment, osteoporosis in men, resting or exercise ECG in asymptomatic but intermediate to high risk adults, celiac disease, screening pelvic examinations in asymptomatic women
- others
- Shared decision making should be done in cases wherein there are no clear recommendations for a particular procedure, especially if the patient is requesting it. The pros and cons, including possible adverse events should be balanced with perceived benefits
- Indicators of healthy ageing would be a perceived good quality of life, survival to a specific age in good health, autonomy in activities of daily living, none or few chronic diseases, little or no disability, none or mild cognitive impairment, high social participation, good health behavior All of these happen in the context of biology/genetics, gender, social services, physical environment, culture and economic determinants, that help promote healthy ageing
- Let’s briefly discuss a multidisciplinary approach to wellness in the elderly
- Given the data set we obtained for the older person, we formulate a management plan with the health care team, including the primary attending doctor, other specialists, nursing team, the rehabilitation team, possibly the fitness coach, social worker and other professionals needed to help address the concerns identified in the entire evaluation processes. This may be a continuing or evolving process, that also needs prioritization.
- If the person is really “well” or there is nothing clearly amiss at the start, the cycle of reassurance, reevaluation of goals, modification of all plans, and revision of management should be done. There may be other important issues that where not initially identified or new ones that develop or revealed over time
- Thank you for listening