Charles P Mouton, MD, MS, School of Medicine, Meharry Medical College
TIPS ABOUT SCREENING TESTS FOR OLDER ADULTS
National organizations, such as the US Preventive Services Task Force (USPSTF), have published recommendations for screening adults for a variety of diseases, based on a consideration of whether screening will lead to improved outcomes. Many of these recommendations are aimed at diseases that are common in older adults. While the USPSTF and other organizations do an excellent job of elucidating when and how to perform screening, less attention is given to when screening should stop. Little evidence and few recommendations are available on which to base such decisions, particularly for those over age 70. The most current information is shown in Table 1.
When choosing to screen for a particular disease, several factors need to be considered. First, the disease must be sufficiently common and serious to present a problem to individuals and to society. Second, there must be a latent or asymptomatic stage during which treatment will be of more benefit than after symptoms occur. Third, there must be a sufficiently accurate, safe, and cost-effective screening test that is acceptable to patients.
When applying screening tests to older adults, four other factors must also be considered: life expectancy, level of disease co-morbidity, ability to undergo the screening test and any ensuing treatments, and personal preference.
Average life expectancy in the US is now about 78 years. Individuals age at different rates, however, leading to considerable variability in survival, even at advanced ages. Vigorous older adults may benefit from many of the standard available screening tests, whereas those with multiple co-morbidities might not live long enough to profit from screening. It is important to note that the average life expectancy of nursing home residents is less than 3 years. Therefore, screening in nursing home residents should be individualized rather than routine.
Because life expectancy is not solely a function of chronologic age, many experts have suggested calculating an estimated life expectancy as a function of health, or "physiologic age."
One easy-to-use method adjusts chronologic to physiologic age by using patients' ratings of their health status. Patients are asked: "How is your health - excellent, good, fair, or poor?" Depending on the response, physiologic age can be determined from Table 2 and the results used to estimate life expectancy (Table 3). Other approaches include gait speed or self-reported functional status. Screening is most appropriate for those with an estimated life expectancy greater than 10 years.
Disease co-morbidity influences the benefits of screening. Individuals with no co-morbidities have overall benefits for cancer screening up to age 76; those with mild, moderate, and severe co-morbidities should consider cessation at ages 74, 72, and 66 years, respectively.
Ability to Participate in Screening and Treatments
Screening tests may be a challenge for older adults with functional limitations, and all aspects of patients' health should be considered prior to ordering screening tests. For example, DEXA testing for osteoporosis may be difficult for individuals with mobility issues or who cannot lie flat. Patients with dementia may be uncooperative and unwilling to participate in testing procedures. Similarly, if a screening test detects a disease whose treatment presents an unacceptable burden to a patient, screening may not be warranted. Information about potential treatments should be discussed before screening occurs.
Personal preferences are an essential part of decisions about screening, and most patients indicate they would continue screening throughout their life, often in spite of a clinician's recommendation against screening. The American Geriatrics Society recommends that older patients should have access to screening tests, even if they do not plan to pursue treatment of a condition that is found. They can still incorporate the test results into planning for their remaining life course, and they should not be denied access to desired testing solely because the test results will not change management.
|Table 1: Recommendations for Screening and Stopping Screening in Older Adults (USPSTF = US Preventive Services Task Force; LE = life expectancy)|
|CONDITION||RECOMMENDATION||WHEN TO STOP||MODIFYING FACTORS|
|Aortic aneurysm||Once in male smokers of ≥ 100 cigarettes||After age 75||Recommendation refers only to abdominal aneurysm; may offer to male non-smokers|
|Breast cancer||Every 2 years||After age 75||If LE >5 yr and can tolerate treatment, continue screening|
|Cervical cancer||Every 1-3 years; every 5 yrs if had HPV vaccine||After age 65 if previous negative results||Continue screening if cervix present and multiple sex partners|
|Colorectal cancer||Depends on screening method||After age 85||Individualized in people between 76 - 85 yrs|
|Dementia||Varying recommendations||Assess whenever there is clinical suspicion|
|Depression||Varying recommendations||Adults >18 yrs and whenever there is clinical suspicion|
|Diabetes||Every 3 years per USPSTF||After age 70 per USPSTF||After age 70, test if there is clinical suspicion|
|Falls||Periodically; no specific interval||Check for vitamin D level if screening positive|
|Hearing||No screening per USPSTF||Other organizations recommend screening every 3-5 years|
|Hepatitis B||Periodically in high-risk groups||If risk factors no longer present||No screening if immunized against hepatitis B|
|Hepatitis C||Once||Only screen if born between 1949-1965|
|Hypertension||Every 1-2 years||If LE <1 yr, consider stopping|
|Lipid disorders||Every 1-5 years||After age 65||If LE >5 yr and treatment likely to benefit, continue screening|
|Lung cancer||Annual if ≥ 30 pack-yrs smoking||Age 80 or ≥ 15 yrs no smoking||Others suggest stopping at age 75|
|Obesity||Routine at office visits||Consider not checking if LE <20 yrs|
|Oral cancer||No specific recommendations||Some organizations recommend screening if high risk|
|Osteoporosis||Once (age 65 women, 70 men)||Consider in men > age 65 with history of fracture|
|Ovarian cancer||No screening|
|Pancreas cancer||No screening|
|Periph artery dz||No specific recommendations||No testing after age 65|
|Prostate cancer||Individualized age 55-69||After age 70||Some recommend individualized screening for high risk groups|
|Sexually transmitted infections||No specific recommendations||Consider screening if new or multiple sex partners|
|Thyroid disease||No specific recommendations|
|Vision||No screening per USPSTF||Other organizations recommend screening every 1-2 years|
|Vitamin D||Insufficient evidence||Consider not checking if LE < 5 years|
Table 2: Estimating Physiologic Age from Chronological Age and Self-Reported Health Status
|Self-Reported Health||Self-Reported Health||Self-Reported Health||Self-Reported Health|
M = Male, F = Female
Adapted from: Welch HG, Albertsen PC, Nease RF, Bubolz TA, Wasson JH. Estimating treatment benefits for the elderly: The effect of competing risks. Ann Intern Med. 1996:124:577-584.
|Table 3: Life Expectancy for Men and Women in the US Based Solely on Chronological Age|
|Life Expectancy In Years (Percentile)|
Data in this table are population statistics that have not been adjusted for health status (physiologic age). Use the information in Table 2 to determine an individual’s physiologic age, and then use the age in this table to estimate life expectancy. Source: JAMA; 285:2751.
References and Resources