Geriatric Care and Screening (Clinical)

Caring for Older Adults

Geriatric population Geriatric Population Geriatric Care and Screening^[5]

• In the US, over 20% of the population will be > 65 years of age by 2030.
• Many factors affect the functional status of individuals in this age group:
  • 80% of individuals have at least 1 chronic condition and 50% have at least 2 chronic conditions.
  • Declines in vision Vision Ophthalmic Exam, hearing, balance, and cognition may impair function.
• Apart from addressing chronic conditions, comprehensive preventive care with functional and psychosocial evaluation are essential in improving geriatric well-being.

Assessment of older adults^[19]

Care for older adults is a team-based approach that involves various professionals (e.g., physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship, social workers, nutritionists, physical therapists) working together to assess the following:

• Physical health:
  • Address and manage current chronic conditions (e.g., heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR), hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease).
  • Discuss nutrition and medication use.
  • Appropriate screening Screening Preoperative Care for other diseases
  • Update the necessary vaccinations.
• Functional ability:
  • Ask about impairments in activities of daily living (ADLs).
  • Address any limitations Limitations Conflict of Interest in their physical and mental abilities:
    • Check for cognitive decline and memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment disturbances.
    • Hearing and vision Vision Ophthalmic Exam assessment
    • Driving assessment
    • Falls and other incidents contributing to functional limitations Limitations Conflict of Interest
• Psychosocial health:
  • Depression may go undetected, as symptoms present in atypical ways.
  • Suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide rate is higher in older adults than in the general population.
  • Social environment:
    • Inquire about family members and support groups.
    • Home safety
    • Screen for any mistreatment Mistreatment Clinician–Patient Relationship.
    • Screen for financial constraints (directly affects health).
• Advance care planning

Physical Health

Nutrition^[5]

• Appetite and body weight generally decline with age.
• Lean LEAN Quality Measurement and Improvement mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast decreases and fat mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast usually increases in this population.
• Unintentional weight loss Weight loss Decrease in existing body weight. Bariatric Surgery occurs in 15%–20% of older adults.
  • Associated with higher risks for morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status and mortality Mortality All deaths reported in a given population. Measures of Health Status
  • Major causes include:
    • Cancer
    • Psychiatric or cognitive conditions
    • Medication side effects
    • Changes in social environment or isolation
  • Proceed with workup of unintentional weight loss Weight loss Decrease in existing body weight. Bariatric Surgery based on presentation (e.g., labs, imaging studies, and cancer screening Screening Preoperative Care, if not yet completed).

Alcohol, tobacco, and substance use^[5]

• Alcohol use:
  • Approximately 50% of adults > 65 years of age consume alcohol.
  • Alcohol use in older adults is associated with:
    • Increased risk of falls
    • Negative effects on function, cognition, and general overall health
  • The American Geriatrics Society recommends asking older adults specific questions regarding the frequency and quantity of alcohol consumption.
    • The CAGE questionnaire asks the patient if they have:
      • Felt they should Cut down on their alcohol intake?
      • Been Annoyed by people criticizing their drinking?
      • Felt Guilty about drinking?
      • Had a drink first thing in the morning (Eye opener) for shakiness or a hangover?
    • A total score of ≥ 2 is clinically significant; it is appropriate to counsel the patient regarding alcohol intake and its adverse effects.

Tobacco use:

• Older adults should be asked about tobacco use.
• If current smokers, counselling on smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases cessation and methods of quitting should be offered.

Marijuana/cannabis use:^[22,23]

• The legal landscape is changing rapidly; marijuana is now legal in most states to varying extents.
• It remains a Schedule 1 drug (medical use is not recognized and is considered a substance at high risk for abuse) under US federal law.
• Older patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship use many forms of marijuana besides smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases (e.g., oral, topical, cannabidiol Cannabidiol Compound isolated from cannabis sativa extract. Cannabinoids ( CBD CBD Atypical Parkinsonian Syndromes) supplements) and may not volunteer this information unless asked.
• Can cause tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, increased blood pressure, or orthostatic hypotension Orthostatic hypotension A significant drop in blood pressure after assuming a standing position. Orthostatic hypotension is a finding, and defined as a 20-mm hg decrease in systolic pressure or a 10-mm hg decrease in diastolic pressure 3 minutes after the person has risen from supine to standing. Symptoms generally include dizziness, blurred vision, and syncope. Hypotension in older adults
• Associated with increased risk of mental and physical health issues and cannabis use disorder Cannabis use disorder Cannabis use disorder (CUD) is characterized by the pathologic consumption of cannabis, which is the most commonly used illicit substance worldwide. While cannabis has some beneficial medical uses, it also has the potential to cause intoxication characterized by psychosis or cognitive impairment, especially in chronic use. Cannabis Use Disorder in older adults

Physical activity^[8]

• Exercise is recommended for all adults and is associated with better overall health, decreased healthcare costs, and fewer mobility limitations Limitations Conflict of Interest.
• Generally, the American Heart Association American Heart Association A voluntary organization concerned with the prevention and treatment of heart and vascular diseases. Heart Failure recommends the following regimen for adults:
  • At least 150 minutes of moderate-intensity exercise every week OR 
  • 75 minutes of vigorous activity 3 days a week
  • Strength training (e.g., weight training, resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing training, or weight-bearing calisthenics) to maintain or improve strength
  • A gradual increase in time and intensity is recommended.
• Routine testing such as ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) or stress testing is not recommended for asymptomatic older adults prior to initiating an exercise program.
• Medical clearance is recommended prior to commencing an exercise program:
  • In symptomatic individuals (e.g., with a complaint of chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea)
  • In individuals with known heart disease or with renal or metabolic disease (factoring in the desired exercise intensity)

Medication Management

Considerations^[11]

• Age-related changes can affect drug absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption, distribution, metabolism, and excretion as well as physiologic effects in older adults:
  • The volume of distribution may increase with age, secondary to a relative increase in body fat and a decrease in lean LEAN Quality Measurement and Improvement muscle mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast.
  • Drug metabolism may be impaired by a decline in hepatic function.
  • Decreased drug clearance due to a natural, age-related decline in renal function
  • Increased sensitivity to the effects of a medication may be seen with increasing age.
• Caution with polypharmacy (the use of 5–10+ medications), which is associated with:
  • ↑ Risk of adverse events and falls
  • ↑ Risk of hospital admissions
  • ↓ Physical and cognitive functioning
• Monitor for drug-drug interactions and adverse effects:
  • Ask about herbal medicines, supplements, and over-the-counter medications due to potential interactions.
  • Closely monitor for adverse effects when initiating a new medication.
  • Avoid “prescribing cascades” (adding a medication to treat adverse effects of another medication)
• Safe prescribing practices include:
  • Regular Regular Insulin review of current medications
  • Stopping unnecessary medications
  • Using the minimal dose required for clinical benefit
  • Considering nonpharmacological approaches when possible

Beers criteria Beers Criteria Geriatric Care and Screening^[24]

• The most widely used criteria developed to reduce potentially inappropriate prescribing and harmful polypharmacy in the geriatric population Geriatric Population Geriatric Care and Screening
• Provides a list of drugs that can pose a risk to older adults due to adverse effects, drug-drug interactions, and drug dose adjustments; updated every 3 years
• Over-the-counter medications are included.
• NSAIDs NSAIDS Primary vs Secondary Headaches are the most commonly used medications that are considered potentially inappropriate.

Screening Exams

Screenings in the older population should consider risk factors beyond merely the individual’s age. The individual and/or caregivers should be involved in decision-making about pursuing screening Screening Preoperative Care. Screening Screening Preoperative Care tests are generally not indicated if the life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is < 5 years.

Abdominal aortic aneurysm Aortic aneurysm An abnormal balloon- or sac-like dilatation in the wall of aorta. Thoracic Aortic Aneurysms^[16]

Men between 65 and 75 years of age with a history of tobacco use should undergo abdominal ultrasound screening Screening Preoperative Care once.

Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer^[3,13]

Based on the US Preventive Services Task Force (USPSTF):

• Women between 50 and 74 years of age: mammography Mammography Radiographic examination of the breast. Breast Cancer Screening screening Screening Preoperative Care every 2 years
• Women > 75 years of age: insufficient evidence to support screening Screening Preoperative Care (American Cancer Society suggests the option of screening Screening Preoperative Care if life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids > 10 years)

Cardiovascular disease^[18,25]

• Screening Screening Preoperative Care for hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension:
  • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension is a major risk factor for ischemic heart disease Ischemic heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease and stroke.
  • USPSTF: check blood pressure annually in all adults > 18 years of age
  • Confirm diagnosis with outside blood pressure measurements (before initiation of treatment).
• Screening Screening Preoperative Care for diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus:
  • Part of cardiovascular risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care
  • The USPSTF recommends diabetes screening Diabetes Screening Adult Health Maintenance for individuals who are 35–70 years of age and those who are overweight or obese ( BMI BMI An indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese). Obesity ≥ 25).
  • Fasting glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance or HbA1c HbA1c Products of non-enzymatic reactions between glucose and hemoglobin a, occurring as a minor fraction of the hemoglobin components of human erythrocytes. Hemoglobin a1c is hemoglobin a with glucose covalently bound to the terminal valine of the beta chain. Glycated hemoglobin a is used as an index of the average blood sugar level over a lifetime of erythrocytes. Diabetes Mellitus screening Screening Preoperative Care (abnormal result needs a repeat test for confirmation, unless both are done at the same time)
  • Those found to have prediabetes should be educated about preventive interventions Preventive interventions Preventive interventions are actions that prevent a disease and reduce the incidence of new cases, including education, vaccines, nutritional interventions, maternal and neonatal interventions, behavioral interventions, and environmental interventions. Points of Intervention.
• Screening Screening Preoperative Care for atherosclerotic cardiovascular disease (ASCVD):
  • The 2019 American College of Cardiology/ American Heart Association American Heart Association A voluntary organization concerned with the prevention and treatment of heart and vascular diseases. Heart Failure (ACC/AHA) guideline recommends:^[25]
    • Routine assessment of cardiovascular risk factors in adults 40–75 years of age, which includes calculation of the 10-year risk of ASCVD
    • Statin therapy for primary prevention of ASCVD in adults 40–75 years of age with low-density lipoprotein Low-density lipoprotein A class of lipoproteins of small size (18-25 nm) and light (1. 019-1. 063 g/ml) particles with a core composed mainly of cholesterol esters and smaller amounts of triglycerides. The surface monolayer consists mostly of phospholipids, a single copy of apolipoprotein B-100, and free cholesterol molecules. The main ldl function is to transport cholesterol and cholesterol esters to extrahepatic tissues. Cholesterol Metabolism cholesterol Cholesterol The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. Cholesterol Metabolism levels ≥ 190 mg/dL, with diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus and those determined to have elevated risk as determined by their 10-year ASCVD risk calculation
    • Individualized discussion on whether to continue statin therapy after age 75
• The USPSTF recommends statin therapy for primary prevention of ASCVD in adults 40–75 years of age who have ≥ 1 CVD risk factor (e.g., hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus) and a 10-year risk of a cardiovascular event of  ≥ 10%.^[30]
• Aspirin Aspirin The prototypical analgesic used in the treatment of mild to moderate pain. It has anti-inflammatory and antipyretic properties and acts as an inhibitor of cyclooxygenase which results in the inhibition of the biosynthesis of prostaglandins. Aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis. Nonsteroidal Antiinflammatory Drugs (NSAIDs) use is considered on a case-to-case basis (due to the risk of bleeding).

Cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer^[4]

• Population at risk:
  • Up to 65 years of age, the options are:
    • Cervical cytology Cervical cytology A procedure in which ectocervical and endocervical cells are collected to evaluate the transformation zone (area at risk for cervical cancer). Cervical Cancer Screening every 3 years
    • High-risk HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) (hrHPV) screening Screening Preoperative Care every 5 years
    • Cytology with hrHPV co-testing every 5 years
  • Screening Screening Preoperative Care ends at age 65 years in the case of adequate negative screening Screening Preoperative Care, which is defined as:
    • 3 consecutive negative cytology results, OR
    • 2 consecutive negative Pap and HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) test results within the past 10 years, with the most recent test within the past 5 years
• If adequate screening Screening Preoperative Care has not been performed, provide cytology/ HPV HPV Human papillomavirus (HPV) is a nonenveloped, circular, double-stranded DNA virus belonging to the Papillomaviridae family. Humans are the only reservoir, and transmission occurs through close skin-to-skin or sexual contact. Human papillomaviruses infect basal epithelial cells and can affect cell-regulatory proteins to result in cell proliferation. Papillomavirus (HPV) screening Screening Preoperative Care every 5 years for 10 years.
• The decision to continue depends on whether the life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is ≥ 10 years and a discussion with the individual.
• May be discontinued in individuals who have had a total hysterectomy:
  • With cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Uterus, Cervix, and Fallopian Tubes: Anatomy removed for benign Benign Fibroadenoma causes
  • Without a history of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer or cervical intraepithelial neoplasia ( CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer)
  • Women with a history of CIN CIN An increased tendency to acquire chromosome aberrations when various processes involved in chromosome replication, repair, or segregation are dysfunctional. Colorectal Cancer after screening Screening Preoperative Care for 20 years post-surgery
• Exceptions: patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with a history of cervical cancer Cervical cancer Cervical cancer, or invasive cervical carcinoma (ICC), is the 3rd most common cancer in women in the world, with > 50% of the cases being fatal. In the United States, ICC is the 13th most common cancer and the cause of < 3% of all cancer deaths due to the slow progression of precursor lesions and, more importantly, effective cancer screening. Cervical Cancer, HIV HIV Anti-HIV Drugs, or other immunocompromise

Colorectal cancer Colorectal cancer Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer^[14]

• 45–75 years of age: routine screening Screening Preoperative Care recommended for everyone
• 76–85 years of age: selective screening Screening Preoperative Care (decision to continue based on individual preferences, prior screening Screening Preoperative Care results, and overall health status/ comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus)
• Screening Screening Preoperative Care may be discontinued if the life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is < 10 years.
• Screening Screening Preoperative Care options:
  • Annual high-sensitivity guaiac fecal occult blood test Fecal occult blood test Colorectal Cancer ( HSgFOBT HSgFOBT Stool-based test – Identifies hemoglobin in stool Colorectal Cancer Screening)
  • Annual fecal immunochemical test Fecal immunochemical test Stool-based test – Measures hemoglobin in the stool Colorectal Cancer Screening (FIT)
  • Stool DNA DNA A deoxyribonucleotide polymer that is the primary genetic material of all cells. Eukaryotic and prokaryotic organisms normally contain DNA in a double-stranded state, yet several important biological processes transiently involve single-stranded regions. DNA, which consists of a polysugar-phosphate backbone possessing projections of purines (adenine and guanine) and pyrimidines (thymine and cytosine), forms a double helix that is held together by hydrogen bonds between these purines and pyrimidines (adenine to thymine and guanine to cytosine). DNA Types and Structure (sDNA)-FIT test every 3 years
  • Flexible sigmoidoscopy Sigmoidoscopy Endoscopic examination, therapy or surgery of the sigmoid flexure. Colorectal Cancer Screening every 5 years (limited to the distal part of the colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy)
  • Flexible sigmoidoscopy Sigmoidoscopy Endoscopic examination, therapy or surgery of the sigmoid flexure. Colorectal Cancer Screening every 10 years + annual FIT
  • Colonoscopy Colonoscopy Endoscopic examination, therapy or surgery of the luminal surface of the colon. Colorectal Cancer Screening every 10 years
  • CT colonography CT colonography A non-invasive imaging method that uses computed tomographic data combined with specialized imaging software to examine the colon. Colorectal Cancer Screening every 5 years

Lung cancer Lung cancer Lung cancer is the malignant transformation of lung tissue and the leading cause of cancer-related deaths. The majority of cases are associated with long-term smoking. The disease is generally classified histologically as either small cell lung cancer or non-small cell lung cancer. Symptoms include cough, dyspnea, weight loss, and chest discomfort. Lung Cancer^[15]

• 50–80 years of age: annual screening Screening Preoperative Care using low-dose CT of the chest for the following individuals:
  • 20 pack-year smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases history
  • Current smokers 
  • Have quit within the past 15 years
• Screening Screening Preoperative Care is discontinued when:
  • Age ≥ 80 years
  • The individual has not smoked for 15 years.
  • Life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is limited.

Osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis^[17,20]

• Women ≥ 65 years of age: Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types mineral density (BMD) screening Screening Preoperative Care is recommended.
• The USPSTF states that there is not enough evidence to support screening Screening Preoperative Care in men.
• However, other organizations (e.g., American College of Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship, Endocrine Society) recommend BMD screening Screening Preoperative Care in men > 70 years of age.
• The most commonly used test is the central dual-energy X-ray absorptiometry Dual-Energy X-Ray Absorptiometry Osteoporosis (DXA) of the hip and lumbar spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.
• Recommendations for calcium Calcium A basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes. Electrolytes 1,200 mg/day and vitamin D Vitamin D A vitamin that includes both cholecalciferols and ergocalciferols, which have the common effect of preventing or curing rickets in animals. It can also be viewed as a hormone since it can be formed in skin by action of ultraviolet rays upon the precursors, 7-dehydrocholesterol and ergosterol, and acts on vitamin D receptors to regulate calcium in opposition to parathyroid hormone. Fat-soluble Vitamins and their Deficiencies 800 IU/day between diet and supplementation are not universally agreed upon.

Prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer^[6,12,26]

• 2nd-most common cancer diagnosis in men; however, most men will die of another cause due to the typically slow growth of prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. cancer. Thus, screening Screening Preoperative Care is controversial.
• Men ages 55‒69 years:
  • Decision to screen is based on preferences, risk factors, and potential risks/benefits.
  • If elected, a blood test to detect PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer alone is recommended as a screening Screening Preoperative Care strategy every 1‒2 years.
  • Digital rectal examination Digital Rectal Examination A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening ( DRE DRE A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening) is not recommended as a screening Screening Preoperative Care method with or without a PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer test.
• Age ≥ 70 years: PSA PSA A glycoprotein that is a kallikrein-like serine proteinase and an esterase, produced by epithelial cells of both normal and malignant prostate tissue. It is an important marker for the diagnosis of prostate cancer. Prostate Cancer screening Screening Preoperative Care is not recommended.

Vaccine Recommendations

Herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination^[1,27]

• CDC recommends the recombinant zoster vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination (RZV) for people ≥ 50 years of age to decrease the risk of developing herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox ( shingles Shingles Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox) and postherpetic neuralgia Postherpetic neuralgia Pain in nerves, frequently involving facial skin, resulting from the activation the latent varicella-zoster virus. The two forms of the condition preceding the pain are herpes zoster oticus; and herpes zoster ophthalmicus. Following the healing of the rashes and blisters, the pain sometimes persists. Herpes Zoster (Shingles).
• Vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. Vaccination should be performed irrespective of previous vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. Vaccination status or disease history.
• Vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination given in 2 doses:
  • 2nd dose typically 2–6 months after the 1st
  • In immunocompromised immunocompromised A human or animal whose immunologic mechanism is deficient because of an immunodeficiency disorder or other disease or as the result of the administration of immunosuppressive drugs or radiation. Gastroenteritis individuals, 2nd dose 1–2 months after the 1st
• Individuals who previously received the live attenuated vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination (Zostavax; not available since 2020) should be given the recombinant zoster vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination ≥ 5 years later.

Influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination^[29]

• > 90% of influenza-related deaths occur in individuals > 60 years of age.
• Influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination should be given to all adults annually unless there is a history of allergic reactions Allergic Reactions Type I hypersensitivity reaction against plasma proteins in donor blood Transfusion Reactions to vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination components.
• Advisory Committee on Immunization Practices (ACIP) 2022 recommendations for adults ages ≥ 65 years:
  • Quadrivalent high-dose or adjuvanted inactivated influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination, OR
  • Quadrivalent recombinant influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination

Pneumococcal vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination^[9,21]

• Reduces the risk of pneumococcal infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease, particularly with Streptococcus Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. Streptococcus pneumoniae, which is the leading cause of bacterial pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
• In all immunocompetent adults ≥ 50 years of age (new recommendations in Oct OCT Macular Degeneration 2024):^[21]
  • For individuals with no previous pneumococcal vaccines received (or vaccination Vaccination Vaccination is the administration of a substance to induce the immune system to develop protection against a disease. Unlike passive immunization, which involves the administration of pre-performed antibodies, active immunization constitutes the administration of a vaccine to stimulate the body to produce its own antibodies. Vaccination status unknown), administer:
    • 1 dose of pneumococcal conjugate vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination (PCV) as PCV20 (alone), or
    • 1 dose of PCV15 followed by pneumococcal polysaccharide vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination (PPSV) as PPSV23 at least 12 months later (8 weeks in immunocompromised immunocompromised A human or animal whose immunologic mechanism is deficient because of an immunodeficiency disorder or other disease or as the result of the administration of immunosuppressive drugs or radiation. Gastroenteritis patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship)
  • For individuals who already received PPSV23 only: give either PCV20 or PCV15 at least 12 months after PPSV23 dose. 
  • For individuals who already received PCV13 only: complete the previously recommended PPSV23 series

Tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus and diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria toxoids (Td) or Tdap^[5]

• Approximately 60% of all tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus cases in the US occur in individuals > 60 years of age.
• Vaccines:
  • Tdap ( tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination, reduced diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination, and acellular pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough))
  • Td
• In the US:
  • Tdap or Td is given intramuscularly every 10 years to all adults with complete prior immunization to tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus and diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria.
  • If an adult has not been vaccinated against tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus and diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria, a 3-vaccine series is initiated with Tdap as the preferred 1st dose, followed by Td or Tdap.
• Older adults:
  • Likely to have decreased antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions either from not having received the initial vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination or the subsequent booster doses
  • Tdap is important for older adults, especially those in contact with children < 1 year of age:
    • Tdap may be given once instead of the Td booster.
    • Tdap can be administered regardless of the interval since the last Td booster.

Respiratory syncytial virus Respiratory Syncytial Virus Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination^[31]

• CDC recommends shared decision-making.
• Approved for ages 60 years and older

COVID-19 COVID-19 Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that mainly affects the respiratory system but can also cause damage to other body systems (cardiovascular, gastrointestinal, renal, and central nervous systems). vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination^[32]

• 1 dose of a bivalent mRNA mRNA RNA sequences that serve as templates for protein synthesis. Bacterial mRNAs are generally primary transcripts in that they do not require post-transcriptional processing. Eukaryotic mRNA is synthesized in the nucleus and must be exported to the cytoplasm for translation. Most eukaryotic mRNAs have a sequence of polyadenylic acid at the 3′ end, referred to as the poly(a) tail. The function of this tail is not known for certain, but it may play a role in the export of mature mRNA from the nucleus as well as in helping stabilize some mRNA molecules by retarding their degradation in the cytoplasm. RNA Types and Structure vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination is recommended.
• Individuals ≥ 65 years of age may receive an additional dose.
• Monovalent mRNA mRNA RNA sequences that serve as templates for protein synthesis. Bacterial mRNAs are generally primary transcripts in that they do not require post-transcriptional processing. Eukaryotic mRNA is synthesized in the nucleus and must be exported to the cytoplasm for translation. Most eukaryotic mRNAs have a sequence of polyadenylic acid at the 3′ end, referred to as the poly(a) tail. The function of this tail is not known for certain, but it may play a role in the export of mature mRNA from the nucleus as well as in helping stabilize some mRNA molecules by retarding their degradation in the cytoplasm. RNA Types and Structure vaccines are no longer recommended.

Functional Assessment

Functional status^[19]

• Functional status is divided into 3 levels of ADLs:
  • Basic ADLs: self-care tasks such as bathing, dressing, feeding, and toileting
  • Instrumental ADLs (IADLs): complex skills to maintain independence such as driving, preparing meals, shopping, managing finances, and performing housework
  • Advanced ADLs: ability to fulfill various societal and familial roles and participate in recreational and occupational tasks
• Screening Screening Preoperative Care:
  • Screen for impairments in ADLs via direct questioning or based on standardized screening Screening Preoperative Care tools.
  • Assess driving ability and safety in individuals > 70 years of age (group with increased risk for motor vehicle accidents Motor Vehicle Accidents Spinal Cord Injuries and higher risks of mortality Mortality All deaths reported in a given population. Measures of Health Status).

Cognitive function^[19]

• Screening Screening Preoperative Care is recommended for individuals with memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment complaints using validated tools (e.g., Mini-Mental State Examination Mini-Mental State Examination Major Neurocognitive Disorders ( MMSE MMSE Major Neurocognitive Disorders), Mini-Cog Mini-Cog Major Neurocognitive Disorders, clock-drawing test).
• Cognitive screening Screening Preoperative Care is not recommended for asymptomatic individuals.

Hearing^[5]

• Hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss:
  • 3rd-most common chronic condition (after hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension and arthritis Arthritis Acute or chronic inflammation of joints. Osteoarthritis) among older adults in the US
  • Associated with cognitive decline, depression, social isolation, and functional disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment
  • Sensorineural hearing loss Sensorineural hearing loss Hearing loss resulting from damage to the cochlea and the sensorineural elements which lie internally beyond the oval and round windows. These elements include the auditory nerve and its connections in the brainstem. Hearing Loss is caused by natural aging of the auditory system.
• The USPSTF has no recommendations for or against screening Screening Preoperative Care for hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss in asymptomatic older adults.
• Clinically recommended screening Screening Preoperative Care for hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss in individuals ≥ 65 years of age:
  • Pure tone audiometry Audiometry The testing of the acuity of the sense of hearing to determine the thresholds of the loWest intensity levels at which an individual can hear a set of tones. The frequencies between 125 and 8000 hz are used to test air conduction thresholds and the frequencies between 250 and 4000 hz are used to test bone conduction thresholds. Ménière Disease:
    • Gold standard to screen for hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss
    • Not readily available in primary care offices
  • Whispered-voice test:
    • Stand behind the individual (to prevent them from lip-reading) and mask the hearing in 1 ear.
    • A sequence of letters and numbers is whispered and the individual is asked to repeat them.
• Refer to otolaryngology for any failed hearing test, chronic otitis media, and sudden hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss.
• Hearing aids for treatment

Vision Vision Ophthalmic Exam^[5]

• Older adults are at a higher risk of visual impairments from conditions such as macular degeneration Macular degeneration Age-related macular degeneration (AMD) is visual impairment due to changes in the macula, the area responsible for high-acuity vision. It is marked by central vision loss with peripheral vision relatively spared. Risk factors include advanced age, smoking, family history, and cardiovascular disease. Macular Degeneration and cataracts.
• The USPSTF has no recommendations for or against routine vision Vision Ophthalmic Exam screening Screening Preoperative Care in asymptomatic adults.
• Clinically, vision Vision Ophthalmic Exam assessment is recommended for individuals with visual complaints, recent cognitive decline, functional impairments, or falls.

Falls^[7,10,28]

• An important cause of morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status and mortality Mortality All deaths reported in a given population. Measures of Health Status among older adults
• Approximately ⅓ of community-dwelling older adults > 65 years of age have a fall each year.
• Evaluate the risk of falls:
  • Tinetti assessment tool:
    • Also called Performance-Oriented Mobility Assessment (POMA) tool
    • Assesses balance and gait Gait Manner or style of walking. Neurological Examination, scale-based scoring
  • Timed Up and Go (TUG) test:^[2]
    • Ask the individual sitting on a chair to stand, walk 10 feet forward, turn around, walk back, and sit down.
    • In general, ≥ 13.5 seconds suggests a high risk of falls.
    • Factors affecting results (e.g., age, joint problems, underlying conditions such as Parkinson’s disease) should be considered during the assessment.
• Prevention:
  • PT and targeted training activity
  • Vitamin D Vitamin D A vitamin that includes both cholecalciferols and ergocalciferols, which have the common effect of preventing or curing rickets in animals. It can also be viewed as a hormone since it can be formed in skin by action of ultraviolet rays upon the precursors, 7-dehydrocholesterol and ergosterol, and acts on vitamin D receptors to regulate calcium in opposition to parathyroid hormone. Fat-soluble Vitamins and their Deficiencies supplementation
  • Securing the household environment (e.g., no clutter or loose rugs) 
  • Use of assistive devices and equipment (e.g., walkers, bedside commode, shower chair, grab bars)

Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence^[5]

• A cause of major social and emotional distress in the geriatric population Geriatric Population Geriatric Care and Screening
• Obtain a targeted history and conduct an examination:
  • Inquire about the presence or absence of urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence biannually.
  • Determine the onset of urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence (acute or chronic), type (e.g., urge, stress, overflow, mixed), and precipitating factors (e.g., cough, medications).
  • Examine:
    • For signs of fluid overload
    • Pelvic (genital and rectal) area
    • Neurologic evaluation
  • Urine and blood tests as indicated, depending on the presenting factors
• Routine urodynamic testing is not recommended.

Psychosocial Evaluation

Depression^[5]

• The USPSTF recommends screening Screening Preoperative Care all adults for depression.
• Short screening Screening Preoperative Care tools, such as Patient Health Questionnaire-2, are available.
  • Asks the patient how often they have had these issues in the past 2 weeks:
    • Little interest or pleasure in doing things?
    • Feeling down, depressed, or hopeless?
  • Score:
    • 0 points: not at all
    • 1 point: several days
    • 2 points: more than half the days
    • 3 points: nearly every day
• Refer to appropriate services when screening Screening Preoperative Care results are positive.

Financial and social support^[5]

• Ask about financial and social resources.
• Limited resources directly impact an individual’s health.
• Provide information regarding the availability of assistance for older adults in the community (e.g., food pantries, centers for seniors, organizations helping with prescriptions).

Elder abuse^[5]

• Up to 8% of older adults are affected by elder abuse.
• USPSTF: Ask older individuals specific questions about abuse.
• Further inquiry and referral to social services are required if the individual exhibits the following signs of abuse and/or neglect Neglect Child Abuse:
  • Contusions, burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns, bite marks
  • Genital or rectal trauma
  • Pressure ulcers
  • BMI BMI An indicator of body density as determined by the relationship of body weight to body height. Bmi=weight (kg)/height squared (m2). Bmi correlates with body fat (adipose tissue). Their relationship varies with age and gender. For adults, bmi falls into these categories: below 18. 5 (underweight); 18. 5-24. 9 (normal); 25. 0-29. 9 (overweight); 30. 0 and above (obese). Obesity < 17.5 (without clinical explanation)

Advance directives Advance Directives The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care (DPAHC), and/or a physician’s order for life-sustaining treatment (POLST). Advance Directives

• It is important to have discussions with older adults regarding advance care directives while they still have the cognitive capacity to make decisions.
• Preferences regarding specific treatments, end-of-life interventions, and the appointed healthcare proxy should be documented.

Billing and Coding

Encounter Codes:

These codes are used for routine health visits for older adults, including the Medicare “Welcome to Medicare” visit and subsequent Annual Wellness Visits, which focus on preventive care and screening Screening Preoperative Care.

Common Procedures & Services:

These codes represent key services for geriatric patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, such as advance care planning discussions, screening Screening Preoperative Care for cognitive impairment, and assessing for fall risk.

Common Diagnoses:

These are examples of common chronic conditions documented and managed during geriatric care visits, such as hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, type 2 diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis, and dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders.