Seniors and their caregivers are often inundated with messages touting the importance of screening tests and the benefits of early detection and increased effectiveness when it comes to treating diseases and managing chronic medical conditions. Unlike diagnostic tests, which are performed to determine the cause of certain symptoms that are already present, screening tests are performed on patients who do not show any symptoms of disease.
For those age 65 and older, Medicare Part B covers more than a dozen preventive and screening services, including bone mass measurements to detect osteoporosis, mammograms to screen for breast cancer and colorectal cancer screenings like colonoscopies.
As older adults begin experiencing age-related decline and requiring more assistance with daily tasks, they and their supportive family members often begin to wonder whether all these tests and frequent doctor’s appointments are entirely necessary. Unfortunately, the answer to this question is rather complex and must be considered on a case-by-case basis.
Age Is Just a Number
Many health organizations, including the American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC) and the U.S. Preventative Services Task Force (USPSTF), rely on age to make medical screening recommendations.
While age is an easy metric to measure and collect, this number can reveal surprisingly little about a patient’s health status. Relying too heavily on age to guide decision-making in health care can lead to confusing interactions between seniors and their doctors. “Screening tests are often done in elderly patients as a knee-jerk reaction,” says Dr. Damon Raskin, a board-certified internist and medical director for two skilled nursing facilities located in Santa Monica, California. “What is more important than age is what’s going on with the patient.”
For example, starting at age 50, the USPSTF recommends that all adults undergo a colonoscopy at least once every ten years until age 75. However, a study conducted by researchers from the University of Texas concluded that 23.4 percent of colonoscopies performed on Texas Medicare patients aged 70 and older were inappropriate, given the patients’ ages and estimated risks for colon cancer. While generally a safe test, a colonoscopy can result in internal bleeding, infection and even perforation of the intestines.
When considering whether to perform a screening test on an elder, the things that a physician should focus on are their overall health, goals, health history and prognosis.
“You can have an 80-year-old who’s really like a 60-year-old in terms of their health. In these instances, screening tests such as mammograms and colonoscopies can be extremely valuable,” explains Dr. Raskin. “However, I’ve also treated 65-year-olds who have end-stage Parkinson’s disease or Alzheimer’s disease. For these individuals, I probably wouldn’t recommend screenings for quality of life reasons.”
Understanding the Implications of Screening Tests
Even if a physician recommends a screening to a senior, they still can’t force their patients to follow through. Given this fact, why is it that so many seniors choose to undergo tests they may not even need?
“I think one big problem is that people don’t always look at the consequences of tests,” Dr. Raskin laments.
For example, a suspicious mammogram typically leads to a doctor recommendation for a breast biopsy where a sample of breast tissue is removed and examined under a microscope to detect abnormal cells. While breast tissue biopsies are typically minor surgical procedures, they still carry a risk of infection, particularly for older adults whose immune systems are compromised. According to the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services, more than one million breast biopsies are performed annually. Of these biopsies, nearly 80 percent come back negative for cancer, meaning that many women are needlessly risking infection.
Most patients are understandably interested in gaining a clear picture of their own health, but do the benefits of these types of tests outweigh the time, possible discomfort, anxiety, expense and physical risks involved? And looking beyond the immediate drawbacks of the tests themselves, the all-important question remains: If results indicate the presence of cancer or another serious medical condition, would the patient seek treatment? Would they be willing to undergo surgery, chemotherapy, or radiation, take additional medications, or go to inpatient rehabilitation?
When a senior already has one or more chronic conditions, screening decisions can become even more complex. For example, a loved one with severe arthritis and limited mobility may find it challenging and painful to attend doctor’s appointments for regular screenings. But if they are in good health otherwise, it may behoove them to continue prioritizing preventative care. Very elderly individuals and those with severe existing medical issues may decide against a particular screening test for another condition that, if present, would probably progress slowly and have little effect on their overall longevity and quality of life.
Screening decisions for elders with Alzheimer’s disease and other forms of dementia typically present the biggest challenge for caregivers. Dementia patients may have trouble understanding the instructions associated with testing and tolerate discomfort poorly, which can result in confusion and even agitated outbursts. General anesthesia, which is needed for some tests like colonoscopies, can exacerbate a senior’s mental decline as well. Ultimately, deciding whether to follow through with recommended screenings and potential treatments boils down to respecting a senior’s goals and desires pertaining to their health care and their quality of life.
Seniors Consider Screenings “Routine” and Morally Obligatory
To gain insight into potential strategies for reducing overscreening of older adults and individuals with existing chronic conditions, researchers at the Indiana University Center for Aging Research set out to collect information on seniors’ perceptions regarding cancer screening cessation.
Researchers conducted a series of in-depth interviews with dozens of older adults and found that many of these individuals had never even questioned their doctors about the need for certain screenings. When asked why they continued to schedule screening tests, aging respondents provided the following reasons.
- “I think I should, because stopping would be the same as me taking my life. And that’s a sin.”
- “I know I need that done because I love my life, you know. I want to live.”
- “Whenever we were supposed to do something, I just, you know, did it.”
- “Because I was routinely getting them [mammograms] every year.”
Respondents viewed continued screening “as a habit or custom not involving any decision” whereas “cessation of screening would require a major decision.”
Study authors also found that many doctors neglected to discuss the risks and benefits of both continuing and discontinuing screening tests with their patients, but it turns out that doing so may have the potential to undermine already fragile doctor-patient relationships. Several respondents said that they would become mistrustful of a doctor who broached the topic of discontinuing a regular screening and reported that they would probably be motivated to seek a second opinion on the matter.
“Changing patient and physician behavior will be difficult in light of older adults’ highly favorable views of screening,” study authors note, citing the results of a separate pilot study, which found that 43 percent of elders would continue screening even if their doctor suggested they stop.
Improving Communication Between Doctors, Patients and Caregivers
Ultimately, Dr. Raskin feels that the only way to prevent unnecessary screenings for older adults is for physicians to foster open, honest communication with their patients (and family caregivers).
“There needs to be a team approach,” he says. “We need to look at an individual and ask, ‘If we were to find something, would we take any action?’ If the answer is no, then the test shouldn’t be done.”
Countless caregivers seek advice on the Caregiver Forum regarding whether aging and ill loved ones should still be receiving pap smears, mammograms, prostate cancer screenings and other tests and treatments. These family members strive to provide their loved ones with the best care possible but following cookie-cutter recommendations for things like screening tests isn’t always the best way to improve a person’s health or quality of life. Unfortunately, there is often a lot of pressure and undeserved guilt that come with deciding whether to forgo widely accepted medical advice.
Unnecessary screenings increase the burden placed on doctors, patients and caregivers alike. The bottom line is that, regardless of whether a senior has never had a suspicious test result or they have a history of a particular condition for which they would immediately seek treatment, doctors and patients must discuss the risks and benefits of both continuing and forgoing screenings. These frank conversations also provide opportunities to explore alternative tests and timelines that may fit better with a patient’s health care goals. As patients age, their caregivers may need to help instigate these difficult conversations, ask questions and communicate care preferences to physicians.
Sources: USPSTF A and B Recommendations (https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/); Potentially Inappropriate Screening Colonoscopy in Medicare Patients: Variation by Physician and Geographic Region (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1666433); Core Needle and Open Surgical Biopsy for Diagnosis of Breast Lesions: An Update to the 2009 Report. Comparative Effectiveness Review No. 139. (https://effectivehealthcare.ahrq.gov/products/breast-biopsy-update/clinician); Older Adults and Forgoing Cancer Screening: “I Think It Would Be Strange” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748399/); Older adults' attitudes about continuing cancer screening later in life: a pilot study interviewing residents of two continuing care communities (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1559693/)