A Primer on Promoting Health and Longevity in Older Adults
Aging is not preventable, but frailty and some diseases that affect older adults are. Preventing, detecting, and managing certain diseases that affect the elderly and are reversible or treatable will greatly influence an older patient’s independence, quality of life, and longevity.1 Preventive strategies should be adapted to the overall health status of each individual patient. Approximately 60% to 75% of older adults are healthy (ie, have no or minimal chronic disease and are functionally independent), approximately 20% to 35% are chronically ill (ie, still independent or minimally dependent in activities of daily living but have multiple chronic disorders and take prescription drugs), and approximately 2% to 10% are frail (ie, have multiple severe chronic disorders and are functionally dependent).2 Healthcare providers should also consider whether the patient is robust, frail, moderately demented, or at the end of life when evaluating older adults for health screening and other preventive measures.3 In general, formulating strategies for disease prevention can be challenging, as recommendations continually change as additional research data become available. In addition, older adults are often excluded from randomized controlled trials on screening recommendations, adding to the challenge.
The three levels of preventive strategies to minimize functional limitations and increase the number of healthy years lived are primary prevention, secondary prevention, and tertiary prevention.3
The goal of primary prevention is to prevent the condition from occurring, with immunization and health education being the more commonly employed approaches. Healthy or robust older adults are most likely to benefit from these interventions. Promoting healthy behavior and immunizations cannot be stressed enough for older adults. Most studies show that they make a significant difference in terms of preventing or improving an individual’s illness, as well as improving or maintaining his or her function.4 Counseling patients to switch to a healthier lifestyle is always appropriate, unless they are at the end of life.
The following are some of the recommended primary preventive strategies:
1. Smoking cessation: Regardless of how long the individual has been a smoker, quitting smoking has numerous benefits to various organ systems, which cannot be overemphasized.5
2. Physical activities and exercise: Randomized controlled studies have shown that physical activities and exercise improve function and several chronic conditions among older adults, such as coronary artery disease, diabetes mellitus, osteoporosis, and gait disorders.4
3. Nutrition: A diet high in fiber and low in animal fat traditionally has been considered optimal in preventing various diseases, particularly those that affect the cardiovascular and gastrointestinal systems. The so-called “Mediterranean diet” has been the focus of some studies that purport certain benefits to the older population, chiefly cardiovascular benefits.6 The Mediterranean diet consists of eating primarily plant-based foods, consuming healthy fats such as olive oil rather than butter, limiting salt intake and using herbs to flavor food, limiting consumption of red meat, eating plenty of fish and poultry, and exercising.7
4. Chemoprophylaxis: Aspirin has been shown to decrease the risk of cardiovascular diseases8 and colon cancer.9 Vitamin D has long been used to prevent osteoporosis and has recently been suggested to play a role in the treatment of dementia.10
5. Accident prevention: Several randomized studies on falls prevention have shown that modalities such as environmental modification and specific exercises (eg, Tai Chi) prevent or minimize injuries and accidents, the latter of which is the ninth leading cause of death in the elderly population.11
6. Immunization: There is an age-related decline in immune response in older adults, leading to increased susceptibility to infection and reduced response to vaccination. Presently, there are four vaccinations recommended for older adults: influenza; pneumococcal; varicella zoster; and tetanus, diphtheria, and pertussis (Table 1 [click thumbnail for full view]).12-16 Routine annual influenza vaccination is recommended for all older adults. The 2011-2012 vaccine is similar to the 2010-2011 vaccine and includes A/H1N1-like, A/H3N2-like, and B/Brisbane/60 2008-like antigens.12 The 23-valent pneumococcal vaccine prevents invasive pneumococcal disease, but has no clear effect on pneumococcal pneumonia.17 Revaccination after 5 years may help those who are chronically ill or frail. In 2008, the Advisory Committee on Immunization Practices (ACIP) recommended the routine zoster vaccination of all persons aged ≥60 years.15 Individuals who report previous herpes zoster eruption and patients with chronic medical conditions can be vaccinated. It should not be given to persons with primary or acquired immunodeficiency. There is no recommended booster administration at this time. For 2011, the ACIP recommends administering the Tdap (combined tetanus, diphtheria, and pertussis) vaccine to adults ≥65 years of age, especially those who have close contact with infants <12 months of age.14 The Tdap vaccination can be administered immediately, regardless of the interval since the last tetanus and diphtheria (Td) vaccination, if the adult has not previously been vaccinated with Tdap, if his or her status is unknown, or in lieu of one of the 10-year tetanus boosters.
(Secondary Prevention on next page)
The goal of secondary prevention is to detect diseases at an asymptomatic stage (eg, screening for cancer, lipid disorders, hypertension). This is particularly beneficial to older patients who are chronically ill. As stated earlier, physicians must strongly consider the life expectancy of the individual patient and the time between screening and the observed benefits (ie, reduced disease-specific mortality3; Table 218-22).
Foremost in secondary prevention strategies in older adults is cancer screening. Screening recommendations for secondary prevention of specific cancer types are detailed in Table 3.23-36 As recently as October 2011, the U.S. Preventive Services Task Force (USPSTF) published a draft recommendation statement that recommends against screening for prostate cancer using prostate-specific antigen (PSA) testing for all men who do not have symptoms that are highly suspicious for prostate cancer. This recommendation applies to every man regardless of age, race, or family history.36 The draft recommendation statement, which is based on a recent evidence review (www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm), states that the PSA test is not specific for prostate cancer and it cannot differentiate between aggressive and indolent forms of the disease. It concludes that PSA does not reduce mortality, and the harms that result from testing are moderate to substantial.36 For colon cancer, the 5-year survival rate for localized disease is 91%.37 Regarding skin cancer, randomized controlled trials suggest that primary care physicians should advise patients to increase sun-protective behaviors and decrease indoor tanning.38 Information on screening for breast and cervical cancers are provided in Table 3.23-36 There are insufficient data to recommend screening for ovarian cancer, oral cancer, lung cancer, thyroid cancer, and testicular cancer.
Secondary prevention recommendations for coronary artery disease, diabetes mellitus, osteoporosis, and geriatric syndromes, among others, are also listed in Table 3.23-36 Screening for diabetes is important since approximately 20% of individuals >65 years of age have diabetes mellitus, and almost half of these individuals have not been diagnosed.39 Screening and treating for osteoporosis is recommended, even for the so-called “old-old” (≥80 years of age).40 Bone mineral density testing is recommended for individuals with high risk factors such as white race, history of smoking, chronic steroid use, alcoholism, previous fracture, weight <127 pounds, and loss of height.40
Geriatric syndromes are not necessarily diagnoses, but instead are common health issues and challenges among older individuals that cause significant morbidity, mortality, and institutionalization. Physicians caring for older adults should routinely check such aspects as functional status, hearing, vision, depression, dementia, gait and mobility, nutritional state, and incontinence.41-43
(Tertiary Prevention, Nursing Homes, and Conclusion on next page)
The aim of tertiary prevention is to prevent subsequent disabilities from a disease that has already been recognized. The comprehensive geriatric assessment (CGA) is an excellent tool to assess the tertiary prevention needs of frail older adults. This is a multidimensional and interdisciplinary diagnostic process to determine frailty and develop an overall care plan. Several randomized controlled trials have shown improved function and decreased mortality, rehospitalization, and nursing home placement as a result of performing a CGA.23
Prevention in Nursing Homes
Routine laboratory screening in the nursing home setting is of limited value and may not be cost-effective. Instead, nursing home staff should monitor patients for the onset of some key geriatric syndromes, such as incontinence, decubitus ulcers, depression, weight loss, and decreased mobility. Appropriate primary preventive interventions in this setting include annual influenza vaccination and screening for tuberculosis using the Tuberculin Purified Protein Derivative skin test44 and isoniazid prophylaxis therapy45 as needed.
We have provided the guidelines for prevention and detection of diseases among older adults, highlighting the most recent updates. For tests with available data, healthcare providers treating the older patient must interpret the results based on the health of the individual patient. The life expectancy and preference of the individual must also be considered. For patients who meet the criteria for prevention and screening, physicians should take the time to explain the potential benefits and harms of a particular test or treatment.
Dr. Galindo is a Staff Member, Dr. Samala is Clinical Fellow, and Dr. Ciocon is Chairman, Department of Geriatric Medicine, Cleveland Clinic Florida, Weston.
The authors report no relevant financial relationships.
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