Care of Older Persons

Philippine Academy of Family Physicians

2244 Taft Avenue, Malate, Metro Manila, Philippines 1004
Tel Nos.: (+632) 516-2900; (+632) 405-0140
Telefax No.: (+632) 254-5646
Cellphone Nos.: +63 9175486550 ; +63 9088666124 ; +63 9328528743
Url: http://www.thepafp.org
E-mail: secretariat@thepafp.org

National Board of Directors 2016-2017

President Eva Irene Yu Maglonzo, MD
Vice-President Policarpio Joves, Jr., MD
Executive Secretary Maria Victoria Concepcion Cruz, MD
Treasurer Lynne Marcia Bautista, MD

National Directors Limuel Anthony Abrogena, MD

Disi Yap-Alba, MD
Elmer Angus, MD
Mercedita Bariso, MD
Mona Lisa Cosme, MD
Aurora Espinoza, MD
Annie Francisco, MD
Karin Estepa-Garcia, MD
Ricardo Guanzon, MD
Cheridine Oro-Josef, MD
Josefina Isidro-Lapea, MD

Regional Directors Judith Amparado, MD

Jane Eflyn Lardizabal-Bunyi, MD
Margaret Jean De Guzman, MD
Evelyn Abasolo-Lao, MD
Ceasar Palma, MD
Delia Pastoriza, MD

PAFP Technical Working Group Care of Older Persons

Eva Irene Yu Maglonzo, MD

Cheridine Oro-Josef, MD
Doris Mariebel Camagay, MD
Cyrin Valencia, MD
Aurora Chan, MD
Josie Marie Icmat-Buenavista, MD
Christine Aquino-Yap, MD
Limuel Anthony Abrogena, MD
Louella Carpio, MD

PAFP Committee on Quality Assurance

Chair Limuel Anthony Abrogena, MD

Co-Chair Sheila Marie Lavia, MD
Members Maria Elinore Concha, MD
Leilanie Apostol-Nicodemus, MD
Isabelita Samaniego, MD
Rojim Sorrosa, MD
Agnes Segunda Gerasmo, MD
Marishiel Mejia-Samonte, MD
Maria Lisa Salas-Dauigoy, MD

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06 CPM 18th ed Care of Older Per53 53 02/03/2017 1:33:33 PM

 Care of Older Persons

Algorithm on Wellness Promotion for Older Persons

Persons 60 years
old on regular
consultation

At risk for certain

diseases based Y Screen and treat
from clinical history appropriately
and physical according to
examination? disease condition.

Initiate wellness
program.

Discuss health Offer needed Perform

promotion vaccination for older disease risk
strategies. persons. assessment.

Nutrition Influenza vaccine Vision screening

Fitness Pneumococcal vaccine Hearing screening
Counseling Tdap/Td vaccine Cognitive screening
Herpes zoster vaccine Depression screening
Osteoporosis screening
Cancer screening

Follow up.

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06 CPM 18th ed Care of Older Per54 54 02/03/2017 1:33:33 PM


Philippine Academy of Family
Physicians Consensus Statements
on Wellness: Care of Older Persons
INTRODUCTION
One of the current challenges in our society is the
increasing aging population. Maintaining health among
older persons remains a demanding task because
morbidity increases with age. In our country it is common
that patients will seek consult only when they are sick
and not for health promotion or disease prevention. As
a response to this challenge, different guidelines were
developed at the international level with some variations.
Since it is important to maintain well-being and promote
quality of life among Filipino older persons, it is imperative
that a wellness recommendation based on evidences
and applicable to the local setting be advocated for
every clinic visits.
A wellness program should include health promotion
such as nutrition and fitness program, specific disease
protection such as immunization and disease prevention
which include the screening tests. The older patient and
their families should be given anticipatory guidance
on this. The Philippine Academy of Family Physicians
launched its Family Wellness Program through its
advocacy project Kalusugan ng Pamilya Mo, Aalagaan
Ko with the primary objective of promoting wellness.
The Consensus Statements Technical Working Groups
(TWG) on Wellness for Older Persons held several
meetings among themselves and consultative meetings
with the PAFP Committee on Quality Assurance and
stakeholders to discuss each of the statements that
will be considered and recommended. Topics on the
components of wellness include health promotion such
as proper nutrition, exercise and counseling; specific
protection such as immunization; chemoprophylaxis
and screening for risk factors. Based from these topics,
the group formulated research questions that will guide
in the search for literature and appraisal of evidences.
Appraised articles were presented amongst the members
of the TWG and formulation of statements followed.
Assessment of the level of quality of evidences utilized
the GRADE (Grading of Recommendations, Assessment,
Development and Evaluation) approach. A high grade
level of evidence connoted that the members were
confident that the true effect lies close to that of the
estimate of the effect. A moderate grade level describes
a moderate confidence in the effect estimate the true
effect is likely to be close to the estimate but there is a
possibility that it is substantially different. A low grade
level means that confidence in the effect estimate is
limited and the true effect may be substantially different.
A fourth measurement (very low grade) was not included
in this process.
The draft statements were then presented in a consensus
conference attended by the current board of directors
of PAFP, representatives of local PAFP chapters and
family medicine residency training programs, and other
stakeholders that included representatives from the Food
and Nutrition Research Institute, Philippine College of
Geriatric Medicine, among others.
06 CPM 18th ed Care of Older Per55 55
Care of Older Persons
The strength of the statements depends on the
recommendations of the voting panel. A statement that
is strongly recommended means more than 80%
of the panel agrees to the statement. The statement
moderately recommended means more than half but
less than 80% of the panel agrees to the statement. A
statement where less than 50% of the panel agrees but
still deemed important to be included in the consensus is
labeled weakly recommended. After the presentation,
additional inputs from the panel were already incorporated
by the TWG as agreed upon during the conference.
The consensus statements formulated aim to advance
understanding of family physicians and medical
practitioners in general on issues, procedures or methods
in the care of the family and should not be regarded as
absolute rules. The approach to each patient and their
family must still be individualized to take into account the
impact of the strategies to their overall wellness.
IMMUNIZATION FOR OLDER PERSONS
The older person is at risk for the following diseases:
influenza, pneumonia, herpes zoster, tetanus and
diphtheria. Immunization aims to induce an immune
response that will protect against later exposure to the
pathogen. The estimated average annual disease burden
was from high to low: pneumococcal disease (37,223
DALYs/year), influenza (7941 DALYs/year), herpes zoster
(942 DALYs/year), and pertussis (812 DALYs/year). The
adaptation of models and parameters specifically for the
elderly resulted in a higher disease burden compared to
the use of general population models.
Pneumococcal Vaccine
Statement 1. PCV13 vaccination is recommended to
65 years or older who have not previously received a
pneumococcal vaccine or whose previous vaccination
history is unknown. A dose of the 23-valent pneumococcal
polysaccharide vaccine (PPSV23) for these patients
should be given 1 year after PCV13 vaccination.
(Moderate grade, Strongly recommended)
Statement 2. If a patient 65 or older has not previously
received the PCV13 vaccine but has received one or
more doses of PPSV23, that patient should receive a
dose of PCV13 at least one year after administration
of the most recent dose of PPSV23. (Moderate grade,
Moderately recommended)
Summary of Evidences.
Both PCV 13 and PPSV23 is recommended for older
person (Tomczyk, 2014 ). They have to be administered in
sequential series. Reverse cumulative distribution curves
of the population antipneumococcal OPA responses
for the vaccination sequences PCV13/PCV13, PCV13/
PPSV23, and PPSV23/PCV13 were compared. As seen
when comparing OPA GMTs, population responses were
generally greater, depending on serotype, following
administration of PPSV23 given after PCV13 compared
with responses following administration of PCV13 given
after PPSV23. Responses following two administrations
of PCV13, given 1 year apart, were also generally greater
than responses following the sequence of PPSV23/
PCV13. However, responses after the PCV13/PCV13
sequence were similar or lower (with the exception of
serotypes 6A, 6B, and 23F) than responses following
PCV13/PPSV23 (Greenberg 2013, Jackson 2013).
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02/03/2017 1:33:33 PM
 Care of Older Persons
Influenza Vaccine
Statement 3. Annual vaccination with Influenza
vaccine is recommended for 65 years old and above.
(Moderate grade, Strongly recommended)
Summary of Evidences.
Sixty-four studies were included in the efficacy /
effectiveness assessment, resulting in 96 data sets. In
homes for elderly individuals (with good vaccine match and
high viral circulation) the effectiveness of vaccines against
ILI was 23% (6% to 36%) and non-significant against
influenza (RR 1.04: 95% CI 0.43 to 2.51). Well matched
vaccines prevented pneumonia (VE 46%; 30% to 58%),
hospital admission (VE 45%; 16% to 64%) and deaths
from influenza or pneumonia (VE 42%, 17% to 59%).
In elderly individuals living in the community, well matched
vaccines prevented hospital admission for influenza and
pneumonia (VE 26%; 12% to 38%) and all-cause mortality
(VE 42%; 24% to 55%). After adjustment for confounders,
vaccine performance was improved for admissions to
hospital for influenza or pneumonia (VE* 27%; 21% to
33%), respiratory diseases (VE* 22%; 15% to 28%) and
cardiac disease (VE* 24%; 18% to 30%); and for all-cause
mortality (VE* 47%; 39% to 54%).
The public health safety profiles of the vaccines
appear to be acceptable. (Rivetti et al, 2010, Cochrane
collaboration).
Herpes Zoster Vaccine
Statement 4. Herpes zoster vaccine is recommended
for 60 years old and above. (Moderate grade,
Moderately recommended)
Summary of Evidences.
Herpes zoster vaccine is effective and safe for persons
60-69 years old (Yao et al, 2015). Receipt of the herpes
zoster vaccine was associated with a lower incidence
of herpes zoster. The risk was reduced among all age
strata (Tseng, 2011). Zoster vaccine reduced the herpes
zoster-related Burden of Interference with ADL by two-
thirds and the herpes zoster-related impact on Health
related quality of life (HRQL) by about half (Schmader,
2010). Shingles Prevention Study group and the study
of Vesikari in 2013 cited that there is no difference in the
single dose versus the 2 doses.
Tetanus and Diphtheria vaccine
Statement 5. Tdap is recommended for 65 years old
and above. Td should be given as booster every 10
years. (Moderate grade, Moderately recommended)
Summary of Evidences
Tdap was found to be immunogenic in subjects 65
years, with a safety profile comparable to US-licensed
Td vaccine (Weston 2012). It was also found to be safe
among this age group (Moro, 2011).
References:
1. Greenberg, RN et al. Sequential administration of 13-valent
pneumococcal conjugate vaccine and 23-valent pneumococcal
polysaccharide vaccine in pneumococcal vaccinenave adults 6064
years of age. Vaccine 32 (2014) 23642374
2. Jackson LA, Gurtman A, van Cleeff M, et al. Immunogenicity and safety
of a 13-valent pneumococcal conjugate vaccine compared to a 23-valent
pneumococcal polysaccharide vaccine in pneumococcal vaccine-nave
adults. Vaccine 2013;31:357784.
3. Jackson LA, Gurtman A, Rice K, et al. Immunogenicity and safety of
a 13-valent pneumococcal conjugate vaccine in adults 70 years of
56
06 CPM 18th ed Care of Older Per56 56
age and older previously vaccinated with 23-valent pneumococcal
polysaccharide vaccine. Vaccine 2013;31:358593
4. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal
conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine
among adults aged 65 years: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Morb Mortal
Wkly Rep 2014;63:8225.
5. Rivetti, D. et al. Vaccines for preventing influenza in the elderly.
[Cochrane Database Syst Rev. 2010]
6. Schmader, KE. Effect of a Zoster Vaccine on Herpes Zoster-Related
Interference with Functional Status and Health-Related Quality of Life
Measures in Older Adults. J Am Geriatr Soc. 2010 September ; 58(9):
16341641.
7. Tseng, HF. Herpes Zoster Vaccine in Older Adults and the Risk of
Subsequent Herpes Zoster Disease. JAMA, January 12, 2011Vol
305, No. 2
8. Yao, C. et al. The Immunogenicity and safety of zoster vaccine in
Taiwanese adults. Vaccine 33 (2015) 15151517
9. Acosta A. Cost-effectiveness of Tdap substitution for Td in prevention
of pertussis in adults 65 years and older. Presented to the Advisory
Committee on Immunization Practices (ACIP), February 22, 2012.
Atlanta, GA: US Department of Health and Human Services, CDC;
2012.
10. Krishnarajah G. Cost-effectiveness analysis of Boostrix (tetanus toxoid,
reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed)
among individuals 65 years of age in prevention of pertussis.
Presented to the Advisory Committee on Immunization Practices (ACIP),
February 22, 2012. Atlanta, GA: US Department of Health and Human
Services, CDC; 2012.
11. Moro, P. et al. Adverse events after Tetanus Toxoid, Reduced Diphtheria
Toxoid and Acellular Pertussis (Tdap) Vaccine administered to adults 65
years of age and older reported to the Vaccine Adverse Event Reporting
System (VAERS), 20052010 . Vaccine 29 (2011) 94049408
12. Weston, WM. Vaccination of adults 65 years of age and older with
tetanus toxoid, reduced diphtheria toxoid and acellular pertussis
vaccine (Boostrix()): results of two randomized trials. Vaccine. 2012
Feb 21;30(9):1721-8
NUTRITION FOR OLDER PERSONS
Older persons are at risk for undernutrition and mal-
nutrition. This may primarily be caused by physiologic
changes that occur during old age, i.e. diminished taste
sensation, loss of teeth. Chronic illnesses, depression
and even social isolation may contribute to decreased
motivation to eat. Healthcare providers for older persons
should be aware of these factors and should be active in
advocating improved nutrition for the older population.
Statement 6. Higher Protein intake is recommended
for healthy older persons. (Moderate grade, Moderately
recommended)
Summary of Evidences
Guidelines for dietary protein intake have traditionally
advised similar intake for all adults, regardless of age
or sex: 0.8 grams of protein per kilogram of body weight
each day (g/kg BW/d). The one-size-fits-all protein
recommendation does not consider age-related changes
in metabolism, immunity, hormone levels, or progressing
frailty. Indeed, new evidence shows that higher dietary
protein ingestion is beneficial to support good health,
promote recovery from illness, and maintain functionality
in older adults (defined as age >65 years). The need for
more dietary protein is in part because of a declining
anabolic response to protein intake in older people;
more protein is also needed to offset inflammatory and
catabolic conditions associated with chronic and acute
diseases that occur commonly with aging. In addition,
older adults often consume less protein than do young
adults. A shortfall of protein supplies relative to needs can
lead to loss of lean body mass, particularly muscle loss.
As a result, older people are at considerably higher risk
for conditions such as sarcopenia and osteoporosis than
are young people. In turn, sarcopenia and osteoporosis
02/03/2017 1:33:33 PM

can take a high personal toll on older people: falls and
fractures, disabilities, loss of independence, and death
(Pedersen and Cederholm, 2013). B12 intake vary from 1.4 to 3.0 g per day and are based
One epidemiological study showed a positive association
between higher dietary protein intake and fewer health
problems in older women. With data from the Health,
Aging, and Body Composition (Health ABC) Study,
Houston et al, were able to assess the association
between dietary protein intake and changes in lean
body mass (LBM) over a 3-year period in healthy, older
adults (n = 2066).
However, based on the recent Food and Nutrition
Research Institute National survey in 2015, the
recommended protein intake remains the same among
adults and older persons (65-72 g/day). They did not
recommend a higher protein intake and advised that
protein requirement remain unchanged among 20 years
old and above (FNRI National Survey, 2015). This
recommendation was based on a national survey and
did not take into account the other metabolic needs of
an older person brought about by aging.
In view of this Technical Working Group, this recom
mendation is too low for older persons. Recent
researches also suggest other specific nutritional
strategies to promote protein absorption and its efficient
use in older people; such strategies deal with protein
source, timing of intake, and specific amino acid content
or supplementation (Bauer, Biolo, et al., 2013)
Statement 7. Calcium plus Vitamin D supplementation
is recommended for older persons to prevent fracture
risk. (Moderate grade, Strongly recommended)
Summary of evidences
Several high quality studies showed consistent results that
Calcium + Vitamin D supplements can reduce fracture risk
in both community-dwelling and institutionalized middle-
aged to older adults. In a review of eight Randomized
Controlled Trials, it has been shown that Calcium + Vit
D supplementation produced as significant 15% reduced
risk of total fractures (SRRE 0.85, 95%CI 0.73-0.98)
and a 30% reduced risk of hip fractures (SSRE, 0.70;
95% CI, 0.56-0.87). The risk of osteoporotic fractures
increases with age among individuals aged >50 years.
Calcium plus vitamin D supplementation has been widely
recommended for the prevention of osteoporosis and
subsequent fractures (Houston, et al., 2014).
Several meta-analyses showed statistically significant
reductions in risk for both total and hip fractures,
which supports the use of calcium plus vitamin D
supplementation to reduce fracture risk. Identification
of strategies to reduce fracture risk is important, given
that osteoporosis and low bone mass is at 19.8%
prevalence in the Philippines, especially among urban
post- menopausal women (FNRI National Survey 2015;
Bauer, Biolo, et al., 2013).
Statement 8. There is insufficient evidence to recom
mend the use of Vitamin B12, Vitamin C and Zinc
supplementation for healthy older patients. (Low
grade, Strongly recommended)
Summary of Evidences
Among healthy elderly, there is not enough evidence to
06 CPM 18th ed Care of Older Per57 57
Care of Older Persons
substantiate the use of Vitamin B12, Vitamin C and Zinc
as supplements. Current recommendations on vitamin
on the amount needed for maintenance of hematologic
status or on the amount needed to compensate obligatory
losses. A systematic review was done to evaluate
whether the relation between vitamin B12 intake and
cognitive function should be considered for underpinning
vitamin B12 recommendations in the future. The study
concluded that current evidence on the relation between
vitamin B12 intake or status and cognitive function is not
sufficient for consideration in the development of vitamin
B12 recommendations. (Pedersen, 2013 and Houston,
2014)
Estimated average requirement for ascorbic acid is
around 40-60 mg day (Bauer, Biolo, et al., 2013). This
level is enough to meet the needs of an older person
60 years old and above (Food and Nutrition Research
Institute Seminar Series, July 2015).
The findings of the ZENITH study showed that between the
ages of 5570 years old, healthy individuals experience
significant alterations in immune function. Such changes,
however, are largely sex-specific. It is unclear what the
long-term impact of suboptimal Zinc intakes may be on
immune function. Zinc is known to be essential for optimal
immune function and our findings suggest that serum Zinc
concentration is negatively correlated with age; thus, it is
possible that maintaining optimal Zinc status during late-
middle age will be advantageous to health and successful
ageing, potentially mitigating against age-related changes
in immune function. Clearly, further research is needed
to explore the effect of improved Zinc status on emerging
immune deficiencies in cell-mediated immunity in healthy
5570 years old. (Coudray, 2005)
References:
1. Pedersen and Cederholm , Evidence Based Recommendation for
Dietary Protein Intake in Older Persons, 2013
2. Houston,et al. Health, Aging and Body Composition (Healh ABC) Study,
2014
3. Food and Nutrition Research Institute National Survey, 2015
4. Bauer, Biolo, et al, Evidence- Based Protein Recommendations for
Optimal Dietary Protein Intake in Older People: A Position Paper from
PROT-AGE Study Group, 2013
5. Weaver, Alexander et al, 2015, Calcium plus vitamin D supplementation
and risk of fractures: an updated meta-analysis from the National
Osteoporosis Foundation, Osteoporosis Int, (2016) 27: 367-376
6. Li-Yu J, NNHeS. Prevalence of osteoporosis and fractures among
Filipino adults. Phil J Int Med, 2007; 45:57-63
7. Doets, van Wiljgarden et al. Vitamin B12 intake and status and cognitive
function in elderly people. Epidemiol Rev. 2013;35:2-21. doi: 10.1093/
epirev/mxs003. Epub 2012 Dec 5.
8. Zhaoli Dai, Woon-Puay Koh. B-Vitamins and Bone HealthA Review
of the Current Evidence. Nutrients. 2015 May; 7(5): 33223346.
9. Dullemeijer, Souverein et al. Systematic review with dose-response
meta-analyses between vitamin B-12 intake and European Micronutrient
Recommendations Aligneds prioritized biomarkers of vitamin B-12
including randomized controlled trials and observational studies in
adults and elderly persons. Am J Clin Nutr. 2013 Feb;97(2):390-402.
doi: 10.3945/ajcn.112.033951. Epub 2012 Dec 26.
10. Coudray, Connor. Introduction to the ZENITH study and summary of
baseline results. European Journal of Clinical Nutrition (2005) 59, Suppl
2, S5S7. doi:10.1038/sj.ejcn.1602304
FITNESS FOR OLDER PERSONS
Physical activity includes exercise as well as other
activities which involve bodily movement and are done
as part of playing, working, active transportation, house
chores and recreational activities.
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 Care of Older Persons
Lack of physical activity has been identified as the fourth
leading risk factor for global mortality (6% of deaths
globally). Moreover, physical inactivity is estimated to be
the main cause for approximately 2125% of breast and
colon cancers, 27% of diabetes and approximately 30%
of ischemic heart disease burden (WHO, 2010).
Statement 9. There is sufficient evidence that
physical activity reduces the risk from mortality from
all causes (Moderate grade, strongly recommended)
Statement 10. There is a dose-response relationship
between level of physical activity and its benefit
(Moderate grade, strongly recommended)
Summary of Evidences
A systematic review of 18 prospective studies of 280,000
individuals showed that a standardized dose of walking
and cycling, when adjusted for other physical activities
reduced risk for death at 10% (95%CI) and 11%
respectively (Kelly, et, al, 2014). The Bambui Health
and Aging Study (Ramalho et al, 2015) looked at other
physical activities and grouped them as light: going up
the stairs at a normal pace, carrying a load, mopping or
scrubbing floors, cleaning windows, rhythmic dancing;
moderate: cycling for leisure or to work, painting as a
home repair, volleyball, tennis, basketball, football; and
vigorous such as walking fast, brisk walking, aerobics/
gym workout, running/jogging, gardening, sewing wood
and horseriding. These levels of physical activity were
grouped according to the level of energy expenditure
of 1 MET equivalent to the oxygen consumption of 3.5
mL/kg/min. This prospective cohort study included 1809
Brazilian residents greater than 60 years old and followed
for 11 years with death as the endpoint. A statistically
significant interaction (P<0.03) was found between sex
and energy expenditure. Among older men, increases in
levels of physical activity were associated with reduced
mortality risk. The hazard ratios were 0.59 (95% CI
0.430.81) and 0.47 (95% CI 0.340.66) for the second
and third tertiles, respectively. Among older women,
there was no significant association between physical
activity and mortality.
Moving from no activity to higher levels of activity was
also found to be more beneficial than having no activity
at all. A systematic review and meta-analysis of 22
cohort studies and observational studies from Europe,
North America, East Asia and Australia for an almost one
million general healthy population ages 35-88 showed
the largest benefit was found among the totally inactive
or no activity at all moving to low levels of activity (RR
19%, 95% CI) such as walking alone at a leisurely pace
at 2.5 hrs/week, classified as moderate activity. Still to
those already engaged in vigorous activities, increasing
to 7 hrs/week of moderate activity, the risk reduction was
still better (RR 22% 95% CI) when additional exercises
were added. (Woodcock, et al, 2010)
Statement 11. Physical activities in a Fall Prevention
Program, e.g., yoga and tai chi, and improving protective
responses from falls, prevent serious injuries from
falls in older people. (High grade, strongly recommended)
Summary of Evidence
In a meta-analysis of 17 randomized controlled
trials using a pooled data of 4305 participants (2195
intervention, and 2110 control; mean age 76.7 years
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06 CPM 18th ed Care of Older Per58 58
where 76% were women) exercise programs designed to
prevent falls in older adults also prevent injuries caused
by falls, including or further most serious falls, and falls
causing medical injuries (El Khouri et al, 2013). Rather
than rest, frail older people should resume their physical
activities after a fall as soon as deemed safe by their
physician.
Statement 12. Frail older persons will also benefit
from home aerobic, resistance and balance exercises
with or without machines, standing or chair-based,
at regular intervals and sustained for long periods.
(Moderate grade, moderately recommended)
Summary of evidences
Frail older people are often unable to do vigorous
exercise programs. However, when supervised, and
with consistent engagement, benefits can be accrued
(Anthony et al, 2013).
In the systematic review of 9 studies by de Labra et al
(2015) which enrolled a pooled 1067 older adults, mean
age 82.5 years and 71% women, the effects of physical
therapy interventions of combined aerobics, resistance
and muscle strength training exercises of frail seniors who
responded to the definition of frailty by Fried. The effects
were compared with no activity or previous lifestyle of a
control group. After 10-12 weeks, there was a significant
increase in knee function in 1 study, reduced falls in
2 studies, and improved the chair-rising ability. Other
studies showed improvement of balance, improvement
of the frailty status with good nutrition, and improved
the time spent on the Timed Up and Go Test but these
changes were not significant. There were also studies
that did not improve functional ability nor improve the
walking speed.
Chair-based exercises were used by Kevin Anthony
et al (2013) involving 230 pooled subjects from a total
of eight (8) randomized controlled trials. High-paced
complex choreographed movements were used in
different studies, another study used moderate intensity
progressive training exercises using Theraband, and
another study used home-video instruction. All activities
were supervised by the physical therapist. Although rated
as low quality because of differences in methodology,
improvements were seen in Timed Up and Go tests,
muscle strength, grip strength, muscle power, cadence
and gait, walking speed and MMSE scores. But the
significant changes were the improvement in chair-rising
ability, heart rate and systolic blood pressure. Further
studies of these natures are recommended therefore to
establish the benefits of physical therapy programs for
frail older people.
References:
1. World Health Organization, 2010. Global Recommendations on Diet
and Physical Activity for Health. Geneva: WHO available at http://www.
who.int/dietphysicalactivity/publications/9789241599979/en
2. Kelly P, Kahlmeier S, et al, 2014. Systematic Review and Meta-analysis
of reduction in all-cause mortality from walking and cycling and shape of
dose-response relationship. International Journal of Behavioral Nutrition
and Physical Activity 11:132. 1-15.
3. Ramalho et al, 2015. Physical activity and all-cause mortality among
older Brazilian adults: 11-year follow-up of the Bambui Health and Aging
Study. Clin Interv Aging; 10: 751758.
4. Woodcock J, et al, 2010. Non-vigorous physical activity and all-cause
mortality: systematic review of meta-analysis and cohort studies.
International Journal of Epidemiology 2011. 40:121138. doi:10.1093/
ije/dyq104
5. Active Aging Partnership. National blueprint: increasing physical
activity among adults aged 50 and older. http://www.agingblueprint.
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org. Accessed August 17, 2016.
6. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for
preventing falls in older people living in the community. Cochrane
Database Syst Rev. 2009(2):CD007146.
7. El Khouri, et al, 2013. The effect of fall prevention exercise programs
on fall induced injuries in community dwelling older adults: systematic
review and randomized controlled trials. British Medical Journal; 347.
F6234 doi: 10.1136/bmj f6234. 1-13.
8. Chief Medical Officers (2011). Start Active, Stay Active, A Report
on Physical Activity for Health from the 4 Home Countries. United
Kingdom.
9. Stevens JA, 2010. A CDC Compendium of Effective Fall Interventions:
What Works for Community-Dwelling Older Adults. 2nd ed. Atlanta, GA:
Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control,
10. Anthony K et al, 2013. Chair-based Exercises for Older People: A
Systematic Review. Biomed Research International. 13: Article ID
309506, 1-9.
11. de Labra et al, 2015. Effects of Exercises on Frail Older People. BMC
Geriatrics 15:154
DOI 10.1186/s12877-015-0155-4
SCREENING FOR OLDER PERSONS
Physiologic changes in aging contribute in the increase
risk of older persons for geriatric syndromes (impairment
of vision and hearing, cognitive impairment, depression),
or certain diseases like osteoporosis and cancer. It is
estimated that as many as 1 in 2 women and 1 in 5 men
are at risk for an osteoporosis-related fracture during
their lifetime.
Most common among cancer are the following: breast
cancer, prostate cancer and cervical cancer. The
incidence of breast cancer in the Philippines is 18.7%
while cervical cancer is 6.8% and prostate cancer is 4.9%.
In the US, in 2015, an estimated 232,000 women were
diagnosed with the disease and 40,000 women died of
it. It is most frequently diagnosed among women aged
55 to 64 years, and the median age of death from breast
cancer is 68 years. Colorectal cancer is most frequently
diagnosed among adults aged 65 to 74 years; the median
age at death from colorectal cancer is 68 years. Seventy
percent of deaths due to prostate cancer occur after age
75 years.
Statement 13. In the primary care setting, Snellens
Visual acuity test is recommended as a screening tool
to identify elderly with low vision. (Moderate grade,
Strongly recommended)
Summary of Evidence
Eight cross-sectional studies were identified that
evaluated the diagnostic accuracy of screening for
impaired visual acuity in older adult. Four studies found
that screening questions are not accurate for identifying
persons with vision impairment compared to the Snellen
chart. Four studies found that visual acuity testing is not
accurate for identifying the presence of vision conditions
compared to a detailed ophthalmologic examination.
One study found that the Amsler grid is not accurate for
identifying the presence of vision conditions compared
to a detailed ophthalmologic examination. One very
small (n=50) study found non-ophthalmologists are as
accurate as ophthalmologists for identifying presence
of cataracts.
Statement 14. It is recommended that the Single
Question Do you think you have difficulty hearing?
be used as a screening tool to detect hearing loss
in the elderly. Those who respond yes should
06 CPM 18th ed Care of Older Per59 59
Care of Older Persons
be referred for audiometric examination. (Moderate
grade, Strongly recommended)
Summary of Evidences
Twenty studies evaluated the diagnostic accuracy of
clinical tests, a single question, a questionnaire, or a
handheld audiometric device for identification of hearing
loss in older adults. For detection of >25 or >30 dB
hearing loss, four studies (one good-quality) found that
the whispered voice test at 2 feet was associated with
a median positive likelihood ratio (PLR) of 5.1 (range,
2.3 to 7.4) and median negative likelihood ratio (NLR)
of 0.03 (range, 0.007 to 0.73). For detection of >25 dB
hearing loss, six studies (four good-quality) found that
a single question was associated with a median PLR of
3.0 (range, 2.4 to 3.8) and median NLR of 0.40 (range,
0.33 to 0.82), and four good-quality studies found that the
HHIE-S (based on a cutoff score of 8) was associated with
a median PLR of 3.5 (range, 2.4 to 11) and median NLR
of 0.52 (range, 0.43 to 0.70). Likelihood ratio estimates
were similar for detection of >40 dB hearing loss. For
detection of >40 dB hearing loss, three studies (two
good-quality) found that the AudioScope (based on ability
to hear tones between 500 and 4000 Hz at 40 dB) was
associated with a median PLR of 3.4 (range, 1.7 to 4.9)
and median NLR of 0.05 (range, 0.03 to 0.08). In direct
comparisons, one good-quality study found that the watch
tick and finger rub tests were associated with similar
NLRs but substantially stronger PLRs compared with
the whispered voice test or a single screening question.
Three studies showed a consistent trade-off between
lower sensitivity and higher specificity for the HHIE-S
compared with a single screening question, resulting in
somewhat stronger PLRs and weaker NLRs.Two studies
found that the AudioScope was associated with stronger
NLRs compared with the HHIE-S, with relatively small
differences in PLR estimates.
Statement 15. Mini Mental Status Examination (MMSE)
can adequately detect dementia and Mild Cognitive
Impairment (MCI) and is therefore recommended
for screening asymptomatic elderly in primary care.
(Moderate grade, Strongly recommended)
Summary of Evidences
There were 41 studies that addressed the diagnostic
accuracy of very brief and brief screening instruments
that could be administered in primary care and seven
studies that addressed instruments that could be self-
administered. The included studies considered a broad
range of participants relevant to older adult primary care
populations and a wide variety of different screening
instruments. Overall, study participants were community-
dwelling older adults selected from the community or
primary care practices. Two studies explicitly included
people in assisted living or residential care facilities.
Almost all studies had a majority of women participants, but
studies varied in the mean age (range of means, 69 to 95
years) and prevalence of dementia (range of prevalence,
1.2% to 47.1%). Education was not always reported.
The best-studied instrument remains the MMSE, which
has a relatively long administration time compared with
other screening instruments included in this review. For
the MMSE, the most commonly reported cut-points were
23/24 and 24/25, although higher and lower cut-points
were evaluated in various studies. Pooled estimates
across 14 studies (n=10,185) resulted in 88.3 percent
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02/03/2017 1:33:33 PM
 Care of Older Persons
sensitivity (95% CI, 81.3% to 92.9%) and 86.2 percent
specificity (95% CI, 81.8% to 89.7%) for a cut-point of
23/24 or 24/25. Studies in populations with low levels of
education (majority with primary school education or less)
used lower cut-points. Test performance to detect MCI
was based on a much smaller body of literature (k=15;
n=5,758). Studies using higher cut-points to detect MCI
did not have better sensitivity or specificity
Statement 16. It is recommended that PHQ-2 be used
as an initial step in identifying risk for depression in
the elderly (using the cut-off 2). Elderly who will be
positively screened should undergo a diagnostic
screen using GDS-15. (Moderate grade, Strongly
recommended).
Summary of Evidences
There were 39 studies that addressed the validity of
PHQ-2 in detecting depression. Thirty-three studies were
excluded, and 6 studies met the inclusion criteria.
One review of the GDS-15 and GDS-30, published in
2010, included a meta-analysis of 17 studies conducted in
primary care settings. The principle inclusion criteria were
studies that compared the diagnostic validity of the GDS
to that of the semi-structured psychiatric interview for
diagnosing late-life (aged 55 years or older) depression.
Studies evaluating the GDS-15 (k=7) used cut-offs
ranging from 3 to 7, resulting in an adjusted sensitivity of
81.3 percent (95% CI, 77.2 to 85.2) and a specificity of
78.4 percent (95% CI, 71.2 to 84.8). Studies evaluating
the GDS-30 (k=10) used cutoffs ranging from 7 to 11,
resulting in an adjusted sensitivity of 77.4% (95% CI, 66.3
to 86.8) and a specificity of 65.4 percent (95% CI, 44.2 to
83.8). In order to more fully examine the clinical utility of
the GDS, the authors also evaluated general practitioners
ability to detect depression without a screening tool.
Using data from six studies, the authors reported a
pooled sensitivity of 56.3 percent (95% CI, 40.0 to 72.0)
and specificity of 73.6 percent (95% CI, 71.7 to 75.5).
The authors concluded that the GDS-30 had modest
diagnostic success, modest clinical utility, and limited
benefit beyond the general practitioners unassisted
clinical skills. The GDS-15, however, was believed to
have adequate diagnostic value with significantly greater
accuracy than the GDS-30 and, thus, good clinical utility.
Furthermore, use of the GDS-15 by general practitioners
has the potential to increase unassisted case detection
by 8 percent.
References:
1. Evidence Synthesis Number 127 Screening for Impaired Visual Acuity in
Older Adults: A Systematic Review to Update the 2009 U.S. Preventive
Services Task Force Recommendation. Roger Chou, MD Tracy Dana,
MLS Christina Bougatsos, MPH Sara Grusing, BS Ian Blazina, MPH.
AHRQ Publication No. 14-05209-EF-1 July 2015
2. Evidence Synthesis 83. Screening for Hearing Loss in Adults Ages 50
Years and Older: A Review of the Evidence for the U.S. Preventive
Services Task Force. Roger Chou, MD Tracy Dana, MLS Christina
Bougatsos, BS Craig Fleming, MD Tracy Beil, MS AHRQ. AHRQ
Publication No. 11-05153-EF-1 March 2011
3. Screening for Cognitive Impairment in Older Adults: An Evidence Update
for the U.S. Preventive Services Task Force. Investigators: Jennifer S.
Lin, MD, MCR Elizabeth OConnor, PhD Rebecca C. Rossom, MD, MSCR
Leslie A. Perdue, MPH Brittany U. Burda, MPH Matthew Thompson,
MD, MPH, DPhil Elizabeth Eckstrom, MD, MPH. AHRQ Publication No.
14-05198-EF-1 November 2013
4. Screening for Depression in Adults: An Updated Systematic Evidence
Review for the U.S. Preventive Services Task Force. Elizabeth OConnor,
PhD Rebecca C. Rossom, MD, MSCR Michelle Henninger, PhD Holly C.
Groom, MPH Brittany U. Burda, MPH Jillian T. Henderson, PhD Keshia
D. Bigler, BS Evelyn P. Whitlock, MD, MPH. AHRQ Publication No. 14-
05208-EF-1 July 2015
60
06 CPM 18th ed Care of Older Per60 60
Statement 17. Screen all elderly women with bone
mineral denitometry whose 10-year fracture risk is
equal to or greater than that of a 65-year-old woman
who has no additional risk factors (moderate grade,
moderately recommended)
Summary of evidences
Measurement of bone density using Dual xray
absorptiometry (DXA) has become the gold standard for
the diagnosis of osteoporosis and for guiding decisions
about which patients to treat. Although DXA is not a
perfect predictor of fractures, DXA of the femoral neck
is considered to be the best predictor of hip fracture and
is comparable with DXA measurements of the forearm
for predicting fractures at other sites. A large prospective
cohort study in the Netherlands that included persons
older than 55 years reported the incidence of vertebral
and nonvertebral fractures approximately 6 years after
patients obtained baseline DXA measurements of the
femoral neck.
Reference
1. Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R. Screening for
osteoporosis: an update for the U.S. Preventive Services Task Force.
Ann Intern Med. 2010;153:1-14. [PMID: 20621892]
Statement 18. The Technical working group adopts
the (US Preventive Service Task Force) recommenda
tions on cancer screening.
a. Biennial screening with mammography is recom
mended for 60-74 years old. (Moderate grade,
moderately recommended)
b. Colonoscopy is recommended every 10 years
for 60-74 years old. (Moderate grade, moderate
recommendations)
c. Routine PSA screening for prostate cancer for 60
years old and above is not recommended. Digital
rectal examination may be done. (Moderate grade,
moderately recommended)
d. Pap smear is not recommended in women older
than age 65 years who have had adequate prior
screening and are not otherwise at high risk for
cervical cancer. (Moderate grade, strongly recom
mended)
Summary of evidences
Mammography
An updated meta-analysis by Nelson and colleagues
of RCTs of screening mammography found similar RR
reductions in breast cancer mortality by age group as
the previous USPSTF evidence review. The combined
RRs were 0.92 (CI, 0.75 to 1.02) for women aged 39 to
49 years, 0.86 (CI, 0.68 to 0.97) for women aged 50 to
59 years, 0.67 (CI, 0.54 to 0.83) for women aged 60 to
69 years, and 0.80 (CI, 0.51 to 1.28) for women aged
70 to 74 years. Updated decision models performed by
CISNET yielded somewhat higher estimates in lifetime
relative breast cancer mortality reductions with biennial
mammography screening in women aged 50 to 74 years
compared with previous analyses (median reduction,
25.8% vs. 21.5%; range across models, 24.1% to 31.8%
vs. 20.0% to 28.0%, respectively). Since its previous
analysis, CISNET has revised the inputs of each of its
6 models (for example, portraying distinct molecular
subtypes and including digital mammography), which
may account for some of the difference. The updated
estimate of the mortality benefit of mammography is also
higher than that obtained via meta-analysis of randomized
02/03/2017 1:33:33 PM

trials for a similar age group (24.1% to 31.8% for women
aged 50 to 74 years in decision models vs. 19% to 22%
for women aged 50 to 69 years in RCTs).
Colonoscopy
A prospective cohort study found an association
between patients who self-reported being screened with
colonoscopy and a lower colorectal cancer mortality
rate.
PSA
Prostate-specific antigenbased screening in men
aged 50 to 74 years has been evaluated in 5 unique
randomized, controlled trials of single or interval PSA
testing with various PSA cutoffs and screening intervals,
along with other screening methods, such as digital rectal
examination or transrectal ultrasonography. No study
found a difference in overall or all-cause mortality. This
probably reflects the high rates of competing mortality
in this age group, because these men are more likely
to die of prostate cancer, as well as the limited power of
prostate cancer screening trials to detect differences in
all-cause mortality, should they exist. Even in the core
age group of 55 to 69 years in the ERSPC trial, only 462
of 17,256 deaths were due to prostate cancer. The all-
cause mortality RR was 1.00 (CI, 0.98 to 1.02) in all men
randomly assigned to screening versus no screening.
Results were similar in men aged 55 to 69 years.
Pap smear
The incidence and prevalence of cervical intraepithelial
neoplasia (CIN) peak in the mid-reproductive years and
begin to decline in approximately the fourth decade
of life, a general pattern also apparent among some
previously unscreened women. Cervical cancer in older
women is not more aggressive or rapidly progressive than
that in younger women. Finally, the rate of high-grade
squamous intraepithelial lesions diagnosed by cytology
is low among older women who have been previously
screened. Modeling studies of the age at which to end
screening indicate no substantial benefit beyond age 65
years in women who have been previously screened.
Specifically, varying the age at which to end screening
from 65 years to 95 years by 5-year intervals provides
a very small (<1 life-year) improvement in life-years
after age 65 years but increases potential harms due to
false-positive results and the increase in the number of
colposcopies and cervical biopsies.
References:
1. Final Update Summary: Prostate Cancer: Screening. U.S. Preventive
Services Task Force. September 2016. https://www.uspreventiveservice-
staskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-
screening
2. Kulasingam SL, Havrilesky L, Ghebre R, Myers ER. Screening for
cervical cancer: a decision analysis for the U.S. Preventive Services Task
Force. AHRQ Publication No. 11-05157-EF-1. Rockville, MD: Agency for
Healthcare Research and Quality; 2011.
3. Mandelblatt JS, Stout NK, Schechter CB, van den Broek JJ, Miglioretti
DL, Krapcho M, et al. Collaborative modeling of the benefits and harms
associated with different U.S. breast cancer screening strategies. Ann
Intern Med. 2016. [Epub ahead of print]
4. Nelson HD, Cantor A, Humphrey L, Fu R, Pappas M, Daeges M, Griffin
J. Screening for Breast Cancer: A Systematic Review to Update the
2009 U.S. Preventive Services Task Force Recommendation. Evidence
Synthesis No. 124. AHRQ Publication No. 14-05201-EF-1. Rockville, MD:
Agency for Healthcare Research and Quality; 2016.
5. Nishihara R, Wu K, Lochhead P, et al. Long-term colorectal-can-
cer incidence and mortality after lower endoscopy. N Engl J Med.
2013;369(12):1095-105.
06 CPM 18th ed Care of Older Per61 61
Care of Older Persons
COUNSELING FOR OLDER PERSONS
In the recent FNRI National Health Survey, older persons
are prone to tobacco addiction and alcohol misuse.
23.9% of the young old and 17.9% of the middle to old
old are current smokers. 56.2 of the young old (60-69)
and 39.9% of the middle to old old (70 and above) are
current drinkers. 51% of the young old are binge drinkers
while 35.1% of the old old are binge drinkers.
Statement 19. Physicians should provide older
persons brief counselling interventions on smoking
cessation to prevent tobacco addiction. (Moderate
grade, Strongly recommended)
Summary of evidence
The association between smoking and risk of dementia,
including Alzheimers disease has been studied. Elderly
current smokers are at increased risk of dementia and
cognitive decline compared with those who have never
smoked but that there remains insufficient data to
determine how past smoking affects risk of both cognitive
decline and dementia.
Statement 20. Once screened for alcohol misuse,
physicians should provide older persons brief
counselling interventions. (Moderate, Strongly
recommended)
Summary of Evidence
The USPSTF reviewed new evidence on the effectiveness
of screening for alcohol misuse for improving health
outcomes, the accuracy of various screening approaches,
the effectiveness of various behavioral counseling
interventions for improving intermediate or long-term
health outcomes, the harms of screening and behavioural
counseling interventions for alcohol misuse.
References
1. Hoffman et al. Systematic Review: Counseling and Cognitive Behavior
Therapy for Substance Abuse. 2012
2. Moyer MD. Screening and Behavioral Counseling Interventions in Primary
Care to Reduce Alcohol Misuse: U.S. Preventive Services Task Force
Recommendation Statement. Annals of Internal medicine, 2013.
ACKNOWLEDGEMENT
The Philippine Academy of Family Physicians wish to thank the
following for their invaluable contribution as members of The
Consensus Group to the development of the PAFP Consensus
Statements on Wellness: Care for Older Persons: Dr. Roy
Cuison (PCGM), Ms. Consuelo Orense and Ms. Marilou Madrid
(FNRI), Dr. Vicky Apuan (Miriam College), Dr. Policarpio Joves,
Jr. (FEU), Dr. Ma. Victoria Concepcion Cruz (UST), Dr. Lynne
Marcia Bautista (MDH), Dr. Elmer Angus (MDH), Dr. Josefina
Isidro-Lapea (UP-PGH), Dr. Annie Francisco, Dr. Mirla Severino
and Dr. Mercedita Bariso (PAFP LaMPPara), Dr. Margaret Jean
de Guzman (PAFP Isabela), Dr. Ricardo Guanzon and Dr. Aurora
Espinoza (PAFP Pangasinan), Dr. Jane Eflyn Lardizabal-Bunyi
(Pacific Global Medical Center), Dr. Ceasar Palma (PAFP Cavite),
Dr. Mona Lisa Cosme (PAFP Laguna), Dr. Judith Amparado
(PAFP Tacloban), Dr. Disi Yap-Alba (PAFP Bohol), Dr. Delia
Pastoriza (PAFP Pagadian), Dr. Karin Estepa-Garcia (PAFP
Manila), Dr. Ferdinand de Guzman (PSPCPTM), Dr. Teresa
Tricia Bautista (QMMC), Dr. Rosario Bieren and Dr. Maria Rosario
Formoso (PAFP MATAPAT), Dr. Serge Tanhueco and Dr. Ethelyn
Joy Pichay (PAFP QC), Dr. Anna Guia Limpoco, Dr. Marishiel
Mejia-Samonte, Dr. Nenacia Ranali Palma-Mendoza (UP-PGH),
Dr. Marilou Lintag (PAFP PaMaMaRiSan), Dr. Maria Pamela
Perlas (PAFP CaMaNaVa), Dr. Ryan Jean Ceralvo, Dr. Gloria de
Alban and Dr. Rosa Marie Flores (PAFP Manila), Dr. Flora Marin
(PAFP QC) and Dr. Shelley dela Vega (NIH-NIA).
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 Care of Older Persons

Index of Drugs Referred to in the Guideline

This index lists the products of interest and/or their therapeutic classifications related to the guideline. This index
is not part of the guideline. For the doctor's convenience, brands available in the PPD references are listed under
each of the classes. For drug information, refer to the PPD references, namely: PPD, PPD App, Better Pharmacy
and TheFilipinoDoctor.com.

Pneumococcal Vaccines Neurobexol/Neurobexol Usana Proflavanol C

Pneumo 23 Forte (Hybrid) Nutritional Sup-
Pneumovax 23 Neurobion/Neurobion plement*
Prevenar 13 Forte 5000 Winthrop Sodium
Synflorix Neuro-BS Ascorbate
Neurofenac
Influenza Vaccines Neurogen-E
Fluquadri Neurolink/Neurolink Forte
Vaxigrip Neuroxel 500
Nevramin
DPT & Tetanus Vaccine Nuron-E
Adacel One-Six-Twelve
Boostrix Oranerv Forte
Easyfive-TT* Pharex Vitamin B-Complex
Hexaxim* Polynerv 1000
Ig Tetano Polynerv 250
Imatet Polynerv 500
Sharjvax Polynerv Forte
Tetagam P Renal Vite Plus
Tetraxim REVAMIN
Rhea Brewers Yeast
Calcium Supplement Rhea Vitamin B-Complex +
AlfaCalcinol C Tablet
CaD3 RiteMED Vitamin B-
Calcebone Complex
Calchews Silymarine Plus Vitamin B-
Calci-Aid Complex
Calciday Super B
Calcidin Supraneuron
Calmag Vaneular
Calsan Vibee
Caltrate Plus Vitagen
Calvin Plus Zecobal
Calvit Gold Zyfort
Calvit Premium
Her Soy Plus Vitamin C/Ascorbic acid/
Osteofos Sodium Ascorbate
Rhea Calcium Lactate AD-C Plus
USANA Optimizers Active Ascortain
Calcium Nutritional Sup- Ascortin
plement Tablet Cal-Cee
Calcidin
Vitamin B Supplements Care-Cee
Beclex-IV Cecon
Bitagen Dayzinc
Centravim Efica-cee
Cramin Forte FERN-C
Dolo-Neurobion Fine-C
Enervon Tablet GNC Vitamin D3
Folanerve HBS Immuno-C
Gavindex Forte Nutricee
Hinuron-E Osteofos
Liver 4 Poten-Cee
Livolin Forte Rhea Ascorbic Acid
Maxi-B Rhea Calcium Ascorbate +
Mebaal-1500 Zinc
Mebaal-500 Rhea Vitamin B-Complex +
Mecovit C Tablet*
Mega B RiteMED Ascorbic Acid
Meganerv-300 RiteMED Sodium
Meganerv 1000 Ascorbate
Meganerv FA RiteMED Zinc-C*
Methycobal Tropicee
Micron-C Ultima-C
Nervafil/Nervafil Max Usana Optimizers Visionex
Nervite Nutritional Supplement
Neural-B Tablet

62

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