Editorials - February 15, 2000 - American Academy of Family Physicians

Editorials

Health Assessment of the Geriatric Patient

ROMAN M. HENDRICKSON, M.D.
Verne E. Gibbs Indian Health Service Health Center
Poplar, Montana

See article in this issue.

Health maintenance of geriatric patients is an integral part of daily medical practice for most family physicians. The number of older patients will increase dramatically in upcoming years, from 34 million in 1998 to 69 million in 2030.¹ Out of necessity, family physicians must be prepared to offer preventive services to this age group in an appropriate and efficient manner.

Preventing injury, improving mobility and dexterity, maintaining optimal vision and hearing, ensuring adequate nutrition, obtaining appropriate immunizations, maintaining sexual function, managing incontinence, evaluating cognitive status, treating depression and maintaining independence are all important health issues for older patients. As more successful interventions become available to address these and other concerns, physicians must evaluate and identify such interventions to optimize function in aging patients.

The majority of ambulatory older patients who visit primary care physicians are without severe disability. This group offers the greatest challenge and opportunity to identify functional deficits early enough to maintain optimal function and the ability to live independently as long as possible.

The evidence reviewed by the U.S. Preventive Services Task Force (USPSTF) demonstrates that educating elderly patients and their caregivers about preventing injury and improving nutrition can significantly decrease morbidity and mortality.² Simple evaluation of mobility and dexterity can identify those at greatest risk for falls or poor function, thereby offering the most timely and appropriate rehabilitative intervention to the most impaired patients.

Vision changes in all of us as we age. If patients do not undergo periodic vision evaluations, quality of life suffers and the risk of falls increases. Hearing is impaired in up to one half of all elderly persons. Failure to identify hearing dysfunction can result in social isolation, depression and an overall decline in well-being.³

Immunizations have been proved efficacious for older adults, yet fewer than 30 percent receive tetanus-diphtheria, influenza and pneumococcal vaccinations that may prevent life-threatening ailments in this high-risk group.⁴

The early identification of cognitive decline has become imperative, with the availability of pharmacologic interventions shown to be of most value if started early in the course of decline. Early identification also allows frank discussions with the patient and family to allow realistic future planning. The diagnosis of depression allows physicians an opportunity to clinically and pharmacologically address a condition that, if left untreated, is likely to increase morbidity and mortality.

Issues related to sexuality and to urinary continence have become topics of more frequent discussion in the lay media and the professional literature. Recent pharmaceutical and surgical options available for those identified with these problems have been widely promoted. A physician's failure to identify and freely discuss these issues with older patients prevents the use of interventions when they may be beneficial.

A commonly promoted method for evaluating the health needs of older patients is "comprehensive geriatric assessment." This process uses a multidisciplinary team and is labor- and time-intensive and, thus, is usually impractical in the average primary care physician's office practice. Numerous studies have found comprehensive geriatric assessment to be of limited or no value in offering improved outcomes for the outpatient groups studied.⁵Indeed, this type of assessment most benefits frail elderly persons, not the average geriatric patient presenting for care at the family physician's office.

The need for an efficient alternative evidence-based approach to preventive services for the elderly is manifest. In this issue, Miller and associates¹ offer a utilitarian evidence-based approach for offering preventive health services to older patients. The authors used the recommendations of the USPSTF as a guide. The USPSTF took an evidence-based approach to review the clinical literature and offer recommendations based on that clinical evidence.²

It was from this same USPSTF report that the American Academy of Family Physicians (AAFP) developed the Recommendations for Periodic Health Examinations.⁶ In addition to the areas of assessment addressed in the Miller article, the AAFP recommends mammography and clinical breast examinations every one to two years until 69 years of age, Papanicolaou smears every three years in women with a cervix, and regular colorectal screening in all adults over the age of 50. Practicing primary care physicians will appreciate the succinct presentation used in the Miller article, with recommended interventions capable of being accomplished in one or multiple clinical encounters.¹ By addressing the primary clinical areas of concern to the elderly, this article will help physicians quickly review the most recent evidence-based recommendations for intervention in older patients.

Dr. Hendrickson is director of geriatric services, Verne E. Gibbs Indian Health Service Health Center, Poplar, Montana.

Address correspondence to Roman M. Hendrickson, M.D., P.O. Box 1605, Poplar, MT 59255.

REFERENCES

Miller KE, Zylstra RG, Standridge JB. The geriatric patient: a systematic approach to maintaining health. Am Fam Physician 2000;61:1089-104.

U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.

Popelka MM, Cruickshanks KJ, Wiley TL, Tweed TS, Klein BE, Klein R. Low prevalence of hearing aid use among older adults with hearing loss: the Epidemiology of Hearing Loss Study. J Am Geriatr Soc 1998;46:1075-8.

Douglas KC, Rush DR, O'Dell M, Monroe A, Ausmus M. Adult immunization in a network of family practice residency programs. J Fam Pract 1990;31:513-20.

Tryon A, Mayfield G, Bross M. Use of comprehensive geriatric assessment techniques by community physicians. Fam Med 1992;24:453-6.

American Academy of Family Physicians. Summary of policy recommendations for periodic health examination. Kansas City, Mo.: November 1996 (rev July 1999).

Genetic Testing

NEIL A. HOLTZMAN, M.D., M.P.H.
Johns Hopkins Medical Institutions
Baltimore, Maryland

See article in this issue.

In questioning whether we are undergoing a genetic revolution, in the "Medicine and Society" article in this issue,¹ Wulfsberg argues that people will not soon be obtaining "genetic profiles" that will predict their risks of future disease, nor he says, will primary care providers use genetic tests to screen for "disorders for which some claim there is compelling therapeutic intervention."² "The lack of effective interventions," Wulfsberg concludes, "and public resistance suggest that genetic technologies will indeed be slow to be adopted into primary care medicine."

Certainly, primary care providers are not going to be deluged with tests that will indicate increased susceptibilities to a host of different diseases, each of which will call for a different intervention. As Wulfsberg¹ points out, "The technical and biologic complexities of genetic diseases has been far greater than expected." The complexity is actually much greater for gene-influenced, common diseases, usually of adult onset (e.g., cancer, hypertension, bipolar disorder and type 2 diabetes [formerly known as noninsulin-dependent diabetes]) than it is for single-gene (Mendelian) diseases (e.g., cystic fibrosis, hemophilia, Marfan's syndrome and thalassemia).

A few years ago, molecular biologists believed that alleles at a single gene locus would prove to be major determinants of the common, adult-onset disorders; however, it is now thought that alleles at several gene loci, often acting in concert and interacting with environmental factors, must be present before disease appears. Finding contributing loci, however, is extremely difficult.

Once a gene is found, tests for susceptibility alleles at that locus will have low predictive value until several of the other inherited and environmental contributing factors are discovered and tests and other methods are devised to detect their presence. Even when alleles at a single gene locus significantly increase susceptibility (as several BRCA1 and BRCA2 alleles increase the risk of breast cancer), future disease is uncertain. Another problem is that different combinations of genetic and environmental factors contribute to the occurrence of a specific disease; tests that detect only one or a few of these combinations will identify only a small proportion of persons who will develop the disease.

In contrast to the common, complex disorders, extraordinary progress in discovering single-gene (Mendelian) diseases has been made in the past decade. Mendelian disorders are characterized by complete or high penetrance of alleles at single gene loci. When the genotype capable of resulting in disease is present, the disease will almost always appear although its severity may vary.

When tests become available for identifying disease-related alleles, the question then arises, will primary care providers offer them when "lack of intervention"¹ is the rule? Clinical laboratories can offer predictive genetic tests without having to demonstrate their clinical validity or utility.³ Thus, without more stringent regulation,⁴ providers should be skeptical of the promotional materials made available by their developers. Situations do arise when offering genetic testing to a patient is appropriate.

One of the benefits of predictive testing for breast or colon cancer--in persons in whom an affected first-degree relative has been found to have a susceptibility-conferring mutation--is sparing patients with negative results from early, periodic monitoring or prophylactic surgery, and removing the uncertainty of whether or not their risk is increased. In healthy relatives with a positive result, the benefits of early monitoring or prophylaxis have not been fully established.

Therapies are available for a few single-gene disorders but, more often, families who unexpectedly have an affected child and ask, "why us?" can be given an answer based on inheritance. Genetic testing also gives parents the opportunity, through prenatal diagnosis and other strategies, to avoid the conception or birth of another affected child. Not all patients or families will want genetic testing for this purpose. Nevertheless, physicians have an obligation to make their at-risk patients aware of the options.

Wulfsberg¹ concludes by predicting that genetics will impact primary care practices "in an evolutionary rather than revolutionary manner." "Primary care physicians who keep current," he adds, "by reading the medical literature and attending professional meetings will not be left in the dust." Although primary care providers will not be flooded with genetic tests, reading and attending professional meetings have not, as innovations have appeared in the past,⁵ proved effective in altering physician practice, and I doubt they will in the future.

Primary care physicians might be spurred into action more readily by a revolution if every patient was eligible for screening. This is unlikely to happen until the benefits are clearly established and far exceed the risks. Instead, physicians will be challenged to recognize which handful of their patients are likely to benefit from genetic testing and other interventions. Sometimes this will entail eliciting a family history of those common disorders for which predictive genetic testing could be of benefit. Sometimes the patient's ethnic background will suggest increased risk. Occasionally, when confronted with unusual symptoms or signs that are refractory to standard therapy, referral may be indicated. A novel approach to improve physicians' understanding is to make them active partners in clinical trials that assess the safety and effectiveness of genetic tests and therapies.

Genetic discoveries are influencing medical practice in a more subtle but important way than the tests and therapies to which they may ultimately lead. Discovering the marked heterogeneity underlying the same complex of symptoms and signs suggests that seldom is there a prototypal case of any disease.⁶ The lesson is that patient management must be individualized. Whether, as the pharmaceutical companies hope, this will mean tailoring drugs to genotypes remains to be seen. But understanding what makes our patients unique, including their social environment, is more likely to improve health than the drugs we prescribe.

Neil A. Holtzman, M.D., M.P.H., is professor of pediatrics at the Johns Hopkins University School of Medicine, of Health Policy and Epidemiology at the Johns Hopkins School of Hygiene and Public Health and director of Genetics and Public Policy Studies at the Johns Hopkins Medical Institutions. Dr. Holtzman is actively engaged in research on the policy implications of genetic tests. He was the chair of the NIH-Department of Energy's Task Force on Genetic Testing.

Address correspondence to Neil A. Holtzman, M.D., Johns Hopkins Medical Institutions, 550 N. Broadway, Baltimore, MD 21205-2004.

REFERENCES

Wulfsberg, EA. The impact of genetic testing on primary care: where's the beef? [Medicine and Society] Am Fam Physician 2000;61:971-8.

Beaudet AL. 1998 ASHG Presidential Address: making genomic medicine a reality. Am J Hum Genet 1999;64:1-13.

Holtzman NA, Watson MS, editors. Promoting safe and effective genetic testing in the United States: final report of the Task Force on Genetic Testing. Baltimore: Johns Hopkins University Press, 1998.

Holtzman NA. Are genetic tests adequately regulated? Science 1999;286:409.

Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5.

Childs B. Genetic medicine: a logic of disease. Baltimore: John Hopkins University Press, 1999.

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