Mayo Clinic Proceedings Home

Common Curbsides and Conundrums in Geriatric Medicine

      Abstract

      Within the next 15 years, the population of adults 65 years and older in the United States will double to approximately 70 million. Physicians must be well prepared to care for this rapidly growing population. Senior adults comprise a large proportion of most primary care practices in the United States, and the unique needs of this population cannot be overstated. Although traditional preventive screening modalities and disease-specific care models are of great utility, these processes may not be appropriate or consistent with the health goals of many older patients with multiple chronic conditions and reduced functional capacity. This Concise Review highlights commonly encountered clinical scenarios important to the care of these older patients. The topics include diagnosis and management of mild cognitive impairment, assessment of the cognitively impaired driver, cancer screening in the older patient, and sarcopenia.

      Abbreviations and Acronyms:

      MCI (mild cognitive impairment), MVC (motor vehicle collision), PSA (prostate-specific antigen), USPSTF (US Preventive Services Task Force)
      CME Activity
      Target Audience: The target audience for Mayo Clinic Proceedings is primarily internal medicine physicians and other clinicians who wish to advance their current knowledge of clinical medicine and who wish to stay abreast of advances in medical research.
      Statement of Need: General internists and primary care physicians must maintain an extensive knowledge base on a wide variety of topics covering all body systems as well as common and uncommon disorders. Mayo Clinic Proceedings aims to leverage the expertise of its authors to help physicians understand best practices in diagnosis and management of conditions encountered in the clinical setting.
      Accreditation: College of Medicine, Mayo Clinic is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
      Credit Statement: College of Medicine, Mayo Clinic designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
      Learning Objectives: Educational objectives. On completion of this article, you should be able to (1) demonstrate the ability to communicate with patients (and their families) about the diagnosis of mild cognitive impairment, (2) apply a paradigm for addressing cancer screening tests with older patients, and (3) recognize the evidence base for treatment of muscle mass loss in the older patient.
      Disclosures: As a provider accredited by ACCME, College of Medicine, Mayo Clinic (Mayo School of Continuous Professional Development) must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course Director(s), Planning Committee members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. Disclosure of this information will be published in course materials so that those participants in the activity may formulate their own judgments regarding the presentation.
      In their editorial and administrative roles, William L. Lanier, Jr, MD, Terry L. Jopke, Kimberly D. Sankey, and Nicki M. Smith, MPA, have control of the content of this program but have no relevant financial relationship(s) with industry.
      The authors have no competing interests.
      Method of Participation: In order to claim credit, participants must complete the following:
      • 1.
        Read the activity.
      • 2.
        Complete the online CME Test and Evaluation. Participants must achieve a score of 80% on the CME Test. One retake is allowed.
      Participants should locate the link to the activity desired at http://bit.ly/13mL9js. Upon successful completion of the online test and evaluation, you can instantly download and print your certificate of credit.
      Estimated Time: The estimated time to complete each article is approximately 1 hour.
      Hardware/Software: PC or MAC with Internet access.
      Date of Release: 06/01/2013
      Expiration Date: 05/31/2015 (Credit can no longer be offered after it has passed the expiration date.)
      Questions? Contact [email protected] .
      Individuals with mild cognitive impairment (MCI) experience clinically important memory loss that does not meet the diagnostic criteria for dementia.
      • Petersen R.C.
      Clinical practice: mild cognitive impairment.
      Mild cognitive impairment is common, with up to 20% of seniors aged 65 years and older having this syndrome.
      • Plassman B.L.
      • Langa K.M.
      • Fisher G.G.
      • et al.
      Prevalence of cognitive impairment without dementia in the United States.
      These individuals are at heightened risk for progressing to dementia, with annual rates of progression to overt dementia ranging from 5% to 15%.
      • Petersen R.C.
      Clinical practice: mild cognitive impairment.
      The National Institute on Aging and Alzheimer’s Association Workgroup
      • Albert M.S.
      • DeKosky S.T.
      • Dickson D.
      • et al.
      The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease.
      has recently updated the diagnostic guideline for the diagnosis of MCI. This updated guideline describes the evolution from the original construct of MCI as a precursor state for Alzheimer dementia to that of a heterogeneous condition that can lead to other types of dementia.
      • Albert M.S.
      • DeKosky S.T.
      • Dickson D.
      • et al.
      The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease.
      The cognitive impairment associated with MCI goes beyond the mild changes in episodic memory for recent events seen with normal aging and is evidenced by objectively lower performance in one or more cognitive domains, such as memory, visual spatial orientation, executive function, and language. Retention of daily functional capacity is the key differentiating factor that distinguishes MCI from dementia.
      • Petersen R.C.
      Clinical practice: mild cognitive impairment.
      These individuals typically score 1 to 1.5 SDs below the mean when compared with age- and educationally matched peers on mental status testing.
      • Albert M.S.
      • DeKosky S.T.
      • Dickson D.
      • et al.
      The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease.
      When results of office-based mental status testing are completely normal and there is still major concern from the patient, family, or clinician, formal neuropsychological testing can be useful. However, routine use of neuropsychological testing is not needed.
      Randomized clinical trials examining the role of cognitive enhancement medications in the prevention of dementia have not shown long-term efficacy.
      • Raschetti R.
      • Albanese E.
      • Vanacore N.
      • Maggini M.
      Cholinesterase inhibitors in mild cognitive impairment: a systematic review of randomised trials.
      One study, which randomized patients with MCI to receive donepezil, higher-dose vitamin E, or placebo, revealed a decreased risk of progression to dementia at 1 year in the donepezil group; however, none of the groups had a significant positive effect on the risk for development of dementia at 3 years.
      • Petersen R.C.
      • Thomas R.G.
      • Grundman M.
      • et al.
      Vitamin E and donepezil for the treatment of mild cognitive impairment.
      Currently, there are no Food and Drug Administration–approved medications for MCI. Individuals being treated off-label with cholinesterase inhibitors need to be counseled about the potential for adverse effects, including diarrhea, weight loss, orthostasis, and bradyarrhythmia.
      Patients and their families should also be counseled about the nonpharmacologic modalities aimed at preservation of cognitive function. Cognitive intervention programs that include cognitive training, stimulation, and/or rehabilitation have been studied and have shown promise in the management of MCI, although published trials are often of small sample sizes. These programs target at least one memory domain via a number of novel modalities, including computer-based training and occupational therapy.
      • Jean L.
      • Bergeron M.E.
      • Thivierge S.
      • Simard M.
      Cognitive intervention programs for individuals with mild cognitive impairment: systematic review of the literature.
      Baker et al
      • Baker L.D.
      • Frank L.L.
      • Foster-Schubert K.
      • et al.
      Effects of aerobic exercise on mild cognitive impairment: a controlled trial.
      randomized older adults with MCI to a daily program of high-intensity exercise vs a placebo stretching program and found that individuals in the aerobic exercise program experienced statistically significant improvement in executive control abilities at 6 months. Systematic evaluation of these cognitive intervention programs revealed statistically significant improvements in objective and subjective measures of memory and quality of life, but the clinically significant effect of such programs is less well understood.
      • Jean L.
      • Bergeron M.E.
      • Thivierge S.
      • Simard M.
      Cognitive intervention programs for individuals with mild cognitive impairment: systematic review of the literature.
      Many health centers now offer cognitive rehabilitation programs for the management of MCI and dementia.
      Mild cognitive impairment is notable for retention of daily functional capacity despite clinically remarkable memory loss. It is important for clinicians to be up front with patients and their families when making this diagnosis and to provide appropriate supportive counseling and anticipatory guidance. Individuals with MCI should be clinically reevaluated at 6- to 12-month intervals for progression to dementia.

      Evaluation of Driving Risk in the Cognitively Impaired Patient

      It has been projected that by 2020 more than 40 million licensed US drivers will be older than 65 years.

      American Medical Association. Physician's Guide to Assessing and Counseling Older Drivers. 2nd ed. http://www.ama-assn.org/ama1/pub/upload/mm/433/older-drivers-guide.pdf. Accessed January 8, 2012.

      Older drivers are at particularly high risk of motor vehicle collisions (MVCs) and are more susceptible to MVC-induced injuries and death compared with younger drivers.
      • Meuleners L.B.
      • Harding A.
      • Lee A.H.
      • Legge M.
      Fragility and crash over-representation among older drivers in Western Australia.
      This risk is even more pronounced among older individuals with cognitive impairment. As the population of older adults with cognitive impairment burgeons, physicians will be increasingly asked to assess their patients’ driving risks and weigh these risks against the patient’s desire for continued transportation independence and adverse effects of driving cessation.
      Consensus exists that individuals with moderately severe dementia, as evidenced by difficulty completing activities of daily living independently, should be completely restricted from driving and that individuals with very mild MCI, with minimal functional limitations, may be permitted to continue driving. However, recent studies have suggested that 55% to 76% of individuals with mild dementia, based on a global assessment measure such as the Clinical Dementia Rating, are still able to pass the on-road test,
      • Brown L.B.
      • Ott B.R.
      • Papandonatos G.D.
      • Sui Y.
      • Ready R.E.
      • Morris J.C.
      Prediction of on-road driving performance in patients with early Alzheimer's disease.
      yet may be at elevated risk for an MVC. Thus, the evaluation of individuals in this intermediate-risk group is challenging in the office. Further, data that correlate office-based mental status testing, such as the Mini-Mental State Examination or patient self-rating of unsafe driving, have been conflicting to date. The diagnosis of MCI or mild dementia is not sufficient, on its own, as a reason to restrict driving privileges. Rather, this decision should be made on the basis of individual driving competence.

      Alzheimer's Association. Driving and Dementia. http://www.alz.org/documents_custom/statements/driving_and_dementia.pdf. Accessed January 8, 2012.

      For individuals in this intermediate-risk group, clinicians should take a comprehensive look at risk factors and clinical features that contribute to an individualized qualitative assessment of driving risk. Historical features that are associated with an increased risk of unsafe driving should be elucidated by the clinician. These features include a caregiver report of unsafe driving, history of an MVC in the past 5 years, traffic citation in the past 3 years, and reduced driving mileage.
      • Iverson D.J.
      • Gronseth G.S.
      • Reger M.A.
      • Classen S.
      • Dubinsky R.M.
      • Rizzo M.
      Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology.
      In addition to cognitive assessment, clinicians must also address comorbid conditions, the use of potentially sedating substances, vision, and musculoskeletal range of motion and strength. The American Medical Association has assembled a multicomponent assessment, Driving Related Skills, which addresses each of these functions. This assessment highlights the Trail Making Part B test and the Freund Clock Draw as preferred cognitive assessment tests because patient performance on these tests is associated with MVCs and poor on-road test performance. These tests also correlate well with traditional office-based cognitive assessments.

      American Medical Association. Physician's Guide to Assessing and Counseling Older Drivers. 2nd ed. http://www.ama-assn.org/ama1/pub/upload/mm/433/older-drivers-guide.pdf. Accessed January 8, 2012.

      They can provide information about the severity of dementia but must be interpreted within the context of the comprehensive assessment. Clinicians can also refer patients to a certified driver rehabilitation specialist for additional clinical and functional (on-road) assessment. These consultations often yield specific recommendations for driving restrictions and potential adaptive techniques.
      Clinicians should counsel at-risk drivers and their families about their concerns in a sensitive yet candid manner. States with mandatory reporting require written documentation to the Department of Public Safety; physicians practicing in states with voluntary reporting can still issue a written letter to the Department of Public Safety or Department of Motor Vehicles in cases in which a high-risk driver continues to drive against medical advice. Written documentation of the patient’s name, date of birth, and address should be included with the request for written examination, driving skills examination, or revocation of driver’s license. Counseling about transportation alternatives must be a part of these conversations.
      No single test result or historical feature can accurately quantify driving risk in the older adult with cognitive impairment; however, clinicians can and should make a qualitative estimate of driving risk and communicate this to patients, families, and state-based authorities. Patients who are permitted to continue driving should be reassessed every 6 months.

      American Medical Association. Physician's Guide to Assessing and Counseling Older Drivers. 2nd ed. http://www.ama-assn.org/ama1/pub/upload/mm/433/older-drivers-guide.pdf. Accessed January 8, 2012.

      Cancer Screening in the Older Patient

      Guiding older adults through decisions about cancer screening can be challenging, particularly when determining the appropriate time to discontinue screening. Although prevention and early detection of disease states are central tenets of primary care, clinicians must balance the potential for efficacy and harm from cancer screening modalities when caring for the older adult with multimorbid conditions or decreased life expectancy.
      • Clarfield A.M.
      Screening in frail older people: an ounce of prevention or a pound of trouble?.
      An individual’s age remains the most important predictor of his life expectancy. Variability exists between the screening cessation recommendations from major specialty organizations, making it critical for the primary care physician to have a general framework for addressing these decisions. In addition to familiarity with available guidelines, the physician must consider the individual’s life expectancy, functional status, comorbid conditions, and overall health goals and preferences and the potential benefits and harms of the screening test (Table).
      • Albert R.H.
      • Clark M.M.
      Cancer screening in the older patient.
      • Terret C.
      • Castel-Kremer E.
      • Albrand G.
      • Droz J.P.
      Effects of comorbidity on screening and early diagnosis of cancer in elderly people.
      Although estimating remaining life expectancy in individuals without a dominant terminal diagnosis is not a precise science, online tools, such as eprognosis.org, can assist clinicians in identifying prognostic tools that best fit their patient’s clinical scenario.
      TableClinical Considerations for Cancer Screening in the Older Patient
      • 1.
        Overall life expectancy at current age
        • Eprognosis.org, a repository of published geriatric prognostic indexes can be used
      • 2.
        Presence of comorbid conditions that limit life span, eg:
        • Dementia
        • Advanced COPD
        • NYHA IV congestive heart failure
        • Hip fracture
      • 3.
        Mean life expectancy based on functional status and disability
        • Dependence in instrumental and basic activities of daily living is independently associated with greater risk of death
      • 4.
        Balancing benefits and harms of:
        • Screening tests
        • Inaccurate test results
        • Disease treatment
      • 5.
        Patient preferences about screening and overall goals of care
      • 6.
        Individuals with a life expectancy of ≤5 y are unlikely to derive survival benefit from cancer screening
        • Terret C.
        • Castel-Kremer E.
        • Albrand G.
        • Droz J.P.
        Effects of comorbidity on screening and early diagnosis of cancer in elderly people.
      COPD = chronic obstructive pulmonary disease; NYHA = New York Heart Association.

      Breast Cancer Screening

      The US Preventive Services Task Force (USPSTF) guideline states that evidence is insufficient for the continuation of screening mammography in women aged 75 years and older.
      • Nelson H.D.
      • Tyne K.
      • Naik A.
      • Bougatsos C.
      • Chan B.K.
      • Humphrey L.
      Screening for breast cancer: an update for the U.S. Preventive Services Task Force.
      The American Geriatrics Society has recommended continuation of mammography for women with a life expectancy of 4 or more years.
      American Geriatrics Society Clinical Practice Committee
      Breast cancer screening in older women.
      Estimated lifetime risk of breast cancer may be quantified through known risk factors calculated with tools such as the online risk assessment provided by the National Cancer Institute (http://www.cancer.gov/bcrisktool/). Screening the oldest old, those 85 years and older, may result in the identification of tumors that may not have become clinically important during a patient’s lifetime.
      • Schonberg M.A.
      • Silliman R.A.
      • Marcantonio E.R.
      Weighing the benefits and burdens of mammography screening among women age 80 years or older.

      Colorectal Cancer Screening

      The USPSTF recommends against routine colon cancer screening in patients between the ages of 76 and 85 years unless there are individual reasons that would support screening (Grade C recommendation). The USPSTF recommends against screening those who are older than 85 years because other competing causes of death preclude any mortality benefit that would outweigh potential risks of the procedure (Grade D recommendation).
      U.S. Preventive Services Task Force
      Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement.
      The decision to screen a patient older than 75 years who has never been screened should depend on the patient's health status, personal risk factors, family history of colorectal cancer, and personal values.
      U.S. Preventive Services Task Force
      Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement.

      Cervical Cancer Screening

      The USPSTF outlines cessation of testing at the age of 65 years if previous screening has been adequate and the patient is not at otherwise high risk for cervical cancer.
      • Moyer V.A.
      U.S. Preventive Services Task Force
      Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement.
      Similarly, the American College of Obstetrics and Gynecology advises screening cessation at the age of 65 years in women with adequate negative prior screening results and no history of cervical intraepithelial neoplasia type 2 or higher.
      Committee on Practice Bulletins—Gynecology
      ACOG Practice Bulletin Number 131: screening for cervical cancer.
      High-grade lesions are relatively rare among older women who have been previously screened and without additional risk factors. Cervical cancer screening may be stopped after surgical removal of the cervix for benign conditions.
      • Moyer V.A.
      U.S. Preventive Services Task Force
      Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement.

      Prostate Cancer Screening

      Debate exists between available guidelines regarding the decision-making process behind prostate-specific antigen (PSA) testing. The USPSTF updated its recommendations in 2012 to recommend against PSA-based screening for prostate cancer, concluding that there is moderate certainty that the benefits of such screening do not outweigh the harms (Grade D).
      • Moyer V.A.
      U.S. Preventive Services Task Force
      Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement.
      The American Urological Society recommends that clinicians continue to dialogue about the risks and benefits of PSA screening and suggest that annual PSA testing and digital rectal examination be continued in men with an estimated life expectancy of 10 years or more.
      • Greene K.L.
      • Albertsen P.C.
      • Babaian R.J.
      • et al.
      Prostate specific antigen best practice statement: 2009 update.
      When counseling older adults about cancer screening, the clinician should review available guidelines, life expectancy, functional status, prognosis of comorbid conditions, and patient preferences. Clinicians should consider transitioning the preventive counseling toward high-yield geriatric syndromes, such as falls, urinary incontinence, advance care planning, cognitive impairment, and mood disorders.

      Sarcopenia

      Sarcopenia is a common geriatric condition that occurs in 5% to 13% of adults between the ages of 60 and 70 years.
      • Wang C.
      • Bai L.
      Sarcopenia in the elderly: basic and clinical issues.
      It is an important clinical entity because it heralds functional decline, falls, nursing home placement, and mortality. The research definition of sarcopenia is still being developed; however, accepted definitions of sarcopenia include gait speed less than 1.0 m/s and a measured appendicular muscle mass of 2 SDs below the muscle mass of a 20- to 30-year-old individual.
      • Morley J.E.
      • Abbatecola A.M.
      • Argiles J.M.
      • et al.
      Sarcopenia with limited mobility: an international consensus.
      Sarcopenia is an important component of the phenotypic geriatric syndrome of frailty, which involves weakness, slow gait speed, unintentional weight loss, and fatigue. Practically, clinicians rarely obtain appendicular muscle mass and often rely on functional strength to define sarcopenia, which leads to the diagnosis of frailty. Important functional office-based strength tests include measured gait speed, Timed Up and Go, and hand grip strength. To administer the Timed Up and Go test, one must instruct the patient to stand up from a straight-backed chair, walk 3 m, and return to the chair. Gait, balance, and speed are observed. The decline in gait speed, which is an outcome of sarcopenia, helps in the determination of treatment and aids in prognostication.
      • Studenski S.
      • Perera S.
      • Patel K.
      • et al.
      Gait speed and survival in older adults.
      Simple clinical observations, such as the manner in which a patient rises from the seated position to standing or difficulty getting onto the examination table, can also suggest sarcopenia.
      The most effective method of treating sarcopenia is exercise. In a recent meta-analysis, exercise improved gait speed, balance, and quality of life.
      • Chou C.H.
      • Hwang C.L.
      • Wu Y.T.
      Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: a meta-analysis.
      Exercise, with a component of resistance training, is a critical and foundational treatment modality for sarcopenia. Nutritional supplementation is a more controversial treatment of sarcopenia. High dietary protein intake is associated with higher lean muscle mass.
      • Houston D.K.
      • Nicklas B.J.
      • Ding J.
      • et al.
      Dietary protein intake is associated with lean mass change in older, community-dwelling adults: the Health, Aging, and Body Composition (Health ABC) Study.
      Most nutritional supplements and medications to enhance appetite have not been successful in improving clinical outcomes in those patients with sarcopenia. In 2012, megestrol, a commonly used medication to improve appetite, was placed on the updated list of inappropriate medications for elderly individuals.
      American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults.
      In a Cochrane meta-analysis of nutritional supplements after hip surgery, there was limited evidence for the efficacy of nutritional supplementation for clinical outcomes in this high-risk group.
      • Avenell A.
      • Handoll H.H.
      Nutritional supplementation for hip fracture aftercare in older people.
      Thus, physical activity appears to be the more effective lifestyle modification that should be recommended to older adults.
      The use of pharmacologic methods to improve sarcopenia is in various stages of clinical and research development. Hormonal therapy with an emphasis on anabolic steroids has mixed findings. In a meta-analysis, use of testosterone resulted in increased lean muscle mass and strength.
      • Ottenbacher K.J.
      • Ottenbacher M.E.
      • Ottenbacher A.J.
      • Acha A.A.
      • Ostir G.V.
      Androgen treatment and muscle strength in elderly men: a meta-analysis.
      In one major trial of 207 men using testosterone, the authors noted improved muscle mass but no effect on functional status.
      • Emmelot-Vonk M.H.
      • Verhaar H.J.
      • Nakhai Pour H.R.
      • et al.
      Effect of testosterone supplementation on functional mobility, cognition, and other parameters in older men: a randomized controlled trial.
      The effect of both testosterone and human growth hormone on clinically meaningful outcomes, such as falls, hip fractures, and avoidance of hospitalization or nursing home placement, has limited evidence.
      Sarcopenia is the syndrome of muscle wasting in older adults that manifests in falls and functional decline. Clinicians should promote physical activity with a component of resistance training as a core strategy to prevent and treat sarcopenia. The use of anabolic agents and appetite stimulants lacks clinical efficacy.

      Conclusion

      Clinicians must be prepared to provide high-quality, safe, and effective medical care to their senior patients. Evidence-based tools for the diagnosis of common geriatric syndromes, such as cognitive impairment and sarcopenia, can be practically incorporated into the busy clinical setting. Further, with the use of the clinical strategies discussed, clinicians can adopt a patient-centered approach in the discussion of cancer screening cessation and restriction of driving.

      Acknowledgments

      We thank Gladys Hebl from Mayo Clinic Grant and Publication Support Services for her assistance in manuscript preparation.

      References

        • Petersen R.C.
        Clinical practice: mild cognitive impairment.
        N Engl J Med. 2011; 364: 2227-2234
        • Plassman B.L.
        • Langa K.M.
        • Fisher G.G.
        • et al.
        Prevalence of cognitive impairment without dementia in the United States.
        Ann Intern Med. 2008; 148: 427-434
        • Albert M.S.
        • DeKosky S.T.
        • Dickson D.
        • et al.
        The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease.
        Alzheimers Dement. 2011; 7: 270-279
        • Raschetti R.
        • Albanese E.
        • Vanacore N.
        • Maggini M.
        Cholinesterase inhibitors in mild cognitive impairment: a systematic review of randomised trials.
        PLoS Med. 2007; 4: e338
        • Petersen R.C.
        • Thomas R.G.
        • Grundman M.
        • et al.
        Vitamin E and donepezil for the treatment of mild cognitive impairment.
        N Engl J Med. 2005; 352: 2379-2388
        • Jean L.
        • Bergeron M.E.
        • Thivierge S.
        • Simard M.
        Cognitive intervention programs for individuals with mild cognitive impairment: systematic review of the literature.
        Am J Geriatr Psychiatry. 2010; 18: 281-296
        • Baker L.D.
        • Frank L.L.
        • Foster-Schubert K.
        • et al.
        Effects of aerobic exercise on mild cognitive impairment: a controlled trial.
        Arch Neurol. 2010; 67: 71-79
      1. American Medical Association. Physician's Guide to Assessing and Counseling Older Drivers. 2nd ed. http://www.ama-assn.org/ama1/pub/upload/mm/433/older-drivers-guide.pdf. Accessed January 8, 2012.

        • Meuleners L.B.
        • Harding A.
        • Lee A.H.
        • Legge M.
        Fragility and crash over-representation among older drivers in Western Australia.
        Accid Anal Prev. 2006; 38: 1006-1010
        • Brown L.B.
        • Ott B.R.
        • Papandonatos G.D.
        • Sui Y.
        • Ready R.E.
        • Morris J.C.
        Prediction of on-road driving performance in patients with early Alzheimer's disease.
        J Am Geriatr Soc. 2005; 53: 94-98
      2. Alzheimer's Association. Driving and Dementia. http://www.alz.org/documents_custom/statements/driving_and_dementia.pdf. Accessed January 8, 2012.

        • Iverson D.J.
        • Gronseth G.S.
        • Reger M.A.
        • Classen S.
        • Dubinsky R.M.
        • Rizzo M.
        Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology.
        Neurology. 2010; 74: 1316-1324
        • Clarfield A.M.
        Screening in frail older people: an ounce of prevention or a pound of trouble?.
        J Am Geriatr Soc. 2010; 58: 2016-2021
        • Albert R.H.
        • Clark M.M.
        Cancer screening in the older patient.
        Am Fam Physician. 2008; 78: 1369-1374
        • Terret C.
        • Castel-Kremer E.
        • Albrand G.
        • Droz J.P.
        Effects of comorbidity on screening and early diagnosis of cancer in elderly people.
        Lancet Oncol. 2009; 10: 80-87
        • Nelson H.D.
        • Tyne K.
        • Naik A.
        • Bougatsos C.
        • Chan B.K.
        • Humphrey L.
        Screening for breast cancer: an update for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2009; 151 (W237-742): 727-737
        • American Geriatrics Society Clinical Practice Committee
        Breast cancer screening in older women.
        J Am Geriatr Soc. 2000; 48: 842-844
        • Schonberg M.A.
        • Silliman R.A.
        • Marcantonio E.R.
        Weighing the benefits and burdens of mammography screening among women age 80 years or older.
        J Clin Oncol. 2009; 27: 1774-1780
        • U.S. Preventive Services Task Force
        Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2008; 149: 627-637
        • Moyer V.A.
        • U.S. Preventive Services Task Force
        Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2012; 156 (W312): 880-891
        • Committee on Practice Bulletins—Gynecology
        ACOG Practice Bulletin Number 131: screening for cervical cancer.
        Obstet Gynecol. 2012; 120: 1222-1238
        • Moyer V.A.
        • U.S. Preventive Services Task Force
        Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2012; 157: 120-134
        • Greene K.L.
        • Albertsen P.C.
        • Babaian R.J.
        • et al.
        Prostate specific antigen best practice statement: 2009 update.
        J Urol. 2009; 182: 2232-2241
        • Wang C.
        • Bai L.
        Sarcopenia in the elderly: basic and clinical issues.
        Geriatr Gerontol Int. 2012; 12: 388-396
        • Morley J.E.
        • Abbatecola A.M.
        • Argiles J.M.
        • et al.
        Sarcopenia with limited mobility: an international consensus.
        J Am Med Dir Assoc. 2011; 12: 403-409
        • Studenski S.
        • Perera S.
        • Patel K.
        • et al.
        Gait speed and survival in older adults.
        JAMA. 2011; 305: 50-58
        • Chou C.H.
        • Hwang C.L.
        • Wu Y.T.
        Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: a meta-analysis.
        Arch Phys Med Rehabil. 2012; 93: 237-244
        • Houston D.K.
        • Nicklas B.J.
        • Ding J.
        • et al.
        Dietary protein intake is associated with lean mass change in older, community-dwelling adults: the Health, Aging, and Body Composition (Health ABC) Study.
        Am J Clin Nutr. 2008; 87: 150-155
      3. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults.
        J Am Geriatr Soc. 2012; 60: 616-631
        • Avenell A.
        • Handoll H.H.
        Nutritional supplementation for hip fracture aftercare in older people.
        Cochrane Database Syst Rev. 2010; : CD001880
        • Ottenbacher K.J.
        • Ottenbacher M.E.
        • Ottenbacher A.J.
        • Acha A.A.
        • Ostir G.V.
        Androgen treatment and muscle strength in elderly men: a meta-analysis.
        J Am Geriatr Soc. 2006; 54: 1666-1673
        • Emmelot-Vonk M.H.
        • Verhaar H.J.
        • Nakhai Pour H.R.
        • et al.
        Effect of testosterone supplementation on functional mobility, cognition, and other parameters in older men: a randomized controlled trial.
        JAMA. 2008; 299: 39-52