Week 1:
• Chapter 1: Principles of Primary Care of Older Adults
• Chapter 5: Wellness and Prevention
• Chapter 6: Cultural Competency and Cultural Humility in Caring for Older Adults
• Chapter 7: Appropriate Prescribing
Principles of Primary Care of Older Adults
- Developmental changes
o According to Erikson, the developmental task of late adulthood is ego integrity vs.
despair. During late adulthood, individuals reflect on their lives. Retirement may be a
primary driver of reflection as older adults adjust to role changes. Successful resolution
of this stage leads to a sense of satisfaction and fulfillment with the life lived, while
unsuccessful resolution leads to a sense of regret. Unsuccessful resolution may result
in depression, loneliness, or withdrawal.
- Age related changes
Decreased brain weight, slower reaction time, changes in sleep cycle
Decreased visual acuity, decreased adaptation to light/dark
Decreased hearing acuity
Decreased taste sensation, decreased salivation
Reduced maximum cardiac function, increased risk of murmurs and valve stenosis
Cilia atrophy= increased risk of infection
Decreased liver size, decreased renal perfusion (up to 50%)
menopause/vaginal atrophy & increased prostate size, decreased ejaculate/reduced erectile intensity
Decreased bone mineral content, decreased muscle mass
Increased risk of skin tears, decreased thermoregulation, wrinkly, loss of body hair
- Categories of
aging Wellness and
Prevention
- Immunizations
Immunizations (Table 5.1)
Medicare and Medicaid beneficiaries approved standing orders for annual influenza vaccinations and
pneumococcal pneumonia vaccinations
Medicare part B covers vaccines to prevent influenza and pneumonia as well as Hepatitis B if the patient
is at a medium to high risk for this disease
All other vaccines are covered under Medicare part D
Influenza inactive (IIV), or recombinant (RIV): 1 dose annually
Tetanus, diphtheria, pertussis (TDAP): 1 dose after age 65 years then Td every 10 years
Varicella recombinant (Shingrix): 2 doses 2–5 months apart. Give to those who had zoster
Pneumococcal: 1 dose of PPSV23 (Polysaccharide, Pneumovax); consider 1 dose PCV 13 in high-risk
patients
Hepatitis A/Hepatitis B (only if high-risk & at least once)
- Health Promotion
, o Science and art of helping people change their lifestyle to move toward a
state of optimal health
o A balance of physical, emotional, social, spiritual, and intellectual health
o Includes: immunizations, lifestyle modifications, prophylactic use of
medication, screening for malignancies
- Health Screenings
o Osteoporosis
▪ Bone mineral density (BMD) and Fracture Risk Assessment Tool (FRAX)
- predicts future fracture risk
o Cognitive screening if patient has subjective memory complaints or if
clinician observes red flags
▪ Mini-Cog: clock drawing test and a 3 item recall
o Breast cancer
▪ The USPSTF recommendation is for biennial screening
mammography for women age 50 to 74 years
▪ After age 75 years screening is up to the patient and clinician.
The American Geriatrics Society recommends continued
screening is reasonable as long as the patient has a 10-year life
expectancy.
o Colon cancer
▪ The USPSTF recommends screening for colorectal cancer for persons
age 50 to 74 years of age with one of the following: yearly fecal occult
blood or fecal immunochemical testing (FIT); every 1 to 3 years FIT
deoxyribonucleic acid; every 5 years sigmoidoscopy or computed
tomography colonography; every 10 years colonoscopy
▪ In adults aged 76 to 85 years, this same set of screenings should
be done selectively based on professional judgment and patient
preference.
o Cervical cancer
▪ The USPSTF recommends against screening for cervical cancer in
women older than age 65 years who have had adequate prior
screening. Women with precancerous lesions, immunosuppression, or
human immunodeficiency virus (HIV)/human papilloma virus (HPV)
infection are at high risk for developing cervical cancer and require
screening at
any age.
▪ Women for whom previous screening is unknown may need screening.
▪ Screening is unnecessary in women who have undergone hysterectomy
with cervix removal, and with no history of precancerous lesion (grade
2
or 3).
o Prostate cancer
▪ The USPSTF states that screening offers only a small benefit of
decreasing the risk of death in men age 55 to 64 years. In this
population, the potential harms of false positives that can lead
to overdiagnosis and overtreatment, and treatment
complications
▪ Risk populations: family history and black men
▪ For men age ≥70 years, prostate-specific antigen (PSA) testing is
not recommended because benefit does not outweigh potential
harm.
, - Patient Education
o Education regarding smoking cessation and the effects smoking has on the
body (table 33.1): CV disease, GI disease, erectile disfunction, pulmonary
disease, RA, osteoporosis, worsening skin elasticity, variety of cancers,
detrimental to pediatric development, effects on mental health, effects on
taste/smell.
- Health Equity
Appropriate
Prescribing
- Polypharmacy: simultaneous use of multiple drugs to treat a single ailment or condition.
1. Prevention strategies
• Review medication list
• Ask if any other provider has changed or added medications since last visit
• Question if every prescribed or OTC medication is necessary, or dosage can
be lowered
• Determine if experiencing any adverse drug reactions
2. Screening tools
• Beers criteria for potentially inappropriate medication use in older adults
(AGS Beers Criteria)
• STOPP/START criteria
• MAI (medication appropriateness index)
- Beers Criteria
• Purpose
• Potentially inappropriate medications in older adults
• Potentially inappropriate medications to avoid in older adults with
certain conditions
• Medications to be used with considerable caution in older adults
• Medication combinations that may lead to harmful interactions
• A list of medications that should be avoided or dosed differently for those
with poor renal function
• Risks: adverse drug reactions (ADR)
The Beers criteria are appropriate for use in evaluating use of certain meds in pts: >65yo
Telehealth
- Laws
• Inconsistent from state to state and across health plans. Currently, health
plans do reimburse for telehealth services
- Security/Privacy
• Chapter 1: Principles of Primary Care of Older Adults
• Chapter 5: Wellness and Prevention
• Chapter 6: Cultural Competency and Cultural Humility in Caring for Older Adults
• Chapter 7: Appropriate Prescribing
Principles of Primary Care of Older Adults
- Developmental changes
o According to Erikson, the developmental task of late adulthood is ego integrity vs.
despair. During late adulthood, individuals reflect on their lives. Retirement may be a
primary driver of reflection as older adults adjust to role changes. Successful resolution
of this stage leads to a sense of satisfaction and fulfillment with the life lived, while
unsuccessful resolution leads to a sense of regret. Unsuccessful resolution may result
in depression, loneliness, or withdrawal.
- Age related changes
Decreased brain weight, slower reaction time, changes in sleep cycle
Decreased visual acuity, decreased adaptation to light/dark
Decreased hearing acuity
Decreased taste sensation, decreased salivation
Reduced maximum cardiac function, increased risk of murmurs and valve stenosis
Cilia atrophy= increased risk of infection
Decreased liver size, decreased renal perfusion (up to 50%)
menopause/vaginal atrophy & increased prostate size, decreased ejaculate/reduced erectile intensity
Decreased bone mineral content, decreased muscle mass
Increased risk of skin tears, decreased thermoregulation, wrinkly, loss of body hair
- Categories of
aging Wellness and
Prevention
- Immunizations
Immunizations (Table 5.1)
Medicare and Medicaid beneficiaries approved standing orders for annual influenza vaccinations and
pneumococcal pneumonia vaccinations
Medicare part B covers vaccines to prevent influenza and pneumonia as well as Hepatitis B if the patient
is at a medium to high risk for this disease
All other vaccines are covered under Medicare part D
Influenza inactive (IIV), or recombinant (RIV): 1 dose annually
Tetanus, diphtheria, pertussis (TDAP): 1 dose after age 65 years then Td every 10 years
Varicella recombinant (Shingrix): 2 doses 2–5 months apart. Give to those who had zoster
Pneumococcal: 1 dose of PPSV23 (Polysaccharide, Pneumovax); consider 1 dose PCV 13 in high-risk
patients
Hepatitis A/Hepatitis B (only if high-risk & at least once)
- Health Promotion
, o Science and art of helping people change their lifestyle to move toward a
state of optimal health
o A balance of physical, emotional, social, spiritual, and intellectual health
o Includes: immunizations, lifestyle modifications, prophylactic use of
medication, screening for malignancies
- Health Screenings
o Osteoporosis
▪ Bone mineral density (BMD) and Fracture Risk Assessment Tool (FRAX)
- predicts future fracture risk
o Cognitive screening if patient has subjective memory complaints or if
clinician observes red flags
▪ Mini-Cog: clock drawing test and a 3 item recall
o Breast cancer
▪ The USPSTF recommendation is for biennial screening
mammography for women age 50 to 74 years
▪ After age 75 years screening is up to the patient and clinician.
The American Geriatrics Society recommends continued
screening is reasonable as long as the patient has a 10-year life
expectancy.
o Colon cancer
▪ The USPSTF recommends screening for colorectal cancer for persons
age 50 to 74 years of age with one of the following: yearly fecal occult
blood or fecal immunochemical testing (FIT); every 1 to 3 years FIT
deoxyribonucleic acid; every 5 years sigmoidoscopy or computed
tomography colonography; every 10 years colonoscopy
▪ In adults aged 76 to 85 years, this same set of screenings should
be done selectively based on professional judgment and patient
preference.
o Cervical cancer
▪ The USPSTF recommends against screening for cervical cancer in
women older than age 65 years who have had adequate prior
screening. Women with precancerous lesions, immunosuppression, or
human immunodeficiency virus (HIV)/human papilloma virus (HPV)
infection are at high risk for developing cervical cancer and require
screening at
any age.
▪ Women for whom previous screening is unknown may need screening.
▪ Screening is unnecessary in women who have undergone hysterectomy
with cervix removal, and with no history of precancerous lesion (grade
2
or 3).
o Prostate cancer
▪ The USPSTF states that screening offers only a small benefit of
decreasing the risk of death in men age 55 to 64 years. In this
population, the potential harms of false positives that can lead
to overdiagnosis and overtreatment, and treatment
complications
▪ Risk populations: family history and black men
▪ For men age ≥70 years, prostate-specific antigen (PSA) testing is
not recommended because benefit does not outweigh potential
harm.
, - Patient Education
o Education regarding smoking cessation and the effects smoking has on the
body (table 33.1): CV disease, GI disease, erectile disfunction, pulmonary
disease, RA, osteoporosis, worsening skin elasticity, variety of cancers,
detrimental to pediatric development, effects on mental health, effects on
taste/smell.
- Health Equity
Appropriate
Prescribing
- Polypharmacy: simultaneous use of multiple drugs to treat a single ailment or condition.
1. Prevention strategies
• Review medication list
• Ask if any other provider has changed or added medications since last visit
• Question if every prescribed or OTC medication is necessary, or dosage can
be lowered
• Determine if experiencing any adverse drug reactions
2. Screening tools
• Beers criteria for potentially inappropriate medication use in older adults
(AGS Beers Criteria)
• STOPP/START criteria
• MAI (medication appropriateness index)
- Beers Criteria
• Purpose
• Potentially inappropriate medications in older adults
• Potentially inappropriate medications to avoid in older adults with
certain conditions
• Medications to be used with considerable caution in older adults
• Medication combinations that may lead to harmful interactions
• A list of medications that should be avoided or dosed differently for those
with poor renal function
• Risks: adverse drug reactions (ADR)
The Beers criteria are appropriate for use in evaluating use of certain meds in pts: >65yo
Telehealth
- Laws
• Inconsistent from state to state and across health plans. Currently, health
plans do reimburse for telehealth services
- Security/Privacy
