Health Promotion/Disease Prevention in Older Adults–An Evidence-Based Update Part II: Counseling, Chemoprophylaxis, and Im
In Part I of this series (Clinical Geriatrics 2004;12: 17-25), the authors presented the case of Mrs. Edna Wilson, a healthy, community-dwelling 82-year-old woman with mild hypertension, osteoarthritis, and hypercholesterolemia, and asked physicians to consider how they could help her maintain her successful aging. Currently recommended screening measures were reviewed. In Part II, the authors examine guidelines for counseling this hypothetical patient, chemoprophylactic agents to consider, and immunizations she should receive.
Counseling on the part of health professionals consists of five essential elements: assessing a patient’s readiness to change her lifestyle; offering specific advice tailored to the patient; establishing mutually acceptable goals; assisting the patient in achieving her goals through provision of educational materials and toolkits; and monitoring progress. Areas that warrant counseling in the older patient include those recommended by national organizations on falls prevention, diet, exercise, weight control, and safe driving. Several governmental agencies and national professional organizations, including the American Geriatrics Society (AGS), have developed clinical practice guidelines that incorporate recommendations for counseling older patients on health promotion topics (Table I). The AGS Guideline for the Prevention of Falls in Older Persons1 urges physicians to advise patients at risk for falling about the use of assistive devices, the importance of arising slowly from a chair, and engaging in both strengthening and balance-type exercises. In the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trial,2 T’ai Chi, an enjoyable oriental dance form, improved physical functioning of older women and prevented falls. A subsequent study confirmed the effectiveness of this method.3
Older patients who live alone can purchase alert devices to notify family members in the event of a fall from which they cannot get up. Both the AGS and the National Institute on Aging (NIA) have published patient handouts for falls prevention that primary care physicians can reproduce and distribute to seniors or their caregivers. These brochures include tips on proper footwear and “fall-proofing” the house. Other professional societies and governmental agencies that offer useful educational material for physicians to distribute to patients are listed in Table II. Whereas T’ai Chi can improve balance, other exercise methods are also recommended for older patients (eg, strength training, aerobic, endurance, range of motion/stretching). The presence of obstructive coronary artery disease (CAD) at autopsy approaches 50% in elderly women and 70-80% in elderly men. The American Heart Association (AHA) has addressed secondary disease prevention for older patients with known CAD. Apart from medical management of hypertension and hyperlipidemia, encouragement of smoking cessation, and counseling regarding weight management, physicians should counsel patients regarding increased physical activity.4 An earlier AHA position statement advocated a greater physician role in counseling patients about increasing their physical activity, properly assessing patients prior to initiation of an exercise program, and monitoring patients’ progress.5
Obesity is prevalent among seniors: 42% of women in one study of community-dwelling elderly between the ages of 60 and 80 were obese. It is estimated that one-third of homebound older persons are overweight. High body mass index (BMI = weight in kg/m2) predicts mobility disability, and weight gain of 20 lbs or more in women over age 65 has been shown to decrease function. Medical comorbidities are significant: type 2 diabetes mellitus, osteoarthritis of the knees, hyperlipidemia, sarcopenia, and sleep apnea, to name a few. Obesity is an established risk factor for coronary heart disease and other chronic conditions.6 A prospective cohort study during 12.5 years of follow-up among 21,414 U.S. male physicians participating in the Physicians’ Health Study showed a significant relative risk of stroke that was independent of the effects of hypertension, diabetes, and cholesterol. Compared with participants who had a BMI of less than 23, those with a BMI of 30 or more had an adjusted relative risk of 2.00.7 The Centers for Disease Control and Prevention (CDC) urge physicians to assess patients’ obesity risk by BMI, waist circumference, and associated cardiovascular risk factors, ask patients about their readiness to lose weight, and design an individualized weight-control program that includes a calorie-restricted yet healthful diet, behavioral therapy, and physical activity as tolerated. The goal should be a 10% weight loss in 6 months or about 0.5-1 lb per week.8 The National Heart, Lung, and Blood Institute (NHLBI) website (www.nhlbi.nih.gov/) includes a BMI calculator to help physicians with this effort.
In December 2003, the American Medical Association (AMA) published Roadmaps for Clinical Practice entitled “The Assessment and Management of Adult Obesity: A Primer for Physicians.” Consisting of 10 booklets, the primer was produced with support from the Robert Wood Johnson Foundation and was developed with the U.S. Department of Health and Human Services as part of Healthy People 2010 and Steps to a Healthier U.S. Although it does not address obesity in the older person specifically, the primer does contain valuable information and is available free online.9,10 Medicare now recognizes obesity as a medical problem and covers costs of treatment. Bypass surgery is not an option for older obese patients with comorbid conditions. Pharmacotherapeutic agents are available to promote weight loss, but studies have not been performed in the elderly population. Recently, several articles have been published comparing very low-carbohydrate diets with low-fat diets. With 12 months (as opposed to 6 months) of follow-up, there was little difference in the degree of weight loss achieved between the two groups.11,12
A study from the Nutrition, Metabolism and Exercise laboratory at the University of Arkansas compared an ad libitum low-fat, high-carbohydrate diet alone and in combination with aerobic exercise training on body weight and composition in 34 older individuals with impaired glucose tolerance over 12 weeks. The high-carbohydrate-plus-exercise group lost the most weight (-4.8 kg ± 0.9 kg) and a higher percentage of body fat (-3.5% ± 0.7%), and there was no decreased resting metabolic rate noted or reduced fat oxidation.13 For patients with hypertension, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)14 advises physicians to counsel patients regarding diet, salt restriction, exercise, and alcohol consumption. The safest diet for older patients, and the one recommended by JNC-7, is the Dietary Approaches to Stop Hypertension (DASH) eating plan, which consists of fruits, vegetables, whole grains, low-fat dairy products, poultry, and fish.15
The NHLBI website offers a brochure with guidelines for patients on how to follow the DASH eating plan, including the servings and food groups for the eating plan and the number of servings appropriate to the patient’s caloric needs. Regular physical activity, which should include aerobic and strengthening exercises, confers many benefits on older patients, even if performed at low levels.5 With patients such as Mrs. Wilson who live alone, other nutritional concerns often arise. Such patients may not want to cook for just one person and instead rely on frozen dinners that are high in salt, fat, and carbohydrate content. Many older patients ask their physicians about the role of vitamin supplements in staying healthy. In 2003, the United States Preventive Services Task Force (USPSTF) concluded that evidence was insufficient to recommend vitamin supplementation for prevention of cardiovascular disease or cancer. The studies reviewed did not take into consideration those who had dietary or vitamin deficiencies.16 Physicians should advise patients like Mrs. Wilson to enjoy lunch at a senior nutrition site and to consume 1200 mg per day of calcium and 400-800 IU of vitamin D daily. A recent meta-analysis showed that 800 IU of vitamin D prevents falls in older subjects.17 Another area targeted for counseling is safe driving. Older individuals have more fatal crashes per mile driven than any other group except teenage males.18
The AMA published a manual for assessing the older driver in 2003 that provides doctors with guidelines for evaluating driving capacity.19 Visual disturbances, strokes with residual deficits, severe arthritis of the neck and limbs, and dementia can impair a geriatric patient’s ability to drive. State law varies regarding mandatory reporting of unsafe drivers. One study compared screening tools that correlated with behind-the-wheel performance and found that the Trail Making Test Part B, the Folstein Mini-Mental State Examination, grip strength, and reaction time were useful.20 Physicians who are in doubt about whether patients are still safe to drive can refer patients to driving instructors who work with disabled patients. Finally, physicians should continue to counsel patients about smoking cessation, use of seatbelts, smoke detectors, moderation with alcohol use, and safe sex—advice similar to what they would provide to a middle-aged adult. Doctors should not assume that widows and widowers are sexually abstinent. Those who are sexually active need to be counseled about safe sex practices, including the use of condoms, to prevent the spread of HIV and other sexually transmitted diseases.21
The CDC periodically updates recommendations for adult immunization. In June 2003, the Advisory Committee on Immunization Practices (ACIP) revised the format of recommendations according to age and underlying medical condition. In 2002, the Centers for Medicare and Medicaid Services (CMS) enacted a new regulation allowing for use of standing orders at Medicare-and Medicaid-participating hospitals, long-term care facilities, and home health care agencies to deliver influenza and pneumococcal vaccinations as recommended by ACIP and the Task Force on Community Preventive Services. Mrs. Wilson should receive the pneumococcal vaccine once if she had not been previously vaccinated or if her first vaccination occurred before age 65. Each autumn she should receive the influenza vaccine, unless she is allergic to eggs. If previously vaccinated, she should receive a tetanus booster once every 10 years. Patients with chronic renal failure, multiple sexual partners, or prolonged international travel to countries with high rates of hepatitis B should receive the hepatitis B virus (HBV) vaccine, but for patients like Mrs. Wilson, this is usually not necessary.22
Results of the Women’s Health Initiative study have changed the role of hormone replacement therapy (HRT) in postmenopausal women. Because women taking HRT had higher risk of breast and uterine cancers, dementia, and cardiovascular and cerebrovascular events compared to controls, HRT is no longer recommended for primary prevention.23 Recently, the National Osteoporosis Foundation (NOF) developed the “Physician’s Guide to Prevention and Treatment of Osteoporosis”24 in conjunction with several specialty and medical subspecialty societies, including the AGS, AMA, and American College of Obstetricians and Gynecologists (ACOG). According to this guideline, assuming no contraindication, women with osteoporosis confirmed by dual-energy x-ray absorptiometry (DEXA) should be advised to take calcium and vitamin D, to perform both weight-bearing and muscle-strengthening exercise, and to be considered for osteoporosis treatment with such agents as biphosphonates, calcitonin, and raloxifene.
Estrogen therapy (ET)/hormone therapy (HT) is approved for the prevention of postmenopausal osteoporosis, but HRT should be used in the lowest doses possible for the shortest period of time to relieve menopausal symptoms. The guideline goes on to say, “When considering ET/HT for prevention of osteoporosis, consider all available medications prior to making a decision.” Parathyroid hormone (PTH 1-34) is a newly approved drug for osteoporosis treatment, although it is expensive.24 Controversial is the role of statin drugs in primary cardiovascular prevention. The PROspective Study of Pravastatin in the Elderly at Risk of vascular disease (PROSPER) trial25 was a double-blind study of subjects with a mean age of 75 and a total cholesterol of 220 mg/dL (155-348 mg/dL). Mean follow-up was 3.2 years. Patients were randomized to receive pravastatin 40 mg a day versus placebo. There was a significant difference (hazard ratio, 0.85; number needed to treat [NNT] for 3 years: 47) in primary outcome (myocardial infarction [MI], stroke, coronary or cardiovascular accident [CVA] death), but there was no significant difference in secondary outcomes (cognition, disability, hospitalization, or all-cause mortality).
The major benefit accrued to high-risk patients with underlying vascular disease, low-density lipoprotein of greater than 132 mg/dL, and high-density lipoprotein of less than 43 mg/dL.25 A recent meta-analysis evaluating the effects of lipid-lowering medications on coronary heart disease (CHD) in women (mean age in studies varied from 54-62) showed that for women without cardiovascular disease, lipid lowering did not affect total or CHD mortality. For women with known cardiovascular disease, treatment of hyperlipidemia did not reduce total mortality (relative risk [RR] 1.0; confidence interval [CI], 0.77-1.29), but did reduce nonfatal MI (RR 0.71; CI, 0.58-0.87), revascularization rates (RR 0.70; CI, 0.55-0.89), and total CHD events (RR 0.80; CI, 0.71-0.91).26 The Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program (NCEP) amended its recommendation for lipid levels with more stringent guidelines for practitioners.27,28
Tables III and IV27,28 summarize the new recommendations based on five randomized, controlled clinical trials with statins. These trials involved patients with known cardiac or vascular disease. While they included older patients, most were in the “young-old” or “mid-old” groups. In patients like Mrs. Wilson who are in the “old-old” category, side effects of drugs need to be considered along with potential benefits. The statins appear to be most helpful in those with underlying cardiovascular disease (ie, in secondary prevention).26 Therapeutic lifestyle changes, including weight management, diet, and exercise, remain an essential method in clinical management. Aspirin has recently been shown in two studies to decrease the rate of adenomatous polyp development in high-risk patients29,30 and the rate of breast cancer.31 Aspirin also offers benefit to patients at high risk of CHD (ie, those with a 5-year risk > 3%).32-34 Physicians need to weigh the benefits versus the risks (major gastrointestinal bleeding, hemorrhagic CVA) before prescribing aspirin. Certainly, in a patient like Mrs. Wilson who has underlying hypertension, low-dose aspirin should be considered. Other chemoprophylactic agents beyond the scope of this article include warfarin for atrial fibrillation, acetylcholinesterase inhibitors, vitamin E and Ginkgo biloba for mild cognitive impairment, selective estrogen-receptor modulators (SERMs) for breast cancer prevention, and antiviral therapy for influenza prevention in communal settings.
HEALTH CARE SYSTEM CHANGES TO PROMOTE PATIENT SAFETY
Increasingly, health care institutions, governmental agencies, and accrediting bodies are advising system-wide changes to promote patient safety and to make it easy for physicians to do the right thing. Standing order protocols for influenza and pneumococcal vaccinations, pharmacy-assisted computerized drug ordering, information technology systems for assuring transfer of clinical information across health care settings, and telehealth technology for monitoring patients at home are a few examples of the ways that physician leaders can have an impact on the overall health of their geriatric patients.
HEALTHY PEOPLE 2010 AND PUTTING PREVENTION INTO PRACTICE
The U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation website (aspe.hhs.gov/ezec/issues/preventive.htm) offers links to other governmental websites that can help physicians incorporate preventive measures into clinical practice (Table I). Healthy People 2010 is the prevention agenda for the nation. It is a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats. The CDC WONDER database of Prevention Guidelines is a comprehensive compendium of all of the official guidelines and recommendations published by the CDC for the prevention of diseases, injuries, and disabilities. The National Center for Disease Prevention and Health Promotion offers specific preventive advice for seniors in the section, Health Information for Older Adults.
Putting Prevention into Practice (PPIP) is a national program sponsored by the Agency for Healthcare Research and Quality (AHRQ) to increase the appropriate use of clinical preventive services such as screening tests, immunizations, and counseling based on the U.S. Preventive Services Task Force recommendations. It provides resources for clinicians, patients, and office systems to increase the delivery of preventive services in the primary care setting. Last year, the AHRQ developed the Pocket Guide to Staying Healthy at 50+ in partnership with the American Association of Retired Persons (AARP). The first 100 copies are free; additional packets of 25 cost $15. A Spanish-language booklet is available. Some physicians have instituted computerized reminders for when patients are due for screening colonoscopy, mammograms, and vaccinations. Fact sheets and informational booklets are available through the NIA “Age Pages” as well as state departments of health. Web-based patient educational resources are also available through the AGS website and the AHRQ (Table II). The Medicare website (www.medicare.gov) offers a preventive services pamphlet, which explains to beneficiaries which preventive services are covered by Medicare. These services are listed in Table V. Many insurance companies now reimburse for preventive services through an annual preventive exam (V codes 99387 for initial preventive E & M and 99397 for established preventive E & M in patients > 65 years).
Mrs. Wilson should be treated for hypertension if her blood pressure is higher than 140/90 mm Hg. She should be counseled regarding advance directives, falls prevention, osteoporosis, diet, weight management, exercise, and safe driving. Assuming no medical contraindication, she should be advised to take calcium and vitamin D supplements. If her blood pressure is elevated, she should be considered for low-dose aspirin therapy. Treatment of her elevated cholesterol should begin with advice regarding the DASH eating plan unless further information from history and physical exam reveals evidence of underlying cardiovascular or peripheral vascular disease. High LDL levels warrant consideration of pharmacologic treatment. Health promotion is a partnership between patients and their primary health care providers. Physicians now have access to strong, evidence-based recommendations for guiding patients. The challenge is how to motivate patients to adhere to a healthful lifestyle. Physician advice is an underutilized yet very powerful motivator.