This is the fifth in a series of posts covering the Healthy Aging Checklist, which is my list of six fundamental activities that will help any older adult maintain the best possible health while aging.
They are:
- Promote brain health and emotional well-being.
- Promote physical health.
- Check for and address common senior health problems (such as falls, memory concerns, depression, incontinence, pain, isolation, polypharmacy).
- Learn to optimize the management of any chronic conditions.
- Get recommended preventive health services for older adults.
- Address medical, legal, and financial advance care planning.
In this post, I’ll cover recommended preventive health services for older adults, based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) and also Medicare’s coverage of preventive health services.
By my count, based on the USPSTF and Medicare guidelines, there are currently 26 preventive health services that older adults should consider. I have a summary list here, and then detailed information on each service starting here.
But before you read about them, let’s go over the basics of how preventive health services work, including why they can sometimes be harmful, or sometimes fall out of favor.
This way, when you review the list of preventive services to consider, you’ll better understand which services are likely to help, and why certain services may not be a good fit for you or your parent.
Understanding Preventive Health Services
Preventive health services essentially fall into three categories:
- Screening for health problems that are not yet causing symptoms noticeable to the patient. This includes some forms of cancer screening, as well as screening for conditions like high blood pressure or high blood sugar, which generally don’t cause symptoms.
- Checking for common problems that do cause symptoms but are easily overlooked in routine clinical care. This includes asking patients about things like depressive symptoms, falls, or even checking for signs of alcohol misuse.
- Administration of vaccines or medications to reduce the risk of a future illness.
In 2011, Medicare began offering a variety of preventive health services for free, because the 2010 Affordable Care Act mandated preventive care with no cost-sharing. (Whereas in traditional fee-for-service Medicare, beneficiaries may need to pay 20% of costs.) However, for services to be free, they may need to be ordered during the Annual Wellness Visit. For more information, see here.
What To Know About Preventive Health Services in Older Adults
Here are 3 key things to know:
1. For a preventive service to be recommended, there should be proof that providing this service results in improved health outcomes for most people.
You should know that for screening or early-detection services to improve health outcomes, clinicians must be routinely able to follow-up with a treatment that works, or somehow improves the health and wellbeing of the patient.
Furthermore, there needs to be proof that the screening or early-detection works better than waiting for the problem to become more symptomatic.
2. Many frequently offered screening services are not currently endorsed by the USPSTF, because research has not proven that detecting certain problems leads to better outcomes.
For instance, screening for prostate cancer by checking prostate-specific antigen (PSA) levels in older men is no longer recommended, because research found that overall screening didn’t save many lives, but did cause men to undergo many painful biopsies or treatment of small prostate cancers that probably would never have troubled them.
In other words, not all testing is useful. Especially when it comes to people with no symptoms, testing can often be harmful, or, at least, wasteful.
However, quite a lot of doctors will offer all kinds of screening and preventive tests, either because they have not kept up with the latest recommendations or because they make money when they do the tests. So it’s essential for you to be informed and learn more about a screening test before proceeding.
3. Many preventive health services become optional — or sometimes even recommended against — when people reach a certain age or state of poor health.
That’s because many preventive services have only been shown to be effective in people likely to live another 5-15 years.
This makes sense when you think about it: prevention services for a relatively healthy person aged 70 will not be the same as what might be recommended for a person who is 82 and has moderate-stage Alzheimer’s disease.
For more on estimating life-expectancy in older adults, you can visit ePrognosis.org, a site created by my colleagues in the UCSF Division of Geriatrics. I especially like their easy-to-use online app to help older adults and families make cancer screening decisions.
About the USPSTF and Its Recommendations
The USPSTF is an independent, volunteer panel of national experts in prevention and evidence-based medicine. Here is a quote from their about page:
[The USPSTF] recommendations are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient’s needs.
The Task Force assigns each recommendation a letter grade (an A, B, C, or D grade or an I statement) based on the strength of the evidence and the balance of benefits and harms of a preventive service.
Broadly speaking, the USPSTF recommendations come in three key flavors. After carefully reviewing the scientific evidence and specifying what types of patients the recommendation applies to (e.g. age range, gender), they will recommend either “for,” “against,” or “neither for nor against” (which means they are not taking a stand either way).
The USPSTF also uses a grading system, which you can learn about here.
Summary of Preventive Services For Older Adults to Consider
Many preventive services for older adults can be checked on as part of the Medicare Annual Wellness Visit.
Remember, some types of prevention are unlikely to help older adults who are very old, very frail, or in poor health due to chronic illnesses. This is especially true with cancer screening.
So before proceeding with any of these services, be sure to review the details section below, to learn more about whether this service is recommended for someone like you or your older relative.
Here is a summary list, which I’ve organized into six key categories:
Preventive Services For Older Adults
The following preventive services are recommended for some or all older adults. Click on the category to jump down to detailed information about the services.
- Mental health, cognitive health, and substance use
- Checking for depression
- Checking for tobacco use
- Checking for alcohol misuse
- Checking for signs of cognitive impairment
- Safety and functional ability
- Asking about falls
- Checking for signs of functional impairment and assessing home safety
- Checking for signs of elder mistreatment
- Physical health
- Screening for high blood pressure
- Screening for high cholesterol
- Screening for obesity
- Screening for abnormal blood glucose and type 2 diabetes
- Screening for abdominal aortic aneurysm
- Screening for osteoporosis
- Screening for hepatitis C
- Screening for HIV
- Screening for other sexually transmitted infections
- Cancer screening
- Screening for colorectal cancer
- Screening for breast cancer
- Screening for cervical cancer
- Screening for lung cancer
- Vaccinations
- Influenza
- Pneumococcal disease (commonly known as the “pneumonia vaccines”)
- Shingles (herpes zoster)
- Tetanus-diphtheria (Td) and tetanus-diphtheria-pertussis (Tdap)
- Medications for prevention
- Aspirin for the prevention of cardiovascular disease
- Vitamin D for the prevention of falls
I’m also including information on two types of screening that used to be popular but are not recommended by the USPSTF:
- Screening for prostate cancer
- Screening for coronary artery disease or other cardiovascular disease with ECG, carotid artery testing, and “non-traditional” risk factors
Advance care planning (which includes completion or review of advance directives) is also usually included in a list of preventive care services, but I will cover that in my next post, which will focus on medical, legal, and financial advance care planning.
Details on Recommended Preventive Services for Older Adults
Mental Health, Substance Use, and Cognitive Health
Recommended by the USPSTF:
- Depression:
- Who: All adults, including older adults. No upper age limit.
- How often: Unspecified per the USPSTF. Yearly screenings are covered by Medicare.
- For more information:
- Tobacco Use:
- Who: All adults
- How often: Unspecified by USPSTF. However, most electronic health record systems have been designed to prompt clinicians to record tobacco use routinely.
- For more information:
- Alcohol Misuse:
- Who: All adults
- How often: Unspecified by the USPSTF. Yearly screening is covered by Medicare.
- For more information:
Not recommended for or against by the USPSTF, but covered by Medicare:
- Cognitive Impairment:
- Who: For community-dwelling older adults with no signs or symptoms of cognitive impairment, screening is not recommended for or against by the USPSTF. However, “detection of any cognitive impairment” is specified as part of Medicare’s Annual Wellness Visit.
- How often: N/A for USPSTF. Covered yearly as part of Medicare’s Annual Wellness Visit.
- Notes: Medicare’s guide for doctors says clinicians should “assess the beneficiary’s cognitive function by direct observation, with due consideration of information obtained via beneficiary reports and concerns raised by family members, friends, caretakers, or others.”
- Medicare’s guide leaves healthcare providers with considerable latitude in how they can assess cognition and “detect” cognitive impairment.
- For more information:
Safety and Functional Ability
Recommended by the USPSTF:
- Falls (assessment for high risk of falling):
- Who: Adults over age 65
- How often: Not specified by the USPSTF. Covered yearly by Medicare Annual Wellness Visit.
- Notes: Medicare’s guide for clinicians does not specify exactly how a clinician should assess fall risk. The CDC provides resources here.
- For more information:
Not recommended for or against by the USPSTF but covered by Medicare:
- Functional ability and safety in the home:
- Who: All older adults
- How often: Covered yearly as part of Medicare’s Annual Wellness Visit
- Notes: Functional ability includes:
- the ability to manage activities of daily living (ADLs), which includes walking, dressing, bathing
- the ability to manage instrumental activities of daily living (IADLs), which includes transportation, shopping, meal preparation, medication management, and more
- vision and hearing
- cognitive abilities (see section on screening for cognitive impairment)
- Additional note: Medicare does not specify how to assess home safety
- For more information:
Not recommended for or against by the USPSTF but a Medicare quality measure, and generally recommended by many experts:
- Elder mistreatment:
- Who: All older adults
- Notes: Screening for elder maltreatment is included in Medicare’s quality improvement program for clinicians. However, it is not specified as part of the Annual Wellness Visit.
- For more information:
Physical Health
Recommended by the USPSTF and covered by Medicare:
- High blood pressure
- Who: All older adults
- How often: Yearly for people aged 40 or older. Covered as part of Medicare Annual Wellness Visit.
- For more information:
- High cholesterol
- Who: All men age 35 or older; women aged 45 or older if they are “at increased risk for coronary heart disease.”
- How often: Per the USPSTF, about every 5 years; adjust based on previous results. Medicare covers cholesterol tests every 5 years as part of preventive care.
- Notes:
- The USPSTF is in the process of reviewing its recommendations on cholesterol testing and also use of statins (medications to treat high cholesterol) to prevent cardiovascular disease.
- Measuring cholesterol is part of assessing a person’s “10-year cardiovascular event risk,” which is being used to move from “one size fits all” prevention recommendations to prevention that is tailored to a person’s individual health risks.
- For more information:
- Obesity (measurement of body-mass index)
- Who: all adults
- How often: Not specified by the USPSTF. Covered yearly as part of Medicare Annual Wellness Visit.
- For more information:
- Abnormal blood glucose and Type 2 Diabetes
- Who: Per the USPSTF, screening is recommended for adults aged 40-70 who are obese. Medicare covers screening for people with one or more risk factors, and doesn’t specify an age range.
- How often: About every three years, per the USPSTF. Covered every 12 months by Medicare, for people with risk factors.
- For more information:
- Abdominal Aortic Aneurysm
- Who: Men aged 65-75 who have smoked
- How often: Once per the USPSTF. Covered by Medicare if referred based on the Welcome to Medicare visit.
- For more information:
- Osteoporosis
- Who: Women aged 65+
- How often: Not specified by the USPSTF. Covered once every two years by Medicare.
- For more information:
- Hepatitis C
- Who: The USPSTF recommends a one-time screening for all adults born between 1945 and 1965.
- How often: Covered at least once by Medicare for adults born during the years above. May be covered more often for those with additional risk factors for hepatitis C infection.
- For more information:
- HIV (Human immunodeficiency virus)
- Who: Adults aged 15-65, and older adults at increased risk for infection
- How often: Not specified by the USPSTF. Covered annually by Medicare.
- Notes: Older adults at increased risk for HIV infection may include men who have sex with men, people with multiple partners, and people with past or present injection drug use.
- For more information:
- Other Sexually Transmitted Infections (STIs)
- Who: Per the Centers for Disease Control (CDC), adults of all ages should be assessed for risk factors for STIs. Those with risk factors should be tested for STIs (usually includes chlamydia, gonorrhea, and syphilis; may include screening for other infections as well).
- Per the CDC, sexually active adults at risk for STIs include women with a new sexual partner and men who have sex with men. There is no upper age limit for these risk factors.
- How often: Assessment of STI risk factors is covered as part of the Medicare Annual Wellness visit. Medicare covers testing if a clinician determines a person has risk factors.
- Notes: The USPSTF recommended screening for syphilis in high-risk adults in 2004, and is now in the process of updating its recommendations.
- For more information:
- Who: Per the Centers for Disease Control (CDC), adults of all ages should be assessed for risk factors for STIs. Those with risk factors should be tested for STIs (usually includes chlamydia, gonorrhea, and syphilis; may include screening for other infections as well).
Not recommended by the USPSTF and not covered by Medicare as part of preventive care:
- Other Screenings for Coronary Artery Disease and Other Cardiovascular Disease
- Note: the USPSTF is in the process of updating several recommendations regarding screening for coronary heart disease and other cardiovascular diseases
- In the past, the USPSTF has reviewed the evidence for the following screening tests and has chosen to not recommend them for adults with no symptoms:
Cancer Screening
Recommended by the USPSTF:
- Colorectal cancer
- Who: The USPSTF recommends for routine colon cancer screening for adults aged 50-75, and against colon cancer screening in adults aged 85 or older. For adults aged 76-85, the USPSTF recommends against “routine screening”; the CDC’s screening guidelines recommend an “individualized decision” for adults aged 75 or older.
- How often: This depends on the screening method used. Screening colonoscopy can be done every 10 years, whereas screening by checking stool for microscopic blood requires annual stool testing.
- Notes: the USPSTF is in the process of updating its guideline on colorectal cancer screenings. The draft recommendations suggest an individualized screening decision for adults aged 76-85, and note that people who have never been screened for colon cancer may be more likely to benefit.
- For more information:
- Breast cancer
- Who: The USPSTF recommends for routine breast cancer screening in women aged 50-74. The USPSTF recommends neither for nor against breast cancer screening in women aged 75 or older.
- How often: The USPSTF recommends screening mammography every two years. Medicare covers screening mammograms every 12 months.
- For more information:
- Cervical cancer
- Who: The USPSTF recommends against cervical cancer screening in women aged 65+ who “have had adequate prior screening and are not at high risk.” They also recommend against cervical cancer screening in women who have had a hysterectomy for non-cancer reasons.
- Older women who have never been screened for cervical cancer, or did not get a Pap smear between the ages of 55-65, should be screened at least once.
- How often: Medicare covers a Pap smear every 24 months for women who are deemed low-risk for cervical or vaginal cancer, and every 12 months for women who are at high risk.
- Notes: Adequate prior screening for cervical cancer means having had three negative Pap smears in a row, with the most recent test within five years.
- For more information:
- Who: The USPSTF recommends against cervical cancer screening in women aged 65+ who “have had adequate prior screening and are not at high risk.” They also recommend against cervical cancer screening in women who have had a hysterectomy for non-cancer reasons.
- Lung cancer
- Who: Per the USPSTF, adults who are age 55-80, have a 30 pack-year history of smoking, and either smoke or have quit within the past 15 years.
- How often: The USPSTF recommends yearly screening for the adults meeting the criteria above, and stopping screening once it’s been 15 years since the person quit smoking. Medicare covers the yearly screening test for people aged 55-77 who otherwise meet the USPSTF criteria.
- For more information:
Not recommended by the USPSTF:
- Prostate cancer:
- Who: The USPSTF recommends against using the prostate-specific antigen (PSA) test to screen for prostate cancer. The American College of Physicians recommends an individualized screening decision for men aged 50-69, and recommends against screening in men aged 70+ or with life expectancy less than 10-15 years.
- How often: Medicare covers a PSA test and digital rectal exam every 12 months.
- Notes: The USPSTF recommendation was published in 2012, and is currently under revision.
- For more information:
Vaccinations
The USPSTF does not issue recommendations regarding vaccinations. For this section, I will refer to recommendations from the CDC’s Advisory Committee on Immunization Practices (ACIP).
- Influenza (flu) vaccine
- Who: The CDC recommends vaccination for seasonal influenza every year, for everyone aged 6 months or older. There is no upper age limit. A high-dose influenza vaccine (Fluzone) is approved for adults aged 65+, and may be better at stimulating an aging immune system.
- How often: Yearly in the fall, once the year’s vaccine becomes available.
- Notes: The flu vaccine cannot give a person the flu, although some mild side-effects are possible, including achiness or fever. Generally, the flu shot has a very low risk of harm. The likelihood of benefit depends on how well matched the vaccine is to the circulating influenza virus in a given year.
- For more information:
- Pneumococcal vaccination (two types as of 2014)
- Who: All adults aged 65+ should get both Prevnar (PCV13) and Pneumovax (PPSV23).
- How often: Once for each, after age 65. The CDC recommends revaccinating high-risk patients who received Pneumovax prior to age 65, once it’s been five years since Pneumovax was first administered.
- Notes: These are often called “pneumonia shots” but technically they vaccinate against Streptococcus pneumoniae, a bacterium that can cause serious illness both inside and outside the lungs. Bear in mind that many viruses and other bacteria can cause pneumonia.
- Previously, only Pneumovax (PPSV23) was recommended for all adults aged 65+. In 2014, the CDC recommended that older adults also receive Prevnar (PCV13), another type of pneumococcal vaccine that offers complementary protection.
- Prevnar and Pneumovax should not be administered at the same time; a 6-12 month interval between them is required.
- It is ok to receive either pneumococcal vaccination at the same time as a different vaccine altogether, such as seasonal influenza vaccine or zoster vaccine.
- For more information:
- Shingles (herpes zoster) vaccine
- Who: The CDC recommends vaccination against shingles for all adults aged 60+. The only approved vaccine is Zostavax.
- How often: Once. Medicare covers this vaccine as part of a person’s Part D plan.
- Although the CDC notes that the vaccine’s protective effect seems to wane after five years, the CDC has not yet issued recommendations regarding revaccination.
- Notes: Shingles is extremely common: nearly 1 in 3 people gets shingles at some point in their life, usually when they are older. Of those who get shingles, 1 in 6 will develop a related chronic pain condition called post-herpetic neuralgia.
- Per the CDC, the shingles vaccine decreases the risk of shingles by 51%.
- For more information:
- Tetanus-diphtheria (Td) and tetanus-diptheria-pertussis (Tdap)
- Who: The CDC recommends a Td booster shot every 10 years for all adults. In 2010, the CDC recommended that adults of all ages get one dose of Tdap to get protection against pertussis (whooping cough), which has become more common.
- Pertussis vaccination is especially important for those who will be around young babies, such as grandparents or childcare providers.
- How often: The Td booster should be given every 10 years. Currently, Tdap is recommended once for adults aged 65+ who have not previously received Tdap in adulthood. Both Td and Tdap are covered under Medicare Part D.
- For more information:
- Who: The CDC recommends a Td booster shot every 10 years for all adults. In 2010, the CDC recommended that adults of all ages get one dose of Tdap to get protection against pertussis (whooping cough), which has become more common.
Medications for Prevention
Recommended by the USPSTF:
- Aspirin for the Prevention of Cardiovascular Disease
- Who: The USPSTF recommends that a daily aspirin be considered for men aged 45-79 and women aged 55-79, provided the risk of cardiovascular disease outweigh the risk of internal bleeding due to daily aspirin.
- Notes: Aspirin used to be more widely recommended to prevent heart attacks and strokes, but now the USPSTF is encouraging a more personalized approach in which doctors and patients review the likely benefits and harms.
- The USPSTF is in the process of revising its recommendations on aspirin for prevention of cardiovascular disease and colon cancer. Draft recommendations are now available; download the PDF consumer guide for the likely recommendations in plain English.
- For more information:
- Vitamin D for Prevention of Falls
- Who: In 2012 the USPSTF recommended vitamin D supplementation in adults aged 65+ who are at increased risk for falls.
- Notes: This recommendation is currently being updated; drafts recommendations are not yet available. The USPSTF has evaluated vitamin D for other preventive purposes, such as fracture prevention, and stated that the evidence is inconclusive. (See here and here.)
- For more information:
What to Do Next
As you can see, there is a quite a long list of preventive health services that are recommended for older adults!
Fortunately, most don’t need to be addressed every year, and some may not apply to you or your older relative at all.
To make sure you get recommended preventive health services, I recommend using the free PDF cheatsheets summarizing these services as follows:
- Tick the checkbox if the preventive service applies to you (or your older relative).
- Find out if you are up-to-date on the service, by checking on when you last received it.
- Make a note of when the preventive service is next due, if applicable.
If you aren’t sure if a preventive service applies to you, make a note to discuss this with your doctors.
By making sure you have gotten those preventive health services that are recommended for people of your age or health circumstances — and by avoiding prevention that is unproven or unlikely to benefit people like you — you’ll be helping to ensure healthier aging.
Questions or comments about these preventive health services? Please post them below!
I like your general rule of, “If you aren’t sure if a preventive service applies to you, make a not to discuss this with your doctors.” My parents have been talking a lot about health checks and preventive measures lately. They are both in their mid 50’s and want to make sure they remain in good shape and health condition. They both understand that they could easily go down hill if they don’t take proactive steps to their health. We’ve actually just started a family health challenge, so that should help. Thanks for the list of everything to consider, it was helpful to read!
Glad you found this article helpful. Be sure to consider the information in the other posts related to the Healthy Aging Checklist, as those cover proven actions to maintain brain health, physical health, etc.
When my mother was in a nursing home the P.A. told me that at the age of 76 routine preventative procedures were no longer allowed. Is this true?
Well, flu shots are recommended for people of all ages and are especially recommended for older adults. So I don’t think it’s accurate to say that at a certain age, preventive procedures are no longer allowed. It really depends on what is the preventive procedure in question.
It also in many cases depends on the person’s likely life expectancy; if you are 50 but have advanced cancer and are unlikely to live more than a year, then many preventive procedures no longer make sense.
I have provided information on the age ranges that apply to the preventive services within the post.