Current Geriatric Diagnosis & Treatment, 1st Edition

Section I - Approach to the Geriatric Patient 

3. Prevention & Health Promotion

Paul E. Tatum III MD

David R. Mehr MD, MS

PREVENTIVE SERVICES

Even in the very elderly, preventive interventions can limit disease and disability. However, selecting appropriate interventions requires consideration of life expectancy and care goals. Preventive interventions are typically categorized as primary, secondary, or tertiary. Primary prevention refers to prevention of disease (eg, immunizations); secondary prevention is the early detection of disease before it becomes symptomatic (eg, mammography to detect early breast cancer); and tertiary prevention refers to activities to optimize health once disease is already detected.

Since the 1980s both the U.S. Preventive Services Task Force (USPSTF) and the Canadian Task Force on Preventive Health Care have provided evidence-based scientific reviews of preventive health services to guide primary care decision making. The fundamental standard applied by the task force is whether the intervention leads to improved health outcomes (eg, reduced disease-specific morbidity or mortality). For screening, tests must be able to detect the condition or risk factor earlier than without screening and without excessive false-positive or false-negative results, and early intervention must be superior to waiting until patients manifest signs or symptoms of disease. For counseling interventions, there must be evidence that changing behavior reduces risk and that counseling to reduce risk is effective in changing behavior. Immunizations must exhibit biologic efficacy, and chemoprophylactic agents must demonstrate both biological efficacy and evidence that patients will comply with use of the drug. For each proposed preventive service, the USPSTF rates the evidence for and against the intervention and provides recommendations based on the weight of the evidence (Table 3-1). In its current approach, the USPSTF separates insufficient evidence from a rating of small benefit. High-quality evidence is very limited for interventions in the elderly population.

Harris RP et al: Current methods of the U.S. Preventive Services Task Force: A review of the process. Am J Prev Med 2001; 20(3S):21. [PMID: 11306229]

Canadian Task Force on Preventive Health Care: Evidence-Based Clinical Prevention. http://www.ctfphc.org

Centers for Disease Control: National Prevention Information Network. http://www.cdcnpin.org

U.S. Preventive Services Task Force: http://www.ahrq.gov/clinic/uspstfix.htm

SCREENING ISSUES FOR THE GERIATRIC PATIENT

The standard approach to evaluating preventive services is more difficult for older people. Many important screening studies have excluded those older than 65 or 70. However, beyond the standard evaluation of preventive services, 2 additional issues assume major importance in evaluating preventive interventions for elderly persons: (1) individual and family values regarding the value of life extension in old age and (2)the effect of limited life expectancy on the usual risk–benefit considerations. Many recommendations concerning preventive geriatrics have suffered from lumping together all elderly people instead of recognizing their distinctions. As individuals move from health to disability, the goals of prevention in many cases will change from life extension to improving quality of life in the near term.

A framework for individualized decision making for cancer screening in elderly patients is shown in Table 3-2. This framework applies more generally to screening when life extension is the primary outcome of interest. The framework can be applied after the individual's life expectancy is estimated. Rather than using the average life expectancy for a given age, the patient's health status should also be incorporated into the prediction (Figure 3-1). Patients with a number of comorbid conditions or functional impairments may have a life expectancy that is lower than average for their age, whereas those without any significant comorbidity or functional impairment may live longer than average. The risk of experiencing the condition and the potential benefit from screening can be weighed against the potential harms.

Table 3-1. Strength of recommendation from the USPSTF.

Evidence quality

Net benefit

Substantial

Moderate

Small

Zero/negative

Good

A

B

C

D

Fair

B

B

C

D

Poor

I

I

I

I

A: strong recommendation to provide service; B: recommendation to provide service; C: no recommendation for or against provision of service; D: recommendation against providing service; I:insufficient evidence to make recommendation.
Adapted from U.S. Preventive Services Task Force: Current Methods of the U.S. Preventive Services Task Force: A review of the process. Am J Prev Med 2001;20(3S):21.

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Screening decisions need to incorporate patients' values and preferences. In general, prevention efforts should be aimed at increasing the percentage of life that is lived in good health rather than prolonging time spent in poor health. However, individual values will differ regarding the extent to which these considerations apply. Therefore, deciding when to discontinue specific interventions, such as cancer screening, requires individual discussion of potential benefits and risks, including the possibility of invasive follow-up tests and treatment-related morbidity or even mortality. The Ethics Committee of the American Geriatric Society (AGS) has issued useful guidelines that highlight the importance of individualizing care decisions.

Walter LC, Covinsky KE: Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001;285:2750. [PMID: 11386931]

American Geriatric Society Ethics Committee: Health Screening Decisions for Older Adults.http://www.americangeriatrics.org/products/positionpapers/stopscreening.shtml

Table 3-2. Steps to individualize decision making for screening tests.

1.

Estimate the individual's life expectancy.

2.

Estimate the risk of dying from the condition.

3.

Determine the potential benefit of screening.

4.

Weigh the direct and indirect harms of screening.

5.

Assess the patient's values and preferences.

Adapted from Walter LC, Covinsky KE: Cancer screening in elderly patients: A framework for individualized decision making. JAMA 2001;285:2750. Used with permission.

SCREENING & TREATMENT

CARDIOVASCULAR DISEASE

Modifiable risk factors for cardiovascular disease include cholesterol levels, hypertension, tobacco use, diabetes, obesity, and physical inactivity.

Hyperlipidemia

As with younger patients, excellent evidence supports treating hyperlipidemia in even very elderly patients with known coronary disease. Systematic reviews of secondary prevention trials have shown 25–30% reductions in 5-year coronary disease outcomes in elderly patients. Although the evidence for specific treatment goals is much less robust, the Third Report of the National Cholesterol Education Program (ATP III) recommends that the goal for patients with coronary artery disease should be a low-density lipoprotein (LDL) cholesterol level<100 mg/dL.

Limited direct evidence exists regarding the benefits and disadvantages of screening and treating patients older than 65 years who do not have coronary artery disease. The ATP III states that older persons who are at higher risk but otherwise in good health are candidates for cholesterol-lowering therapy. The USPSTF indicated that evidence favors continued screening in older persons. The USPSTF recommended that screening incorporate some assessment of overall coronary disease risk (eg, Framingham or ATP III risk models) and that treatment be based on at least 2 measurements. This recommendation appears sound at least for those 65–75 years old and even older individuals with reasonable life expectancy at higher risk for coronary disease (eg, smokers, hypertensives, diabetics). Examination of cholesterol levels every 5 years may be reasonable if the patient desires. For very elderly individuals, physicians will need to carefully weigh life expectancy and care goals in deciding whether dietary or drug treatment for hyperlipidemia outweighs potential risks. Dietary restriction should be avoided in those at risk for undernutrition.

Statin drugs are generally well tolerated. However, rhabdomyolysis, the most serious side effect of statins, is commonly the result of drug interactions rather than a specific response to the drug itself. Therefore, care must be exercised when prescribing statins for elderly patients taking multiple drugs.

 

Figure 3-1. Life expectancy by age. From Walter LC, Covinsky KE: Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001;285:2750. Used with permission.

LaRosa JC et al: Effect of statins on risk of coronary disease: A meta-analysis of randomized controlled trials. JAMA 1999; 282:2340. [PMID: 10612322]

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Pignone MP et al: Screening and treating adults for lipid disorders. Am J Prev Med 2001;20(3S):77. [PMID: 113-6236]

Hypertension

A systematic review demonstrated the benefits of detecting and treating systolic and diastolic hypertension in individuals 60–80 years of age. One cardiovascular death was prevented for every 50 hypertensive elders treated over 5 years, and total cardiovascular morbidity and mortality was reduced 5.2% (number needed to treat = 19). Although the specific data supported treatment of blood pressures above 90 mm Hg diastolic and 160 mm Hg systolic, risk from hypertension at all ages is probably continuous. In view of this, Report 7 of the Joint National Commission on Detection, Evaluation, and Treatment of High Blood Pressure recommends that the upper limit of 140 mm Hg for systolic blood pressure be used for the elderly. Little evidence exists regarding treatment of hypertension in those older than 80. Some observational data even suggest that high blood pressures may be better than low blood pressures in the very old. Clearly, in the very old, particularly those with multiple comorbidities, hypertension should be treated cautiously to avoid such complications as orthostatic hypertension, which may contribute to falls. Nonetheless, all elders who are candidates for active medical treatment should undergo periodic screening for hypertension. The optimal interval for screening has not been determined.

Mulrow C et al: Pharmacotherapy for hypertension in the elderly (Cochrane Review). In: The Cochrane Library, Issue 2 ed. Update Software, 2003.

Satish S et al: The relationship between blood pressure and mortality in the oldest old. J Am Geriatr Soc 2001;49:367. [PMID: 11347778]

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CANCER

Breast Cancer

Strategies to prevent breast cancer include self-breast exam, clinical breast exam, and screening mammography. The USPSTF gives both self-breast examination and clinical breast examination alone an “I” rating (see Table 3-1) and mammogram screening for women older than 40 a “B” rating. The USPSTF concluded that, because the risk of breast cancer was high after age 70, the evidence from randomized controlled trials was generalizable to older women. Others have suggested that women with 5 years of life expectancy may be reasonable candidates for continued screening. However, patients' preferences, physicians' judgment, and concurrent illnesses should be major considerations in determining whether or not to screen. Elderly women in whom breast cancer develops and who have 3 or more comorbid conditions, such as cancer, hypertension, diabetes, stroke, or coronary artery disease, are 20 times more likely to die from a cause other than breast cancer over a 3-year period. Screening elderly women with multiple comorbidities may thus cause an undue burden.

Women who have moderate to high risk factors or who are very concerned about the development of breast cancer may choose to continue screening after age 75 or 80. Those who are unwilling to suffer the potential negative consequences might choose to stop screening earlier despite a possibly increased risk of dying from breast cancer.

Parnes BL et al: When should we stop mammography screening for breast cancer in elderly women? J Fam Pract 2001;50:110. [PMID: 11219555]

U.S. Preventive Services Task Force: Screening for breast cancer: recommendations and rationale: http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm

Colorectal Carcinoma

Colorectal cancer incidence approximately doubles each decade from age 40 to 80, thereby justifying screening considerations in older patients. Consensus favors colorectal cancer screening beginning at age 50 for average-risk individuals, although there is less agreement on when to conclude screening. The USPSTF strongly recommends some form of colorectal cancer but does not make a firm recommendation on the specific approach. The American Cancer Society (ACS) has endorsed guidelines recommending either of the following for average-risk patients: (1) total colon examinations (air-contrast barium enema or colonoscopy) every 10 years or (2) annual fecal occult blood tests and flexible sigmoidoscopy every 5 years.

Strong evidence supports fecal occult blood testing's effectiveness in preventing colorectal cancer mortality. Annual examinations provide higher rates of detection but also more false positives. Weaker evidence (several case-controlled studies) supports sigmoidoscopy, and a single case-control study and indirect evidence suggest the effectiveness of colonoscopy. Taking into account the usual slow transformation of polyps into cancers, elderly adults may not live long enough to achieve any screening benefits. Therefore, unless there is a history of carcinoma, those with several endoscopic examinations may be able to discontinue screening between ages 75 and 80 unless they are unusually healthy.

Risks of screening include discomfort and complications from endoscopic examinations (eg, perforation or hemorrhage). These may also occur from follow-up of the many false-positive results of fecal occult blood testing.

Rudy DR, Zdon MJ: Update on colorectal cancer. Am Fam Phys 2000;61:1759. [10750881]

Tatum P, Mehr D: At what age can colorectal cancer screening stop? J Fam Pract 2001;50:575. [PMID: 11485702]

Towler BP et al: Screening for colorectal cancer using the faecal occult blood test, Hemoccult (Cochrane Review). In: The Cochrane Library, Issue 2 ed. Update Software, 2003.

U.S. Preventive Services Task Force: Screening for colorectal cancer: recommendations and rationale: http://www.ahrq.gov/clinic/3rduspstf/colorr.htm.

Cervical Cancer

Most cervical cancer in the elderly occurs because of inadequate screening. For that reason, most women who have had repeatedly normal smears probably do not need to continue Pap smears indefinitely. The USPSTF recommends ceasing screening at age 65 in women who have had adequate recent screening with pap smears and are otherwise not at high risk for cervical cancer. The AGS recommends screening until at least age 70 but indicates that little evidence exists for or against screening after this age. However, the AGS does recommend that any older woman of any age who has never had a Pap smear be screened until she has 2 negative pap smears 1 year apart. Additionally, a history of multiple sexual partners presumably remains a risk factor in old age. Older women who begin new sexual relationships might benefit from at least temporary resumption of screening. Women who had a hysterectomy for a nonmalignant indication may also stop having Pap smears if no cervical tissue remains.

The follow-up of an abnormal Pap smear is an area of some controversy, but the American Society for Colposcopy and Cervical Pathology 2001 Consensus Guidelines for the management of women with cervical

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cytologic abnormalities serves as a useful reference. Postmenopausal women with atypical squamous cells of uncertain significance (ASC-US) have a lower incidence of cervical intraepithelial neoplasia grades 2 and 3 than younger women. Providing a course of intravaginal estrogen and repeating a Pap smear 1 week after completing the estrogen is a reasonable option for ASC-US follow-up, with a repeat test at 4–6 mo. Negative Pap smears may indicate that normal surveillance can be resumed, but if the repeat screen remains ASC-US colposcopy should be performed. A course of intravaginal estrogen followed by a repeat Pap smear is also a reasonable approach to treatment of postmenopausal women with a low-grade squamous intraepithelial lesion. In contrast, women with atypical glandular cells not otherwise specified (AGC-NOS) have a substantial risk for cervical neoplasia, and colposcopy with endocervical sampling is recommended. If atypical endometrial cells are present, the patient should have endometrial biopsy. Women with high-grade squamous intraepithelial lesions should have colposcopy and endocervical sampling.

American Geriatric Society: Screening for cervical carcinoma in older women. J Am Geriatr Soc 2001;49:655. [11380762]

Sawaya GF: Positive predictive value of cervical smears in previously screened postmenopausal women: The Heart and Estrogen/Progestin Replacement Study (HERS). Ann Intern Med 2000;133:942. [PMID: 11119395]

Videlefsky A et al: Routine vaginal cuff smear testing in post-hysterectomy patients with benign uterine conditions: When is it indicated? J Am Board Fam Pract 2000;13(4):233. [PMID: 10933286]

Wright TC et al: Consensus statement: 2001 consensus guidelines for the management of women with cervical cytological abnormalities. JAMA 2002;287:2120. [PMID: 11966387]

U.S. Preventive Services Task Force: Screening for cervical cancer:http://www.ahrq.gov/clinic/3rduspstf/cervicalcan/cervcanrr.htm

Prostate Cancer

Screening tests for prostate cancer are among the most controversial potential preventive services. Prostate-specific antigen (PSA) testing can detect early-stage cancers, but whether a screening program will result in better or worse overall health outcomes is not clear. Furthermore, screening for prostate cancer is associated with important harms, including frequent false-positive results and complications of treatment for some cancers that might never have affected a patient's health. Although no major organization recommends universal screening, there are clearly marked differences in enthusiasm. The USPSTF in its most recent recommendations (2002) states that information is insufficient to recommend for or against routine screening (Recommendation I). They further indicate, “Given the uncertainties and controversy surrounding prostate cancer screening, clinicians should not order the PSA test without first discussing with the patient the potential but uncertain benefits and the possible harms of prostate cancer screening.” In contrast, the ACS recommends offering screening with digital rectal exam and PSA testing. They recommend discussion about the “benefits and limitations of testing. In elderly men, the screening controversy is particularly important because of both the smaller potential time of life remaining to benefit and the increased prevalence of histological cancer of the prostate with age. Furthermore, prostate cancer screening is associated with significant risks to quality of life in older men. For every 100 men undergoing a PSA, 10 will have an abnormal result, but only 3 of the 10 will actually have cancer. For those undergoing treatment for prostate cancer, about 50% will have significant side effects, including impotence, urinary incontinence, and rectal injury.

Since 1997, the ACS has recommended that screening be continued annually as long as men have a 10-year life expectancy. The 10-year life expectancy is a reasonable time to stop screening if one chooses to screen at all. For many men, this will occur by age 75 (see Figure 3-1). Because of the uncertainty, the importance of shared decision making between patients and physicians has been emphasized to enable patients to make informed decisions about screening based on the risks and benefits. A discussion tool kit available from the American Academy of Family Physicians (AAFP) may be a useful adjunct.

Gambert SR: Prostate cancer: when to offer screening in the primary care setting. Geriatrics 2000;56:22. [PMID: 11196336]

Smith RA: American Cancer Society guidelines for the early detection of cancer:update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001;51:38. [PMID: 11577479]

American Academy of Family Physicians: Prostate cancer screening counseling tools: http://www.aafp.org/x19519.xml

U.S. Preventive Services Task Force: Screening for prostate cancer:recommendations and rationale: http://www.ahrq.gov/clinic/3rduspstf/prostatescr/prostaterr.htm

Lung Cancer

The USPSTF, ACS, and AAFP recommend against screening for lung cancer with routine chest radiographs or sputum cytologies. Low-dose computed tomography screening can identify smaller nodules than routine chest radiographs; however, as with prior screening interventions, the key issue is whether screening will reduce mortality. For that reason, the Society of Thoracic Radiology does not recommend mass screening for lung cancer. Prevention efforts should still focus on encouraging older smokers to quit.

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Aberle DR et al: A consensus statement of the Society of Thoracic Radiology: Screening for lung cancer with helical computed tomography. J Thorac Imaging 2001;16:65. [PMID: 11149694]

Patz EF et al: Current concepts: Screening for lung cancer. N Engl J Med 2000;343:1627. [PMID: 11096172]

Skin Cancer

The ACS recommends an annual total body skin examination for all individuals older than 40. Alternatively, the USPSTF concluded that there is insufficient evidence for or against routine screening for skin cancer (Recommendation I) but urges clinicians to remain alert for skin lesions with malignant features: rapidly changing lesions and those with asymmetry, border irregularity, color variability, or a diameter > 6 mm.

Helfand M et al: Screening for skin cancer. Am J Prev Med 2001; 20(3S):47. [PMID: not available]

Jerant AF et al: Early detection and treatment of skin cancer. Am Fam Physician 2000;62:357. [PMID: 10929700]

Ovarian Cancer

The ACS recommends annual pelvic examinations to screen for ovarian cancer despite a lack of evidence of any improvement in outcome with any screening method (pelvic examination, ultrasonogram, or serum tumor markers). The American College of Obstetrics and Gynecology Committee on Gynecologic Practice makes no specific recommendations for ovarian cancer screening. Even in the elderly, most women with positive screening tests will not have ovarian cancer but will require invasive studies (eg, laparoscopy) for confirmation. The USPSTF and several other organizations recommend against screening. Routine screening for ovarian cancer in an asymptomatic population is not recommended.

American College of Obstetricians and Gynecologists Committee on Gynecologic Practice: Routine cancer screening. ACOG Committee Opinion 2000;247:1. [PMID: not available]

DIABETES MELLITUS

Despite the known complications of diabetes and the proven benefits of interventions to control blood sugar, there is no direct evidence of the benefit of early identification of diabetes in elderly people. The American Diabetes Association recommends screening every 3 years with a fasting blood sugar in all patients older than 45 and suggests a fasting sugar of 126 as the threshold for a diagnosis of diabetes. A 1998 cost-effectiveness analysis from the Centers for Disease Control estimated potential screening benefits. For those older than 65, earlier identification had minimal effect on reducing renal disease or blindness and produced no increase in life years or quality-adjusted life years. According to the USPSTF, insufficient evidence exists to recommend for or against screening the general population. However, in a recent update, the USPSTF recommends screening for diabetes mellitus in adults with hypertension or hyperlipidemia because treatment goals for those conditions might be altered with the additional diagnosis. Clinicians additionally might choose to screen older individuals at particularly high risk for diabetes mellitus, notably obese patients, with a fasting serum glucose. Potential benefits will clearly decline with age; thus, screening those older than 75 or 80 years has very limited potential for benefit.

THYROID DISORDERS

Hypothyroidism may be difficult to detect clinically in older people and is common in older women. It may cause significant functional impairment, such as fatigue and constipation, as well as elevations in cholesterol and weight gain. In 1998, the American College of Physicians issued a clinical guideline that recommended screening asymptomatic women older than 50 for occult thyroid disease. The authors of the evidence review concluded that 1 case of overt thyroid disease is found for every 71 women screened who are older than 60. The preferred screening test is a sensitive thyroid-stimulating hormone (TSH) level. Follow-up free thyroxine (free T4) is indicated when the TSH is undetectable or > 10 mU/L. For older men and women, a wide range of problems should prompt diagnostic testing, but this is a separate issue from routinely screening asymptomatic patients.

Insufficient data exist to recommend for or against treatment of subclinical hypothyroidism (elevated TSH with normal free T4) or subclinical hyperthyroidism (undetectable TSH with normal free T4 and normal triiodothyronine [T3]). In general, subclinical hypothyroidism progresses to overt hypothyroidism at the rate of about 2–3% per year. Treating subclinical hypothyroidism may prevent this progression, reduce serum lipids, and reverse subtle symptoms of mild hypothyroidism. However, treatment requires continued medication at some cost and may cause iatrogenic hyperthyroidism. Treating subclinical hyperthyroidism may reduce atrial fibrillation and osteoporosis; however, over a 10-year period only one third of patients will experience atrial fibrillation, whereas two thirds will remain in sinus rhythm.

Cooper DS: Clinical practice. Subclinical hypothyroidism. N Engl J Med 2001;345:260. [PMID: 21342639]

Toft AD: Clinical practice. Subclinical hyperthyroidism. N Engl J Med 2001;345:512. [PMID: 21396742]

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SENSORY DISORDERS

Vision Impairment

The USPSTF recommends visual acuity screening with a Snellen chart or other method for all elderly people; however, they conclude that there is insufficient evidence to recommend for or against routine fundoscopy or glaucoma screening by primary physicians. Primary physicians may want to consider periodic referral to vision care specialists for glaucoma screening.

Hearing Impairment

Elderly people should be questioned about their hearing; otoscopy and audiometric testing should be performed on those who indicate problems. Alternatives include structured questionnaires and screening audiometry with an instrument such as the Welch Allyn AudioScope. Although it is clear that physicians should do some form of hearing screening, the optimum approach is unsettled.

HEALTH PROMOTION

Common behavioral activities that relate to health include smoking cessation, healthy diet, regular physical activity, and appropriate alcohol use. Appropriate behavioral counseling interventions to cover these issues differ from screening interventions because they address complex behavior related to daily living; require repeated action; need to be modified over time; and are influenced by multiple spheres of influence, including family, peers, and community. However, many barriers prevent effective delivery of behavioral interventions, including focus on medically urgent issues, lack of time, inadequate training, low patient demand, and lack of supportive resources. Furthermore, clinicians may not notice health benefits, even though they may be substantial. For example, a group for tobacco cessation might achieve 30% quit rates, whereas primary care may only achieve a 5–10% success rate. However, the group may reach only a small proportion of smokers, whereas individual counseling might reach 70% of smokers and, therefore, have greater impact.

One useful approach to counseling is known as the “Five As” (Table 3-3) and involves minimal contact interventions that can be used in a brief encounter.

Stone EG et al: Interventions that increase use of adult immunization and cancer screening services: A meta-analysis. Ann Intern Med 2002;136:641. [PMID: 21987734]

Table 3-3. The five A's of behavioral change.

Assess:Ask about health risks and factors affecting choice of
      behavior change.
Advise:Provide behavior change advice that is clear, specific,
      and personalized.
Agree:Select treatment goals and methods based on patient's
      interest and willingness to change.
Assist:Use behavior change techniques such as self-help and
      counseling combined with medical treatment when appropriate.
Arrange:Schedule follow-up contacts to assist/support and
      adjust treatment plan as needed.

Modified from Evaluating Primary Care Behavioral Counseling Interventions: An evidence-based approach. Am J Prev Med 2002; 22:267. Used with permission.

PHYSICAL ACTIVITY

To assess and motivate the sedentary older patient to exercise, a detailed exercise history should include lifelong patterns of activity, activity in the last 2–3 mo, patient concerns about exercise, level of interest, and social preferences regarding exercise. An exercise prescription on a prescription pad is useful to encourage activity and should be personalized to include time for exercise, type of activity, and frequency. In addition, it should take into consideration the facilities available and comorbidities of each patient. At follow-up, progress should be monitored and care taken to address any pain and monitor for injury.

Christmas C, Andersen RA: Exercise and older patients: Guidelines for the clinician. J Am Geriatr Soc 2000;48:318. [PMID: 20195199]

Singh MA: Exercise comes of age: Rationale and recommendations for a geriatric exercise prescription. J Gerontol A Biol Sci Med Sci 2002;57:M262. [PMID: 21979673]

SMOKING CESSATION

Counseling and provision of assistance (eg, nicotine patch or bupropion) by health care providers significantly improve abstinence rates over at least 1 year. Offices and clinics should establish routine procedures to regularly question patients about whether they have smoked in the last 3 months, a more sensitive approach than simply than asking whether patients are current smokers. Advice to quit is an important motivator in tobacco cessation. Smokers who are identified should be counseled about the benefits of quitting and encouraged to set a date for quitting. Because tobacco use is a chronic condition, repeated efforts are warranted, and there is a strong relationship between intensity of tobacco dependency counseling and its effectiveness. Ongoing

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support after quitting is also important. The U.S. surgeon general's guideline is a helpful resource.

U.S. Public Health Service Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives: A clinical practice guideline for treating tobacco use and dependence. JAMA 2000;283:3244. [PMID: 20325308]

NUTRITION

For the general population, the USPSTF recommends counseling to reduce fats and increase fruits, vegetables, and grain products containing fiber in the diet. In patients older than 75 or 80, protein-calorie malnutrition becomes an important concern. Some elderly people remain on restrictive diets despite weight loss. Certainly in those at significant risk for malnutrition, restrictive diets should be avoided if possible.

Suboptimal levels of vitamins may be risk factors for chronic disease such as cardiovascular disease, cancer, and osteoporosis. For most individuals, a single multivitamin should provide adequate levels. Because the recommended intake of vitamins B12 and D is closer to twice the recommended dairy intake, it is reasonable to recommend multivitamin supplements with additional vitamin D and B12.

Fairfield KM, Fletcher RH: Vitamins for chronic disease prevention in adults: Scientific review. JAMA 2002;287:3116. [PMID: 12069675]

Fletcher RH, Fairfield KM: Vitamins for chronic disease prevention in adults: Clinical applications. JAMA 2002;287:3127. [PMID: 12069676]

INJURY PREVENTION

Falls

Risk of recurrent falls can be predicted by asking all older persons about falls in the past year. Those who report a fall should have a test of functional gait. Persons with abnormal gait may require further assessment and intervention.

Burns & Automobile Accidents

The USPSTF recommends that elderly drivers be counseled to wear seat belts and avoid alcohol use when driving. All older people should be counseled to use smoke detectors, avoid hazardous use of cigarettes (eg, in bed), and reduce tap water temperature to 120–130°F.

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention: Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49:664. [PMID: 21275673]

IMMUNIZATIONS & CHEMOPROPHYLAXIS

IMMUNIZATIONS

Both influenza and pneumococcal vaccination are widely recommended and important preventive strategies for general health in the elderly.

Influenza Vaccine

The effectiveness of the influenza vaccination depends on the recipient's age and immunocompetence. Among community-dwelling adults older than 60, the vaccine has been 56% effective in reducing influenza-related illness, although efficacy may be lower among those older than 70. Among elderly long-term care residents, vaccine effectiveness in preventing influenza may only be 30–40%; however, it may be 50–60% effective in preventing pneumonia and hospitalization and 80% effective in preventing death. Several studies suggested that vaccinating health care workers may be as or even more important than vaccinating residents in preventing deaths.

Healthy People 2010 set a goal of 90% vaccination coverage for all persons older than 65. The optimal time to receive the vaccine is October or November; however, given the potential for shortage of vaccines, elderly patients should be given the vaccine in October. Side effects are typically minor and last less than 2 days. Major side effects are generally related to hypersensitivity in patients with egg allergy, because the vaccine comes from highly purified inactivated flu virus grown in eggs.

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Health People 2010.

U.S. Department of Health and Human Services, 2000.

Pneumococcal Vaccine

The 23-valent pneumococcal vaccine represents 85–90% of the serotypes that cause invasive disease in the United States and has been shown to be 56–81% effective in preventing invasive bacteremia. The Advisory Committee on Immunization Practices (ACIP) recommends that persons aged 65 or older who were vaccinated before age 65 should receive 1 revaccination 5 years after the initial vaccination and that previously unvaccinated individuals should receive 1 dose at age65. Whether repeated pneumococcal vaccinations should be given and at what interval remain unclear. The vaccine has rarely been associated with major side

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effects, although up to half of vaccine recipients will have a mild local reaction that persists for 48 h.

Tetanus Immunization

Most cases of tetanus in the United States occur in unvaccinated older people. If an adult has never had a primary series of tetanus, then 3 doses are required; otherwise, the ACIP recommends a booster dose of tetanus-diphtheria toxoid vaccine every 10 years. However, the USPSTF and others have noted that far fewer immunizations may be sufficient to maintain immunity. A realistic and important goal, nonetheless, is for older individuals who received a primary immunization series to receive at least 1 additional booster.

Bridges C et al: Prevention and control of influenza: Recommendations and Reports. MMWR Morb Mortal Wkly Rep 2002;51:1. [PMID: not available]

Zimmerman RK: Adult vaccination: Part 1. Vaccines indicated by age. Teaching Immunization for Medical Education (TIME) Project. J Fam Pract 2000;49(suppl):S41. (PMID: not available]

CHEMOPROPHYLAXIS

Hormone Replacement

Although evidence from observational studies supported hormone replacement therapy, randomized trials have shown smaller benefits and increased risks. The Heart and Estrogen/Progestin Replacement Study trial found an increased risk of mortality from coronary artery disease in women using hormone replacement after myocardial infarction. The conjugated estrogen/medroxyprogesterone acetate arm of the Women's Health Initiative was terminated early because of excess risk of breast cancer and evidence that overall risks exceeded benefits (rates of coronary artery disease, stroke, and pulmonary embolism were also higher than in the control group). The role of estrogen replacement alone in those who have had a hysterectomy remains to be determined; however, long-term combined therapy for prevention of cardiovascular disease and fractures seems imprudent.

Grady D et al: Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/Progestin Replacement Study Follow-Up (HERS II). JAMA 2002;288:49. [PMID: 12090862]

Writing Group for the Women's Health Initiative Investigators: Risks and benefits of estrogen plus progestin in health postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002; 288:321. [PMID: not available]

Aspirin

Aspirin reduces the risk of death and infarction in patients with established heart disease and should be considered for primary prevention as well.

The use of aspirin may reduce the risk of CHD but not total mortality and stroke. In addition, the benefit of its use may increase substantially with increasing cardiac risk. The risk of GI bleeding is higher in the elderly.

The USPSTF strongly recommends (Recommendation A) that clinicians discuss aspirin chemoprevention with adults at increased risk for CHD, concluding that the benefit of aspirin outweighs the risk of bleeding in patients who have a 5-year risk of heart disease of at least 3%. Because most elderly patients will have a risk greater than 3%, it may be reasonable to limit aspirin for prevention to those with a life expectancy of 5 years or more. Clinical calculators are now available to help accurately predict cardiac risk, and an estimate of 5-year mortality may be gained by halving the 10-year estimate of risk.

Hayden M et al: Aspirin for the primary prevention of cardiovascular events: Summary of the evidence. Ann Intern Med 2002;11136(2):161. [PMID: 11790072]

Lauer MS: Clinical practice. Aspirin for primary prevention of coronary events. N Engl J Med 2002;346:1468. [PMID: 12000818]

U.S. Preventive Services Task Force: Aspirin for the primary prevention of cardiovascular events: recommendations and rationale:http://www.ahrq.gov/clinic/3rduspstf/aspirin/asprr.htm