Journal of Gerontological Nursing

Editorial 

Screening of Older Adults - An Ethical Issue

Patricia M Lentsch, RN, C, MPH

Abstract

The 95% of older adults who live independently in the community have been the targeted recipients for many years of a myriad of health promotion and screening programs, including health fairs, blood pressure screening, health education programs, and comprehensive multiphasic screening programs. Factors as diverse as categorical funding, sophisticated medical technology, and media hype have resulted in a proliferation of screening programs as an end in themselves. To some extent older adults have become the victims of a screening phenomenon out of control. It is time for nurses, as the primary care providers and advocates of older adults, to look at the issues surrounding screening.

One overriding principle of screening is that the service is designed to provide the greatest good for the greatest number at the lowest cost. Let us consider the criterion of the greatest good. The major esoteric goal of most health promotion programs for older adults has been to improye the quality of life. The major goals of disease prevention programs have been to prevent disease and/or to identify and treat it in the early stages.

In order to achieve these goals certain issues, concepts and facts must be taken into account in planning screening services. First is an awareness of both the positive and negative impacts that diagnostic testing and medical treatment have on the quality of life of older adults. Second is the economic impact of screening on both older adults and on the health care system. Third is the realiability and validity of the screening tools, ocnsidering age referenced physiological and psychological norms. Fourth is the practice of using screening as a method for determining program eligibility. Last is appropriate utilization of nurses in providing health promotion services. Many screening programs established for the "good" of older adults have not taken these factors into account.

Screening services are often considered an end in themselves. For example, one evaluation method frequently employed is simply to count the number of individuals screened and referred. This method tells us something about who has experienced the service but nothing about how the service has impacted on the consumer's health status or quality of life. Screening by itself is not a program, it is a process and technology used within health promotion programs. As such, evaluation should focus on the outcome as experienced by the consumer, be it positive or negative.

And there is a very real potential for negative impact. For example, because the physiology of aging has not yet made a significant impact on the technology of screening, laboratory tests, results and interpretations have a high potential for inaccuracy. For example, using standardized non-age specific criteria for serum glucose tests would label over half of the older adults tested as diabetic. Many of those individuals inappropriately referred for diagnostic tests and treatment will experience unnecessary diagnostic testing. Some will actually be treated for a disease they do not have. Multiphasic laboratory testing of older adults generally yields some unexpected borderline abnormalities that have little clinical or diagnostic meaning in reality, but that are often followed up comprehensively with invasive, expensive, time-consuming, and sometimes painful testing. Older adults often become passive recipients of a high technology medical system that neither they nor we can afford and, indeed do not add to the quality of life but may significantly detract from it.

Professional nursing's involvement in screening must also be questioned. If one considers the nursing process as the framework for professional practice, and that the activity of screening frequently involves only data collection and possibly referral, one must question whether the nurse as a screener is practicing…

The 95% of older adults who live independently in the community have been the targeted recipients for many years of a myriad of health promotion and screening programs, including health fairs, blood pressure screening, health education programs, and comprehensive multiphasic screening programs. Factors as diverse as categorical funding, sophisticated medical technology, and media hype have resulted in a proliferation of screening programs as an end in themselves. To some extent older adults have become the victims of a screening phenomenon out of control. It is time for nurses, as the primary care providers and advocates of older adults, to look at the issues surrounding screening.

One overriding principle of screening is that the service is designed to provide the greatest good for the greatest number at the lowest cost. Let us consider the criterion of the greatest good. The major esoteric goal of most health promotion programs for older adults has been to improye the quality of life. The major goals of disease prevention programs have been to prevent disease and/or to identify and treat it in the early stages.

In order to achieve these goals certain issues, concepts and facts must be taken into account in planning screening services. First is an awareness of both the positive and negative impacts that diagnostic testing and medical treatment have on the quality of life of older adults. Second is the economic impact of screening on both older adults and on the health care system. Third is the realiability and validity of the screening tools, ocnsidering age referenced physiological and psychological norms. Fourth is the practice of using screening as a method for determining program eligibility. Last is appropriate utilization of nurses in providing health promotion services. Many screening programs established for the "good" of older adults have not taken these factors into account.

Screening services are often considered an end in themselves. For example, one evaluation method frequently employed is simply to count the number of individuals screened and referred. This method tells us something about who has experienced the service but nothing about how the service has impacted on the consumer's health status or quality of life. Screening by itself is not a program, it is a process and technology used within health promotion programs. As such, evaluation should focus on the outcome as experienced by the consumer, be it positive or negative.

And there is a very real potential for negative impact. For example, because the physiology of aging has not yet made a significant impact on the technology of screening, laboratory tests, results and interpretations have a high potential for inaccuracy. For example, using standardized non-age specific criteria for serum glucose tests would label over half of the older adults tested as diabetic. Many of those individuals inappropriately referred for diagnostic tests and treatment will experience unnecessary diagnostic testing. Some will actually be treated for a disease they do not have. Multiphasic laboratory testing of older adults generally yields some unexpected borderline abnormalities that have little clinical or diagnostic meaning in reality, but that are often followed up comprehensively with invasive, expensive, time-consuming, and sometimes painful testing. Older adults often become passive recipients of a high technology medical system that neither they nor we can afford and, indeed do not add to the quality of life but may significantly detract from it.

Professional nursing's involvement in screening must also be questioned. If one considers the nursing process as the framework for professional practice, and that the activity of screening frequently involves only data collection and possibly referral, one must question whether the nurse as a screener is practicing nursing and providing the most beneficial service to the consumer. Blood pressure screening clinics are a case in point. One program I am aware of processes 50 high rise residents in a two-hour period each week. Because of the volume of clients, the resource constraints of the system, and the system mandate giving blood pressure measurements top priority, the nurse has no time to spend in providing the services she views as most important: teaching, counseling, therapeutic listening, reassurance and guidance. In addition, the residents leaving the clinic with a "normal" blood pressure leave with the false reassurance that all is well with their health. One nurse has analyzed the situation thus: "through our screening efforts a weekly blood pressure reading has replaced the daily bowel movement as the primary indicator of health for older adults."

Another issue is the practice in the public sector of using screening to determine eligibility for services such as home care. There is an inherent arbitrary nature to both eligibility criteria and screening criteria that at times works to the detriment oi the older adult consumer. The nurse, asa public employee, may be required to screen clients for the good of the system and not necessarily for the good of the client.

In this age of professional accountability it is time for nursing to consider these ethical dilemmas - and act.

10.3928/0098-9134-19810401-05

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