Medicare's annual wellness visit: 10 years of opportunities gained and lost.

Medicare annual wellness visits (AWV) were initiated 10 years ago. Though AWVs emphasize on disease prevention and health promotion for older adults was a huge step forward, the current "one size fits all" approach does not adequately meet the wellness needs of a diverse population of older adults. Current AWVs do not sufficiently take into consideration the medical, psychological, functional, racial, cultural and socio-economic diversity of older adults. Updated AWVs should be tailored to meet the needs and priorities of older adults receiving them. Several geriatrics approaches to care, including geriatrics Glidepaths and the 4Ms of an Age-Friendly Health System, could help develop and guide a more patient-specific geriatrics focused approach to AWVs. Medicare's IPPE is an ideal time to advise new Medicare beneficiaries regarding what they should and should not do to maximize their ability to be healthy and functionally independent into their 80s, 90s, and 100s.

Atrial fibrillation in older adults with cancer.

Cancer and atrial fibrillation (AF) are common co-morbid conditions in older adults. Both cancer and cancer treatment increase the risk of developing new AF which increases morbidity and mortality. Heart rate and rhythm control along with anticoagulation therapy remain the mainstay of treatment of AF in older adults with both cancer and AF. Adjustments to the treatment may be necessary because of drug interactions with concurrent chemotherapy. Cancer and old age increase the risk of both, thromboembolism and bleeding. The risk of these complications is further enhanced by concomitant cancer therapy, frailty, poor nutrition status and, coexisting geriatric syndromes. Therefore, careful attention needs to be given to the risks and benefits of using anticoagulant medications. This review focuses on the management of AF in older patients with cancer, including at the end-of-life care.

The prevention of osteoporosis and sarcopenia in older adults.

Osteoporosis and sarcopenia are common in older adults. Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Bone fractures can result in changes in posture, pain, the need for surgical repair and functional impairment. Sarcopenia is the progressive and generalized loss of skeletal muscle mass, strength and/or physical performance. Older adults with sarcopenia experience increased risk of frailty, disability, hospitalizations, mortality, and a reduced quality of life. In this narrative review we provide guidance regarding the prevention of both osteoporosis and sarcopenia, including interventions that prevent both conditions from occurring, recommended screening and treatment to prevent progression.

Age-Related Trajectories of Cardiovascular Risk and Use of Aspirin and Statin Among U.S. Adults Aged 50 or Older, 2011-2018.

OBJECTIVES: To examine age-related trajectories of cardiovascular risk and use of aspirin and statin among U.S. adults aged 50 or older. DESIGN: Repeated cross-sectional study using data from 2011 to 2018 National Health and Nutrition Examination Surveys. SETTING: Nationally representative health interview survey in the United States. PARTICIPANTS: Non-institutionalized adults aged 50 years and older (n = 11,392 unweighted). MEASUREMENTS: Primary prevention was defined as the prevention of a first cardiovascular event including coronary heart disease, angina/angina pectoris, heart attack, or stroke, whereas secondary prevention was defined as those with a history of these clinical conditions. Medication use was determined by self-report; aspirin use included dose and frequency, and statin use included generic names, days of prescription fills, and indications. We examined linear trends between age and each medication use, after controlling for period, sex, and race/ethnicity. RESULTS: Prevalence of those eligible for primary prevention treatment increased with age from 31.8% in ages 50-54 to 52.0% in ages ≥75 (p < 0.001). Similarly, those eligible for secondary prevention treatment increased with age from 2.7% in ages 50-54 to 21.1% in ages ≥75 (p < 0.001). Low-dose daily aspirin use increased with age (p < 0.001), and 45.3% of adults aged ≥75 took low-dose aspirin daily for primary prevention. Statin use also increased with age (p < 0.001), and 56.4% of adults aged ≥75 had long-term statin use for secondary prevention. CONCLUSION: While adults aged ≥75 do not benefit from the use of aspirin to prevent the first CVD, many continue to take aspirin on a regular basis. In spite of the clear benefit of statin use to prevent a subsequent CVD event, many older adults in this risk category are not taking a statin. Further education and guidance for both healthcare providers and older adults regarding the appropriate use of aspirin and statins to prevent CVD is needed.

Promoting Healthy Aging During COVID-19.

Older adults have been markedly impacted by the coronavirus disease 19 (COVID-19) pandemic. The American Geriatrics Society previously published a White Paper on Healthy Aging in 2018 that focused on a number of domains that are core to healthy aging in older adults: health promotion, injury prevention, and managing chronic conditions; cognitive health; physical health; mental health; and social health. The potentially devastating consequences of COVID-19 on health promotion are recognized. The purpose of this article is multifold. First, members of the Healthy Aging Special Interest Group will present the significant difficulties and obstacles faced by older adults during this unprecedented time. Second, we provide guidance to practicing geriatrics healthcare professionals overseeing the care of older adults. We provide a framework for clinical evaluation and screening related to the five aforementioned domains that uniquely impact older adults. Last, we provide strategies that could enhance healthy aging in the era of COVID-19.

Cancer Prevention and Screening for Older Adults: Part 1. Lung, Colorectal, Bladder, and Kidney Cancer.

The incidence of most cancers increases with age. Cancer is the second most common cause of death in older adults after cardiovascular disease. Many common cancers in older adults can be prevented from occurring or can be identified at an early stage and treated effectively. The prevention and identification of cancer in its early stages, in an attempt to reduce discomfort and disability associated with advanced cancer and cancer treatment, is also a priority. Overscreening for cancer in older adults can lead to unnecessary diagnostic testing and unnecessary treatment. Both older adults and their healthcare providers need guidance on the appropriate use of cancer prevention and screening interventions. This first of a two-part review addresses special considerations regarding cancer prevention for adults aged 65 and older. Screening decisions and the impact of limited life expectancy and an older adult's ability to tolerate cancer treatment are also addressed. Guidance is provided regarding the prevention and early identification of lung, colorectal, bladder, and kidney cancer in older adults. The prevention of breast, prostate, and female urogenital cancers are addressed in Part 2. J Am Geriatr Soc 68:2399-2406, 2020.

Cancer Prevention and Screening for Older Adults: Part 2. Interventions to Prevent and Screen for Breast, Prostate, Cervical, Ovarian, and Endometrial Cancer.

The incidence of most cancers increase with age. Cancer is the second most common cause of death in older adults after cardiovascular disease. Many common cancers in older adults can be prevented from occurring or can be identified at an early stage and treated effectively. Although cancer is feared primarily because of premature mortality, for many older adults, preventing and identifying cancer in its early stages, in an attempt to reduce discomfort and disability associated with advanced cancer and cancer treatment, is also a priority. Overscreening for cancer in older adults can lead to unnecessary diagnostic testing and unnecessary treatment. Both older adults and their healthcare providers need guidance on the appropriate use of cancer prevention and screening interventions. This is the second part of a two-part clinical review on cancer prevention and screening for adults aged 65 and older. Guidance is provided regarding the prevention and early identification of breast, prostate, cervical, ovarian, and endometrial cancer. The prevention of lung, colorectal, bladder, and kidney cancer is addressed in Part 1.

The Prevention of Cardiovascular Disease in Older Adults.

Cardiovascular disease (CVD) is common in older adults. CVD is a significant cause of both death and disability in old age. Though the prevention and treatment of CVD have been extensively studied, historically older adults and especially those older than 75 years have been underrepresented in clinical investigations designed to determine the best way to prevent or treat CVD. As a result, geriatrics clinicians frequently need to decide which interventions to recommend for their patients by extrapolation from existing data, which may or may not be applicable to the patients they are caring for. This narrative review summarizes existing data regarding the prevention of three common CVDs in older adults: stroke, coronary artery disease, and peripheral artery disease. Special emphasis is given to the prevention of CVD in those aged 75 years or older. J Am Geriatr Soc 68:1098-1106, 2020.

The Prevention of Infections in Older Adults: Oral Health.

The oral cavity is exposed to the external environment and from a very young age is colonized by infectious agents. Under certain circumstances including poor oral hygiene, dry mouth, trauma, and the use of antibiotics, oral infections can occur. They can result in damage to the oral cavity including teeth and their support structures. Oral infections can also lead to the extension of infection into surrounding tissues and to systemic infections. Chronic oral infection is a recognized risk factor for heart disease. Older adults are at high risk for oral infections and associated complications. Tooth loss, for which infection is the most significant cause, leads to cosmetic changes and a decreased ability to masticate certain foods that can lead to malnutrition. Chronic oral infections and the manipulation of teeth and supporting structures can lead to the hematogenous spread of infection including the infection of artificial joints and endocardial implants. Good oral hygiene, the use of fluoride, regular dental care, and the appropriate use of antibiotics can all reduce oral infections and their associated complications. J Am Geriatr Soc 68:411-416, 2020.

The Prevention of Infections in Older Adults: Vaccination.

All living beings are at risk for experiencing infections; humans are no exception. The prestige and credibility of modern medicine is built in large part on achievements in preventing and treating infectious diseases. For most of human history, there was little that could be done to prevent and treat infections. Millions of humans, of all ages, have died from infections; and in some parts of the world, infection-related deaths remain common. Advances in preventing and treating infectious diseases include improved sanitization, sterilization, pasteurization, immunization, and antibiotics. Vaccination has played a major role in the prevention of lethal diseases, such as smallpox, diphtheria, cholera, and influenza. Because of developing or waning immune function, the young and the old are at particularly high risk of experiencing infections. Influenza and pneumonia remain common causes of death in older adults. Influenza, in particular, has the potential to result in premature mortality for all age groups, including those who are older and particularly those who live in congregate settings. Vaccination is important in promoting healthy aging. J Am Geriatr Soc 68:207-214, 2019.

Healthy Aging: American Geriatrics Society White Paper Executive Summary.

In July 2015, the Journal of the American Geriatrics Society published a manuscript titled, "Failing to Focus on Healthy Aging: A Frailty of Our Discipline?" In response, the American Geriatrics Society (AGS) Clinical Practice and Models of Care Committee and Public Education Committee developed a white paper calling on the AGS and its members to play a more active role in promoting healthy aging. The executive summary presented here summarizes the recommendations from that white paper. The full version is published online at GeriatricsCareOnline.org. Life expectancy has increased dramatically over the last century. Longer life provides opportunity for personal fulfillment and contributions to community but is often associated with illness, discomfort, disability, and dependency at the end of life. Geriatrics has focused on optimizing function and quality of life as we age and reducing morbidity and frailty, but there is evidence of earlier onset of chronic disease that is likely to affect the health of future generations of older adults. The AGS is committed to promoting the health, independence, and engagement of all older adults as they age. Geriatrics as an interprofessional specialty is well positioned to promote healthy aging. We draw from decades of accumulated knowledge, skills, and experience in areas that are central to geriatric medicine, including expertise in complexity and the biopsychosocial model; attention to function and quality of life; the ability to provide culturally competent, person-centered care; the ability to assess people's preferences and values; and understanding the importance of systems in optimizing outcomes. J Am Geriatr Soc 67:17-20, 2019.

Dementia and the law in Connecticut.

Laws pertain to almost every aspect of our lives. How a law applies to a person or one situation is dependent on many variables. One important variable is the capacity of a person to understand the ramifications of their actions. One of the most common reasons for permanent loss of decisional capacity is the development of dementia. Dementia is primarily a disease of old age. As the population of Connecticut ages and the prevalence of dementiaincreases, physicians will be presented with an increasing number of difficult decisions, where the interface between the law and medical practice will have an impact on their approach to the patient and their medical care. Familiarity with pertaining Connecticut laws and the appropriate procedures to follow as outlined by those laws will help physicians address these complex issues.

Diagnosis and management of Alzheimer's disease.

Alzheimer's disease is a progressive neurological condition that usually presents with short-term memory impairment, and then progresses to profound cognitive and physical disability. The diagnosis is based primarily on clinical findings with a definitive diagnosis only being possible with pathological examination of brain tissue. Alzheimer's disease causes distress to patients, families and caregivers. Most patients with advanced Alzheimer's disease need 24-hour supervision, often provided in a long-term care setting. Although no cure is available, with a variety of treatments, modest but measurable benefits are available. Research is being conducted to find more effective treatments and hopefully in time a cure or means of prevention. All physicians whose practice includes older patients need to possess some familiarity with the diagnosis and management of Alzheimer's disease.

Best practices in hospital end-of-life care.

The Connecticut Best Practices in End-of-Life Care project was initiated in response to the concern that Connecticut hospitals were not meeting the needs of dying patients. The records of 420 patients with a diagnosis of cancer or with an admission to an intensive-care unit were reviewed for the period 04/01/2000 to 03/31/2001. Utilizing a chart extraction tool, measures of "best practice" were developed as a means of assessing the quality of end-of-life care provided to the patient cohort. Some of the findings on the "best practice" indicators were as follows: 65 (15.3%) of the patient cohort died during their hospital stay. Three hundred forty (81.3%) had a pain assessment on admission. Three hundred eighty-six (92.6%) had a pain assessment on at least one occasion during their hospital stay. Two hundred forty-two of 397 (61%) patients who received an analgesic medication had their pain reassessed within fours hours of receiving the medication. One hundred ninty-five (46.4%) patients had their prognosis discussed with them. Eighteen patients (< 5%) were referred to hospice. Connecticut hospitals are doing well in assessing patient pain. However, they are doing poorly in discussing prognosis with sick patients and referring them to hospice.