Treating older female patients
Common medical issues
By Amy Diede, MD
From Minnesota Healthcare News
As a family medicine physician, I treat patients of all ages and have learned that it takes more diligence to identify, diagnose, and treat some of the more common medical conditions in older women. The average 75-year-old has at least three chronic conditions and takes five or more medications, according to “About Medical Care for the Elderly” by Thomas Day, director of the National Care Planning Council. In addition, some older patients may be reluctant to admit to physical problems or limitations for fear of treatment or changes in lifestyle. Following are some lessons I’ve learned through the years when treating older women patients.
Screenings and immunizations
Standard protocol suggests yearly mammograms for women, beginning at the age of 40, unless a woman is at high risk for breast cancer or has an immediate issue. Changes in breast density as women age make it more difficult to detect problems with a physical exam, making mammograms even more important.
Most physicians today follow guidelines recommending Pap testing every three years until the age of 65, if previous tests for cervical cancer have been negative. After that, barring any new issues, they can be discontinued.
DEXA scans are important for women with osteopenia or osteoporosis to evaluate any change in severity. According to the American Congress of Obstetricians and Gynecologists, osteoporosis is five times more prevalent in women than in men. It recommends DEXA screening beginning at age 65 or sooner if a woman is at higher risk.
Colonoscopies are suggested for all patients, beginning at the age of 50, and then every 10 years if the results are normal. Women (and men) at high risk for colon cancer, or those with polyps or abnormal colonoscopy results, should repeat the test every three to five years.
Immunizations are important, as well. Everyone should have a tetanus vaccine every 10 years and a flu shot every year. The shingles (Zoster) vaccine only needs to be given once but is important in preventing or reducing the severity of shingles. To prevent or reduce the complications of pneumonia, your patients should receive both the Pneumovax 23 and Prevnar 13 pneumonia vaccines. They are recommended for all adults over 65.
Some older women may need help navigating the side effects of menopause, from hot flashes and mood changes to weight gain and vaginal dryness. While there are numerous hormone therapies on the market today, most physicians prefer to limit the length of time they prescribe these medications, due to the long-term side effects, which can include cancer. In 2013, the U.S. Food and Drug Administration approved Brisdelle (paroxetine) as the first non-hormonal treatment for moderate to severe vasomotor symptoms, including hot flashes. Other non-hormonal options also exist to help with menopausal symptoms, and a variety of lubricants are available for vaginal dryness.
Risk for heart disease
One in four women will die from heart disease, according to the National Heart, Lung and Blood Institute, and the risk increases with a woman’s age. We need to be vigilant about evaluating for symptoms that patients might not
connect with high blood pressure, a risk factor for stroke and heart disease. Ask them about frequent headaches, dizziness, and ringing in the ears. Coronary artery disease is the most common cause of heart disease. Make sure your patients know the warning signs of heart disease, including fatigue, shortness of breath, nausea or indigestion, jaw or throat pain, or pain in the left arm.
Many older women suffer in silence from urinary incontinence (stress incontinence, urge incontinence, or overactive bladder) because of their reluctance to bring up such a private issue with their physician. Yet, today there are drugs, surgical treatments, and implanted devices, such as the InterStim Therapy System, that are highly effective for urinary incontinence. Sometimes urinary incontinence is caused by vaginal atrophy or pelvic prolapse. According to Vanessa Knoedler, MD, gynecologist with Metro OBGYN, pelvic organ prolapse affects as many as 35 percent of adult women worldwide and is associated with age and obesity. In addition to lifestyle changes, physical therapy, and Kegel exercises, women with pelvic prolapse can be treated with pessaries and surgery.
Discussions about medications
Many older women take multiple medications daily, increasing their risks for side effects, negative interactions, and addiction, especially to narcotic pain medications. Make sure to update a patient’s medication list diligently at each visit. In addition, test for liver and kidney function, as impairment in either can alter the effectiveness of a medication. Non-compliance can also be a factor in elderly patients, especially those with limited incomes who may have to choose between purchasing a medicine and buying groceries.
Impaired hearing and vision
According to experts at Hearing Health, more than 80 percent of individuals with clinically advanced hearing loss are never diagnosed or treated. A routine hearing screening by licensed clinical staff taking only 30 to 45 seconds is now part of every complete Apple Valley Medical Clinic exam for adults 55 and older. If follow up is needed, we offer comprehensive four-part audiometry, video otoscopy, or referral for ENT consultation and testing. Vision problems, too, are common in elderly women. Macular degeneration, glaucoma, and cataracts are the most common diagnoses. Watch for signs that your patient may not see as well as she should, and refer her to an ophthalmologist if you suspect a vision deficiency.
Dementia and Alzheimer’s disease
Older women patients may become forgetful and somewhat confused at times, but dementia is not a normal part of aging. Alzheimer’s disease is a specific form of dementia and accounts for up to 80 percent of all cases, according to the Alzheimer’s Association. Certain signs to watch for include changes in a patient’s mood or personality, withdrawal from activities she used to enjoy, change in judgment, difficulty speaking or writing, and confusion about time and place. Spend a little time probing for signs of dementia with the use of simple mental status evaluations.
Screening for depression
Taking time in a primary care visit to screen for depression can be difficult, but depression is a common comorbidity of certain illnesses that affect elderly women, such as arthritis, diabetes, thyroid disorders, and heart disease. Older adults are often misdiagnosed and undertreated, according to the Centers for Disease Control and Prevention’s “Mental Health and Aging” website. This is because health care providers may see symptoms of depression as a reaction to illness or life changes, and the patient may not seek help because she doesn’t know she could feel better with treatment. Anti-depression drugs and psychotherapy can be effective treatments for depression, even in elderly patients.
Exercise and proper nutrition
As our patients age and their metabolism changes, they often face a higher propensity toward obesity. Remind them that being overweight can lead to joint degeneration, heart problems, stroke, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and other conditions. In addition, as patients age there is a tendency to become more sedentary, making it more important for us to stress the benefits of physical activity. Even seemingly minor exercises can result in less joint pain from osteoarthritis, lower blood pressure, less depression, fewer heart attacks, lower incidence of cancer and diabetes, fewer life-threatening falls, and the possibility of reducing the number of medications.
As a family medicine physician, I am honored to care for patients of all ages and look forward to helping my female patients enter their later years with grace, happiness, and good health.
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