Screening and

PreventionAging Q3 ACOVE

September 21, 2010 updated 8-10-12

Elisha Brownfield, MD

Screening and Prevention Work

Group

Overview

• Prevention Definitions

• Outpatient project details

• Inpatient project details

• Questions/answers

Learning Objectives

• Understand the need for continued preventive health measures in the elderly patient

• Summarize impact of HM cues on physician ordering behavior

• Recall the indications for Pneumovax booster

• Recall Medicare 90 day rehospitalization rates with top reasons for medical readmission

• Understand the Inpatient and Outpatient components of this ACOVE

Types of prevention

Tertiary – Treatment of a disease to prevent further complications

Secondary – Diagnosing and curing disease in early stages to reduce the prevalence

Primary – Reducing the instance of the illness in a population

Why are we talking about

prevention in the elderly?

Walter, L.C. and K.E. Covinsky (2001) Cancer Screening in Elderly Patients: A Framework for Individualized Decision Making. JAMA 285:21. 2750-6.

Primary Prevention

• Vaccination

• Diet/Exercise counseling

• Smoking cessation

Secondary Prevention

• Cancer Screening• Prognosis/Life-expectancy• Patient preferences

Tertiary Prevention

• Controlling chronic disease

• Preventing rehospitalizations

Outpatient ACOVE• Summarize the impact of HM cues and reminders on ordering

behavior

• Explain the need for yearly influenza vaccination

• Detail the indications for pneumovax booster

• Understand the indications/contraindications for flu, pneumovax and tetanus boosters

• Outline the health effects of obesity in the elderly

• Outline the benefits of exercise in the elderly

• Draw the major components of the ADA plate diet

• Navigate the PP HM template

• Prescribe aerobic and resistance exercise

• Counsel patients on smoking cessation

Role of Reminder Systems

on Health Maintenance

Completion• Patient reminders effective (Cochrane

Review 2009 - OR = 2.19, 95%CI = 1.21, 3.99)

• Office organizational changes and patient self-management effective (Ann Intern Med 2002:136:641-651)

Effectiveness of Intervention Components To Improve the Use of Screening Services.

Stone E G et al. Ann Intern Med 2002;136:641-651

©2002 by American College of Physicians

Tetanus booster

• From 1995-1997, 33 percent of reported cases of tetanus occurred among persons 60 years of age or older and 60 percent occurred in patients greater than 40 years of age.

• The National Health Interview Survey found that in 1995, only 36 percent of adults 65 or older had received a tetanus vaccination during the preceding 10 years.

www.cdc.gov

Tetanus booster

• PP immunization rates – patient 65+

•10%

Pneumococcal Vaccine

• Invasive disease from Streptococcus pneumoniae (pneumococcus) is a major cause of illness and death in the United States, with an estimated 43,500 cases and 5,000 deaths among persons of all ages in 2009

• In 2003 alone, there were 30,000 fewer cases of invasive pneumococcal disease caused by strains included in the vaccine www.cdc.gov

Pneumococcal Vaccine

• PP immunization rates – patient 65+

•8.4%

Seasonal Influenza Vaccine

• A/California/7/2009 (H1N1)-like virus (the same strain as was used for 2009 H1N1 monovalent vaccines);

• A/Perth/16/2009 (H3N2)-like virus;

• B/Brisbane 60/2008-like antigens.

• Influenza epidemics were associated with estimated annual averages of approximately 36,000 deaths during 1990--1999 and approximately 226,000 hospitalizations during 1979--2000. Adults 65+ especially vulnerable.

www.cdc.gov

Influenza Vaccination

• PP immunization rates – patient 65+

•84.6%•WHY? Standing order

intervention

Vaccination Intervals for

Adults 65+• Td – every 10 years

• replace one booster with Tdap if contact with child <12 months

• Influenza – yearly during flu season

• Pneumococcal – once after age 65• If <65 when received, and 5 years since

shot, then give again at or after age 65

• Zoster – once after age 60

Blue Sheet and Vaccinations

• Standing orders for Td, Pneumococcus, Influenza

• Have you had a flu shot this season?

• Have you had a tetanus shot in the last 10 years?

• Have you had a pneumonia shot in the past 5 years?

Effects of Obesity in the Elderly

• Increased risk of chronic diseases

• Increased nursing home/homebound

• Higher frailty, low physical function, and self-reported physical disability

• Age 70 obese men would spend one third and obese women one half of their expected life expectancy disabled

• Increased risk of cognitive decline

Exercise Goals

• Moderate aerobic exercise (like walking) 30 minutes/5 days per week

• Resistance exercising 2-3 days per week

www.cdc.gov

Exercise in the Elderly

• Reduced mortality

• Primary prevention of coronary heart disease

• Lipid profile improvement

• Reduction in fat mass,

• Reducing blood pressure

• Prevention of stroke

• Prevention of type 2 diabetes

• Prevention of some cancers (breast and colon)

• Increasing bone density

• Prevention of falls

• Reduced risk of developing dementia and Alzheimer's disease

Resistance Training

• Fewer than 15% of adults aged 65 and older strength-train twice a week

• A multidimensional activity program that includes endurance, strength, balance, and flexibility training is optimal for health and functional benefits

Resistance Training

Can you push or pull a large thing, like a living room chair?

Exercise prescription – resistance bands

Exercise Interventions

Prochaska and DiClemente, 1982

Weight Loss in the Elderly

• Trial of Nonpharmacologic Interventions in the Elderly - 30% reduction in diagnosis of hypertension, treatment of hypertension, or cardiovascular events

• Diabetes Prevention Program was more effective in reducing the incidence of type 2 diabetes in participants aged 60 years and older than in participants under 60 years of age

Dietary Goals

• High vegetable intake - reduced risk of chronic diseases: cardiovascular diseases, type 2 diabetes, and cancers in certain sites (oral cavity and pharynx, larynx, lung, esophagus, stomach, and colon-rectum)

• Diets rich in foods containing fiber, such as fruits, vegetables, and whole grains, may reduce the risk of coronary heart disease.

Diet

• In looking back over the last 24 hours, how many servings of vegetables have you eaten (not including potatoes, pasta and rice)?

• <3 Plate Diet

Dietary Interventions

https://www.musc.edu/cce/ORDFRMS/pdf/ah_all_dc_pated_diabetesdcinstructions.pdf

Smoking Cessation

• Elderly smokers - greatest burden of smoking-related diseases and associated health care costs (U.S. Department of Health and Human Services [USDHHS], 2000).

• 70% of smokers want to quit and 46% attempt each year (USDHHS, 2000).

• Older adults have the same quit rates as young adults - brief interventions are effective (USDHHS, 2000).

Inpatient - Tertiary Prevention

• Medicare patients – 34% rehospitalization rate at 90 days

• Top three diagnoses: COPD, CHF, Pneumonia

• Discharge communication poor

• Solutions yet unknown

Inpatient - Tertiary Prevention

• Follow-up appointment made before discharge

• Communicate self-care instructions and contact information

• Systems-based practice

Inpatient - Tertiary Prevention

• Adults receive recommended therapies 56.1% of the time

• Discharge orders, order sets, checklists

• Multidisciplinary service

Inpatient - Tertiary Prevention

• Consults for interdisciplinary care

• Discharge instructions for CHF, DM, COPD in Zones

• Follow-up appointment in 7-14 days

Karen Lucas, RN key facilitator