Women now constitute 62 percent of the U.S. population over 65 years of age.1 They account for more than 106,000 office visits to physicians annually, with most of these visits to primary care physicians.1 It is important that physicians understand the unique health needs of older women so that they can provide appropriate care to this growing patient population. Because one aspect of this care is health screening, primary care physicians need to be aware of the screening tests recommended for older women.
Because of the high prevalence of chronic disease and frailty in older women, the focus of outpatient treatment shifts from curing disease to maintaining maximal independence, function and quality of life. Maintaining function necessitates screening for conditions that could lead to disability. Appropriate screening and subsequent interventions can prevent disease, decrease mortality, improve patient management and provide modest health gains.2 This article discusses selected screening needs for older women and highlights some of the current controversies concerning such screening.
Screening Factors and Guidelines
Although much attention has been given to cardiovascular disease, cerebrovascular disease and cancer, many other conditions can be responsible for disability or death in older women. Hearing and vision loss, dysmobility and functional impairment, osteoporosis, cognitive impairment, depression, urinary incontinence and domestic violence are major contributors to chronic disease and disability in older women. Preventive efforts aimed at these conditions require the availability of both screening techniques and efficacious interventions.
A number of screening guidelines have been formulated. However, in preparing this article, the authors have relied on the guidelines developed by the U.S. Preventive Services Task Force (USPSTF)3 and the Agency for Health Care Policy and Research (AHCPR [Web site: www.ahcpr.gov]). Furthermore, attention is focused on the factors or conditions that are unique to women 65 years or older, have a high prevalence in this age group and contribute significantly to morbidity.
Both the USPSTF and AHCPR base their recommendations on critical review of the literature and debate among experts. In the 1996 USPSTF report,3 the quality of each screening recommendation is ranked using a five-letter grading system. An “A” or “B” grade indicates that a recommendation has proven effectiveness or demonstrates consistent benefit. A screening recommendation with a “D” or “E” grade has no proven benefit and has associated risks of complications. A “C” grade indicates that a screening recommendation has insufficient evidence of effectiveness.
Screening for Problems with Hearing and Vision
Hearing problems are a major cause of morbidity in older adults. Hearing loss affects physical, emotional, cognitive and social function.4 Some degree of hearing loss is present in more than 33 percent of persons over 65 years of age and in more than 50 percent of persons older than 85 years.5 In nursing home residents, the prevalence of hearing loss approaches 70 percent.4
The USPSTF indicates that routine screening for hearing loss in adults after the age of 65 years demonstrates consistent benefit (a “B” recommendation).3 Formal audiometry is the gold standard for this screening, but whispered voice or finger rub techniques can be used as brief tests of hearing. These techniques are at least 70 to 80 percent accurate in identifying hearing impairment.5 The Hearing Handicap Inventory for the Elderly–Screening Version can also identify hearing loss.6
Once hearing impairment is detected, hearing aids can often resolve the impairment and improve social, cognitive, emotional and communicative function.5
Visual problems occur in 21 to 50 percent of older adults.7 An inability to see well can make it difficult to drive a car or perform many activities of daily living; the risk of falling is also increased.8 Unfortunately, problems with vision often are not detected in older adults. Almost 20 percent of nursing home residents have undetected visual impairment, and 25 percent of older adults wear inappropriate visual correction aids.7,8 The USPSTF recommends routine annual visual screening for adults after the age of 65 years (a “B” recommendation).3
Poor visual acuity is easily detected using a wall-mounted or handheld Snellen chart. One objective outlined in the Healthy People 2000 report9 is to increase vision screening by primary care physicians to 60 percent of elderly persons. The American Academy of Family Physicians10 advocates Snellen acuity testing in elderly patients. If necessary, patients older than 65 years should be referred for more detailed eye examinations.
Refractive errors detected by vision screening can be readily corrected with eyeglasses or contact lenses. Other causes of visual impairment, such as glaucoma, can be treated medically. Primary care physicians can use Schiøtz's tonometry, applanation or noncontact (air-puff) tonometry devices in the office setting. However, the USPSTF states that glaucoma screening is best done by eye specialists.3 Macular degeneration and cataracts are other common problems that affect visual acuity in older women. Cataracts may require surgical intervention.
Assessment of Functional Status
One of the primary reasons that older women seek medical care is to maintain physical function. The functional status of women declines rapidly after the age of 65 years. This decline is associated with a threefold increase in five-year mortality and a fourfold increase in long-term disability.11–13
So that strategies can be applied to prevent or delay functional decline, primary care physicians need to routinely assess the physical function of older women. Most activities that rely on functional ability occur outside the physician's office. Nonetheless, most experts agree that older women should be assessed routinely with a self-report instrument, a performance-based measure or both.11 In its 1996 guide,3 the USPSTF did not review functional assessment studies but instead advised primary care physicians to periodically ask patients about their functional status and to remain alert for changes in physical performance.
Self-report questionnaires include the Activities of Daily Living (ADL) scale and the Instrumental Activities of Daily Living (IADL) scale.14–16 The ADL index has proved fairly reliable and valid in evaluating behaviors that are predictive of the independent living ability of older adults.16 Physicians can use this instrument to identify older women who are frail and may benefit from assisted living or an increased level of care. The IADL index15 has proved reliable and valid in older populations. Impairment identified by this scale should trigger the development of a plan for supporting the continuation of independent living.
The ADL and IADL scales are limited by their reliance on self-reporting. Consequently, performance-based tools have been developed to provide more objective measurement of functional status.17–20 These instruments include the Balance and Gait evaluation,17 the Get Up and Go test19 and the Timed Manual Performance test.18 The Get Up and Go test and the Gait and Balance evaluation are two simple means of assessing gait. These tests evaluate a core physical activity: the ability to stand without assistance, maintain balance and ambulate. The Timed Manual Performance test assesses upper extremity function as determined by the patient's ability to open a sequence of locks.
The detection of lower extremity dysfunction and gait disorders is an important part of functional evaluation in older women. Normal gait represents the coordination of complex sets of neuromuscular movements, and a gait abnormality may be the sign of a serious underlying disorder. The gait assessment can detect diseases of the peripheral nervous system (e.g., peripheral neuropathy), peripheral motor system (e.g., degenerative joint disease), middle sensorimotor area (e.g., Parkinson's disease) and high sensorimotor areas (e.g., normal-pressure hydrocephalus). Approximately one half of falls are caused by gait problems, and one third of falls are caused by balance problems.19 If a gait abnormality is detected, weight-bearing exercise and physical rehabilitation may prevent further decline and lessen the risk of falls.21
The care of frail older women with ADL impairment can be facilitated by referral to the local network of agencies that offer home health care, social work case management and long-term care placement. Physicians should maintain an up-to-date list of agencies that provide services to older persons, and they should be aware of the quality and extent of care that each agency provides.
Screening for Home Safety
Falls are the leading cause of nonfatal injuries in older women. Debilitated physical function plays a role in falls, but environmental factors also increase the risk of falling. Environmental factors include narrow stairs, pavement irregularities, slippery surfaces, loose rugs, inadequate lighting, floor clutter, unstable or low furniture and incorrect footwear.21–23 Furthermore, the home may not have smoke detectors, or the regulator on the hot water heater may be set higher than the recommended maximum of 120°F to 125°F (48.8°C to 51.6°C).
Screening older women for home environment safety and helping to change an unsafe environment may reduce the number of falls.21 Instruments such as the Home Safety Screen are useful in detecting safety hazards in this population. The USPSTF indicates that environmental safety screening for fall prevention has consistent benefit (a “B” recommendation).3
Screening for Osteoporosis
After menopause, bone loss accelerates because of the decline in estrogen production by the ovaries. Osteoporosis is responsible for 70 percent of the fractures that occur in older adults. More than 12 percent of women over 60 years of age sustain a hip fracture; 15 to 20 percent of these women die as a result of their injury.24
The USPSTF gives densitometry screening for osteoporosis a “C” recommendation because of its inconvenience and high cost, and because of the lack of universal criteria for initiating treatments based on screening measurements.3 However, the USPSTF does recommend osteoporosis screening in women at high risk for osteoporosis who would consider preventive therapy.
Screening methods for detecting osteoporosis include conventional radiographs, computed tomography, single and dual photon absorptiometry, dual energy x-ray absorptiometry and ultrasonography. Dual energy x-ray absorptiometry is arguably the most useful screening tool in the clinical setting, but ultrasound techniques are currently being studied for clinical feasibility.25 If ultrasound techniques prove to be accurate in determining bone mass, future USPSTF reports may upgrade the current “C” recommendation.3
Once osteoporosis is detected, plans should be instituted to prevent fractures and slow bone loss. Because older women often have nutritional insufficiencies that contribute to bone loss, supplemental dietary calcium and vitamin D have been recommended as part of a fracture prevention program.25 Estrogen replacement has been shown to improve bone density and thus far is the most effective strategy for lowering the risk of osteoporotic fractures.26,27 Bisphosphonates may be indicated to prevent bone mineral density from declining further in older women who have already sustained an osteoporosis-related fracture. Newer agents such as raloxifene (Evista), a selective estrogen receptor modulator, are also beneficial in preventing the decline of bone mineral density.
Assessment of Cognition
Like physical function, cognition also declines with older age. Dementia, characterized by a decline in memory, language and other cognitive functions, affects more than 5 percent of adults over the age of 65 years and almost 50 percent of adults over 80 years of age. Several studies show dementia to be more prevalent in women than in men.28,29 Women with dementia lose the ability to live independently.
The USPSTF found insufficient evidence to recommend for or against dementia screening in asymptomatic older adults (a “C” recommendation).3 At the time of the USPSTF review, effective treatment for dementia was not available. Future task force reports will incorporate data on acetylcholinesterase inhibitors and other interventions in the recommendations.
Several instruments can be used to assess cognitive function.28–30 The Mini-Mental State Examination (MMSE) and the Short Portable Mental Status Questionnaire can be completed in five to 15 minutes. In contrast, the Alzheimer's Disease Assessment Scale and formal neuropsychiatric batteries require an hour or more for completion.
The scoring of the brief instruments must be adjusted for elderly members of minority ethnic groups. The MMSE score also needs to be adjusted for patients with educational levels below the eighth grade. The Short Portable Mental Status Questionnaire has been validated in older African American women,28,31 but it is less sensitive in detecting milder deficits in cognitive function. Primary care physicians should choose a screening instrument that is appropriate for their patient population and should regularly screen older women for memory difficulties or cognitive dysfunction.
When cognitive impairment is detected, its cause should be determined. Dementia may be reversible in fewer than 10 percent of patients.30 If a reversible cause is found, treatment is directed at altering the neurophysiologic impairment or preventing further degeneration.
Several therapies have demonstrated some efficacy in slowing the decline of cognitive function. Two acetylcholinesterase inhibitors, tacrine (Cognex) and donepezil (Aricept), are the only agents the U.S. Food and Drug Administration has labeled for the treatment of dementia of the Alzheimer's type. These drugs, which primarily slow the decline of cognitive function, appear to have similar efficacy in women and men. To date, however, relatively small numbers of patients have been enrolled in clinical trials of these drugs. Estrogen replacement therapy also appears to slow the decline in cognitive function. Clinical trials are necessary to document its future use in women with cognitive impairment. Treatment with platelet inhibitors such as aspirin and other nonsteroidal anti-inflammatory drugs has been recommended to prevent further progression of vascular dementia.
Early identification of dementia can alert patients and their families to potentially hazardous situations and allow time for financial and medical planning.30 Information on reversible causes of dementia, including endocrine disorders, vitamin deficiencies, normopressure hydrocephalus, infections of the nervous system, and liver and renal disorders, is limited in women.
Screening for Depression
As many as 15 percent of older women have symptoms of depression. Women 65 years of age and older are twice as likely to have depression as are men of the same age.32 Studies in family practice and general medicine clinics indicate that 11 to 33 percent of older patients have at least some symptoms of depression.33,34
In its 1996 report,3 the USPSTF gives depression screening a “C” recommendation, citing the lack of evidence for or against routine screening. However, the USPSTF does advise primary care physicians to maintain a high index of suspicion for symptoms of depression in their patients.
Instruments available to screen for depression include the Beck Depression Inventory, the Zung Depression Scale, the Geriatric Depression Scale and the Primary Care Evaluation of Mental Disorders. Many physicians use the Geriatric Depression Scale.35 This easily administered tool has good reliability and validity in older adults. The Primary Care Evaluation of Mental Disorders allows physicians to screen for multiple coexistent psychiatric conditions.36 A recent study37 showed the reliability of screening for depression by asking patients one simple question: “Have you been feeling sad or depressed lately?”
Once depressive symptoms have been detected, physicians need to determine whether comorbid conditions or medications may be contributing to or aggravating depression. The type of treatment depends on the nature and severity of the depressive symptoms. Options include psychotherapy and pharmacologic therapy. Patients with severe refractory depression may require electroconvulsive therapy.
Screening for Seat Belt Use
Although older women have fewer motor vehicle accidents than persons in other age groups, they have one of the highest fatality rates for such accidents. Therefore, counseling older women to wear seat belts is an important preventive measure. Wearing seat belts can reduce the risk of moderate-to-serious injury by up to 55 percent and the risk of crash-related death by 40 to 50 percent.38,39 Counseling patients to wear seat belts receives the highest recommendation from the USPSTF, an “A” rating indicating convincing evidence of benefit.3
Screening for Urinary Incontinence
The AHCPR recommends that primary care physicians question their patients regularly about the occurrence of urinary incontinence. Sample questions include the following: “Do you have trouble with your bladder?” Do you ever lose your urine or get wet?” or “Do you have trouble holding your urine?”
Once urinary incontinence is identified, physicians can use more specific questions and monitoring to determine whether the problem is urge, stress or overflow incontinence. Further diagnostic studies and subsequent treatment can then be targeted at correcting or ameliorating the problem.
Screening for Alcohol Abuse
Alcohol abuse affects 1 to 1.5 percent of community-dwelling older women.42 Chronic alcohol use can lead to dementia, hepatitis, cirrhosis, osteomalacia, thiamine deficiency, cardiomyopathy and gastritis.
Two widely used instruments for detecting alcohol abuse are the CAGE questionnaire43 and the Michigan Alcoholism Screening Test–Geriatric Version (MAST–G).44 The CAGE screening tool consists of a brief set of four questions, whereas the MAST–G tool contains 24 questions. Other screening instruments include the Alcohol Use Identification Test, which in recent studies was shown to perform better than the CAGE questionnaire, especially in women.45,46 The USPSTF indicates that screening to detect alcohol abuse has consistent benefit (a “B” recommendation).3
When alcohol abuse is detected, pharmacologic or psychologic treatment can be attempted. In older adults, pharmacologic treatment is recommended only for acute detoxification. Intermediate-acting benzodiazepines, such as lorazepam (Ativan), may be used as initial treatment because they do not accumulate active metabolites. Long-acting agents, such as chlordiazepoxide (Librium), may be necessary to prevent withdrawal symptoms. In nondependent drinkers, five to 15 minutes of outpatient counseling may be effective in reducing drinking by 32 to 38 percent.47
Screening for Domestic Violence
In the United States alone, as many as 2 million adults over 65 years of age are victims of domestic violence every year. Most of these victims are women.48 Older women may present with traumatic physical injuries, gynecologic complaints and gastrointestinal disorders, or with general symptoms of fatigue, headache, myalgias, depression and anxiety.49,50 In frail older women, domestic violence can be particularly lethal. The higher degree of functional limitation and lower physiologic reserve in this group increases the risk of serious injury from violence.
Studies show that as many as 14 to 25 percent of women of all ages seen at ambulatory medical clinics and 20 percent of women seen in emergency departments have been physically abused.51,52 In older women, an estimated one in 14 cases of physical abuse is accurately identified.48 The direct medical costs associated with violent injuries in women are estimated to add more than $5.3 billion to annual health care expenditures in the United States.53 Studies are currently being conducted to understand how domestic violence affects the health of older women.
Screening for domestic violence improves the detection of abuse. Compared with self-report surveys, direct questions from physicians have been shown to elicit more positive reports about domestic violence.54 However, the value of screening is limited if the abuser is the sole caregiver and is present during the interview.
Once abuse is detected, effective interventions are often limited. The only safe action may be for the abused older woman to give up her current residence and move to a nursing home or assisted living facility. Intervention may also lead to estrangement from relatives, especially if a relative is the abuser. Furthermore, many states require mandatory reporting of abuse involving an older adult. Because of the difficulties with intervention, the USPSTF gives screening for domestic violence a “C” recommendation.3