Am Fam Physician. 2000;61(4):949-950
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 care-givers 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.5 Indeed, 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.