Screening in frail older people: an ounce of prevention or a pound of trouble?

Screening for subclinical disease has provided benefit to many asymptomatic patients, especially those who are relatively young and otherwise healthy. However, frail older people do not always profit from such maneuvers, for several reasons. First, older individuals usually have less physiological reserve and greater comorbidity and resultant polypharmacy than their younger counterparts. As such, they may tolerate the invasive interventions called for after a positive screening test less easily. In addition, shorter natural life expectancy shifts the focus to quality of life improvement after screening tests rather than simply offering a promise of "more years." Lack of education and cognitive decline may also interfere with the older person's ability to give truly informed consent to these maneuvers. Thus, on the whole, in this rapidly growing subpopulation, screening programs may tilt the balance toward the likelihood of causing more harm than good. For many frail older patients, an individualized approach to screening is recommended, adjusted to comorbidity, life expectancy, and patient preference. One size does not fit all.