# Presentation: 102563

## IHS Elder Care InitiativeExcellence in Care of the ElderlyBruce Finke, MD

- Working to help AIAN elders maintain health, function, and their vital role in the life of their community and culture

## The Goal of Elder Care...

- Maintain health
- Maintain function
- Maintain ability to play a vital role in the life of community and culture
- Prevent or delay disability, frailty, and displacement from home and community

## Is The Care We Provide to Older Women Good Enough?

- How good is “good enough”?

## Does every older woman you care for
 have access 
to the full array 
of recommended
 evidence-based 
preventive care services? 

-  have access
- to the full array
- of recommended
-  evidence-based
- preventive care services?

## Preventive Care Guidelines for the ElderlyHow did we get here?

- USPSTF Recommendations
- Interdisciplinary Indian Health on-line work group
- “Expert Opinion” recommendations
- Meant to be modified

## Preventive Care Guidelines for the ElderlyUSPSTF

- Blood Pressure
- Height
- Weight
- BMI (uncertain predictive value over 75)

## Age-Adjusted Cerebrovascular Diseases

**Age-Adjusted Cerebrovascular Diseases**
**Death Rates, CY 1996-1998**

- IHS Adjusted Total - All Areas = 29.5

- U.S. All Races (1997) = 25.9

- Regional Differences in Indian Health – 2000-2001
- Chart 4.29

## Preventive Care Guidelines for the ElderlyUSPSTF

- Colorectal Cancer Screening
- Either
- FOBT – annual
- Sigmoidoscopy – q 5 years
- Colonoscopy – q 10 years
- Double contrast BE and sigmoidoscopy q 5 yrs

## Age-Adjusted Colon-Rectal Cancer Death Rates

**Age-Adjusted Colon-Rectal Cancer Death Rates**
**CY 1996-1998**

- IHS Adjusted Total - All Areas = 14.1

- U.S. All Races (1997) = 12.1

- Regional Differences in Indian Health – 2000-2001
- Chart 4.34

## Colorectal Cancer Mortality, Men, by Ethnicity, 1990 to 1998

**MMWR, January 25, 2002 / 51(03);49-53**

## Preventive Care Guidelines for the ElderlyUSPSTF

- Mammogram
- AGS recommends annually until age 75 then q 2-3 years after unless life expectancy is less than 4 years.
- USPSTF does not suggest an upper limit age, but states: the balance of benefits and potential harms, therefore, grows more favorable as women age.

## Age-Adjusted Female Breast Cancer Death Rates

**Age-Adjusted Female Breast Cancer Death Rates**
**CY 1996-1998**

- IHS Adjusted Total - All Areas = 15.6

- U.S. All Races (1997) = 19.4

- Regional Differences in Indian Health – 2000-2001
- Chart 4.32

## Preventive Care Guidelines for the Elderly USPSTF

- Cervical Cancer Screening
- Women who have a cervix
- Quit at age 65 if “adequately screened”
- (three or more negatives in the 10 years before cessation of screening).
- American Cancer Society says quit at 70

## Age-Adjusted Cervical Cancer Death Rates

**Age-Adjusted Cervical Cancer Death Rates**
**CY 1996-1998**

- IHS Adjusted Total - All Areas = 4.2

- U.S. All Races (1997) = 2.5

- Regional Differences in Indian Health – 2000-2001
- Chart 4.33

## Preventive Care Guidelines for the Elderly USPSTF

- Vision screen
- Optometry exam is optimal
- Glaucoma screen also
- Snellen is next best thing
- Vision has large impact on fall and injury risk
- Hearing impairment
- ROS – screening question
- Office evaluation

## Preventive Care Guidelines for the Elderly USPSTF

- Depression
- New recommendation
- Problem drinking
- Also ask about family members

## Preventive Care Guidelines for the Elderly USPSTF

- Lipids
- Annually if at increased risk
- No good data on primary prevention in the elderly.
- Lipids levels remain fairly stable past age 65
- Secondary prevention statin trials have shown reduction in stroke

## Preventive Care Guidelines for the Elderly USPSTF

- Fall risk
- Ask if they have fallen in the past year.
- Use fall prevention protocol.
- Ask about alcohol
- Osteoporosis
- All women 65 and older
- High risk women 60-64 (NOF uses 55-64)

## Age-Adjusted Unintentional Injury Death Rates

**Age-Adjusted Unintentional Injury Death Rates**
**CY 1996-1998**

- IHS Adjusted Total - All Areas = 94.7

- U.S. All Races (1997) = 30.1

- Regional Differences in Indian Health – 2000-2001
- Chart 4.18

## Injury Visits By Patients 60-69 Years Old Indian Health Center

## Injury Visits By Patients Over 70 Years Old Indian Health Center

## Preventive Care Guidelines for the Elderly USPSTF

- PPD – high risk only
- Includes diabetes and chronic renal failure

## Preventive Care Guidelines for the ElderlyExpert Opinion

- Functional Status
- ADLs and IADLs
- Weight gain or loss over the preceding year
- Medication review
- Oral health examination
- Cognitive Impairment

## Screening for Dementia

- Pay attention to the conversation.
- Ask the family
- Doubt your impression.
- Supplement impression with objective testing
- 3 item recall and clock face (Mini Cog)
- Jan-Dec / Dec – Jan
- Count change

## Preventive Care Guidelines for the ElderlyExpert Opinion

- Chronic Pain
- Diabetes
- Urinary Incontinence
- Elder Mistreatment
- Abuse, neglect, exploitation

## Preventive Care Guidelines for the ElderlyUSPSTF

- Discuss Prostate Cancer Screening
- USPSTF rates it I (indeterminate)
- If helpful, likely to be helpful age 50-70
- If obtaining a PSA, should probably do a digital prostate examination also.

## Age-Adjusted Prostate Cancer Death Rates

**Age-Adjusted Prostate Cancer Death Rates**
**CY 1996-1998**

- IHS Adjusted Total - All Areas = 11.5

- U.S. All Races (1997) = 13.9

- Regional Differences in Indian Health – 2000-2001
- Chart 4.35

## Key Points in Prostate Cancer Screening - ACP

- Prostate cancer is an important health problem
- The benefits of one-time or repeated screening and aggressive treatment have not yet been proven
- Digital rectal examination and serum PSA testing can have false-positive and false-negative results
- There is a high probability that invasive evaluation will be required if a screening test is positive
- There is a small but definite risk of early death and larger risk of chronic illness (particularly sexual and urinary dysfunction) associated with treatment for prostate cancer
- Early detection may save lives

## Preventive Care Guidelines for the ElderlyUSPSTF

- Immunizations
- Influenza
- Tetanus-Diphteria
- Pneumococcal Vaccination
- Revaccination after 5 years
- Revaccination after 65 if first is before 65

## Age-Adjusted Pneumonia and Influenza Death Rates

**Age-Adjusted Pneumonia and Influenza Death Rates**
**CY 1996-1998**

- IHS Adjusted Total - All Areas = 21.5

- U.S. All Races (1997) = 12.9

- Regional Differences in Indian Health – 2000-2001
- Chart 4.25

## Preventive Care Guidelines for the ElderlyUSPSTF

- Aspirin - chemoprophylaxis
- Men and postmenopausal women with increased risk of CAD (when risk exceeds 3% in 5 years).
- Not good data 75 and above
- Aspirin does not affect risk of stroke, but does increase risk of hemorrhagic stroke
- At age 65 all men would be considered at increased risk
- In Zuni, risk of CAD is lower than Framingham cohort, in White Earth it is higher
- In Zuni would reserve it for those with specific risk factors
- How about White Earth?

## Age-Adjusted Heart Disease Death Rates

**Age-Adjusted Heart Disease Death Rates**
**CY 1996-1998**

- IHS Adjusted Total - All Areas = 157.1

- U.S. All Races (1997) = 130.5

- Regional Differences in Indian Health – 2000-2001
- Chart 4.28

## Preventive Care Guidelines for the ElderlyExpert Opinion

- Adequate Vitamin D and Calcium
- MVI
- Calcium / Vitamin D

## What is ReimbursableMedicare B - Now

- Comprehensive exam to follow chronic disease
- e.g. HTN, DM, CVD, Arthritis
- Colorectal Cancer Screening
- Mammography, Pap
- Osteoporosis Screening
- PSA
- Immunizations, PPD

- Payment for the test, not for time involved in setting it up

## What Will be ReimbursableMedicare B - MMA

- “Introduction to Medicare” visit
- “Initial Preventive Physical Exam”
- Within 6 months of Medicare eligibility
- Only once!!!
- “Cardiovascular Screening Blood Test”
- Not more often than every 2 years
- “Diabetes Screening Test”
- Not more often than every 6 months

- Effective January 1, 2005

## Strategies for Preventive Care

- “Chip Away”
- At chronic care and acute visits
- Need a good system to remind us
- “Dedicated Time”
- Requires additional visit
- Focus on the task at hand
- Pick Priority Areas
- The art of the possible

## Tools to Help Us

- Comprehensive Elder Care PCC
- Elder PCC+
- Electronic Health Record with reminders
- Patient Reminders
- Mailed reminders
- Preventive care record (like pediatric immunization record)

## Is It Possible?How good is good enough?

## One last thought........

## Prevent or delay disability, frailty, and displacement....

- Where do you expect to be when you are older and need help?
- Who knows what you would do or want from your doctor?  Who can speak for you if you are not able to speak for yourself?
- Talk about it with your family!!

## Be the Local Champion

- 413-584-0790
- 615-417-4915 (cell)
- bruce.finke@mail.ihs.gov