What is the recommended evaluation and management plan for a 72-year-old female who drinks socially and smokes marijuana, presenting for a health visit after a 10-year absence?

Comprehensive Evaluation and Management Plan for a 72-Year-Old Female After 10-Year Absence

For this 72-year-old female who drinks socially and smokes marijuana, presenting after a 10-year absence from healthcare, a systematic evaluation focusing on age-appropriate preventive care, cardiovascular risk assessment, and addressing substance use is essential.

Initial Assessment Priorities

Cardiovascular Risk Assessment

• Calculate 10-year ASCVD risk (essential for patients 40-79 years) 1
• Measure blood pressure with goal of SBP <130 mmHg for ambulatory community-dwelling adults ≥65 years 1
• Obtain fasting lipid panel and glucose measurements 1
• Screen for other cardiovascular risk factors (family history, physical activity level)

Substance Use Evaluation

• Assess cannabis use pattern:
  • Frequency, amount (grams/day), method of consumption
  • Screen for cannabis use disorder if using more than once daily 1
  • Document time of last cannabis use 1
  • Evaluate for adverse effects (cardiovascular, respiratory, cognitive)
• Document alcohol consumption pattern:
  • Frequency, quantity, and type
  • Screen for alcohol use disorder

Age-Appropriate Cancer Screening

• Colorectal cancer screening
• Breast cancer screening
• Cervical cancer screening based on prior screening history
• Lung cancer screening if smoking history warrants

Management Plan

Cardiovascular Risk Management

• Initiate antihypertensive therapy if BP ≥130/80 mmHg, with goal SBP <130 mmHg 1
• Consider patient's comorbidity burden and life expectancy when determining BP treatment intensity 1
• Prescribe statin therapy based on ASCVD risk calculation
• Recommend lifestyle modifications:
  • Physical activity (150 minutes/week of moderate-intensity activity)
  • Healthy diet with sodium restriction if hypertensive
  • Weight management if indicated

Cannabis Use Management

• If cannabis consumption is >1.5 g/day inhaled, >300 mg/day CBD oil, or >20 mg/day THC oil, consider tapering 1, 2
• Provide education on potential risks:
  • Cardiovascular events including myocardial infarction and stroke 1
  • Risk of arrhythmia in patients with chronic pain 1
  • Potential drug interactions with prescribed medications
• Consider referral to addiction medicine if cannabis use disorder is identified 2
• Do not delay surgery if planned, but inform anesthesia team about cannabis use 1

Alcohol Use Management

• Advise limiting alcohol to moderate consumption (≤1 drink/day for women her age)
• Screen for alcohol-related health issues

Social Determinants of Health

• Screen for social determinants affecting health (transportation, food security, housing) 1
• Connect with community resources as needed

Special Considerations for Older Adults

Polypharmacy Review

• Review all medications including over-the-counter and supplements
• Assess for potential drug interactions with cannabis and alcohol
• Consider medication appropriateness for her age

Functional Assessment

• Evaluate mobility and fall risk
• Assess activities of daily living
• Screen for cognitive impairment

Mental Health Screening

• Screen for depression and anxiety
• Assess social support network

Follow-up Plan

• Schedule follow-up within 1-3 months to assess adherence to recommendations
• Establish regular preventive care schedule to avoid another prolonged absence from healthcare
• Consider more frequent monitoring if significant cardiovascular risk factors or substance use issues are identified

Pitfalls to Avoid

• Do not dismiss cannabis use as benign; it carries specific risks in older adults including sedation and potential cardiovascular effects 1
• Avoid abrupt cessation of cannabis if heavy use is identified; gradual tapering is preferred 1, 2
• Do not overlook the potential for cannabis-medication interactions
• Avoid aggressive BP targets in frail elderly patients or those with orthostatic hypotension 1

By following this systematic approach, you can provide comprehensive care addressing both the patient's age-related health needs and substance use considerations.