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CHAPTER 4: PREVENTIVE CARE


What Aspects of Aging Can We Influence?

Since we are apt to be active and functional in old age, we should expect to benefit from programs to promote health just as younger people do. It is important for us to remember that on average a person who is 65 can expect to live another 16 years. People 75 and 85 can expect to live another 10 and 6 years, respectively, and can expect to be functionally independent for at least half of that period. Because of this, the goal of promoting our health care shifts from maximizing longevity to postponing dependency. Health promotion emphasizes prevention of decline in function while supporting those abilities we need to remain independent.

    In order to make optimal use of our health care resources, all of us--old and young--need to understand the overall organization of health care institutions. This is just as important in preventing illness and disease as it is in getting help once a health problem occurs. Prevention of illness and disability has been traditionally considered in terms of primary, secondary, and tertiary prevention. Primary prevention refers to interventions that are designed to reduce the risk of getting a disease. The methods of intervention include counseling to encourage a change in behavior (regarding diet, exercise, alcohol or nicotine use, etc.), and immunization. Secondary prevention refers to efforts to improve outcomes in people who already have a given disease. This type of prevention is most effective when routine screening during a medical checkup allows the early detection of the disease. Tertiary prevention refers to efforts to prevent the progression of disability through systematic identification, treatment, and rehabilitation. Tertiary prevention is particularly applicable to older persons who often do not seek care for common sources of disability.

    It is clear that the goals of prevention change in late life. In younger people, the goals target disease-specific disability and death, but in view of the multiple chronic conditions that commonly occur as we age, this focus loses its value. Our focus is on vitality, function, and quality of life, rather than on survival alone.

Primary Prevention

Exercise is an important means of preventing a wide range of health problems, including cardiovascular disease, falls, and depression. Older adults probably receive more health benefits from regular physical activity than adults who are younger and more fit. One long-term study of health-related behavior that started in the middle 1950s identified seven good health practices: seven to eight hours of sleep at night, weight control, exercise, limited alcohol consumption, not smoking, eating breakfast, and seldom snacking. Walking, which is available in all settings at a low cost, is recommended to all persons who are physically able. Activity should be habitual and not unduly strenuous. People who engage in light to moderate exercise daily, equivalent to sustained walking for about 30 minutes a day, can achieve health gains. Evidence suggests that even small increases in exercise by those who are least active produces benefits.

    When older smokers quit, they can increase their life expectancy, reduce their risk of heart disease, and improve the function of their lungs and circulation. Cigarette smoking remains the single most preventable cause of death in the United States for both men and women. Those who have stopped smoking have found it helpful to set a quit date, to have scheduled reinforcement visits, to use self-help packages that are available from several voluntary organizations, and to make visits to community-based smoking-cessation programs. Some physicians prescribe nicotine gum or the nicotine patch to help, but smokers should have completely stopped smoking before they begin using these products. They should use them for at least three months--the time during which the risk of relapse is highest--but for no more than six months.

    Dietary excesses are important causes of disease as we age, and therefore a regular review of dietary intake of calories, fluid, cholesterol, fiber, sodium, and minerals is useful. Caloric intake should be balanced against the expenditure of energy. Saturated fats should be reduced to less than 10 percent of the total calories. This can be done by eating fish, chicken without skin, low-fat dairy products, and lean meats. Whole grains, fruits, and vegetables are also highly recommended. Salt use should be modestly restricted by limiting the salt that is added at the table and by reducing the use of prepared (canned) foods. Women generally need to increase their calcium intake. In addition, if you have specific health problems and dietary needs, you should receive individualized counseling from a nutritionist, dietitian, or physician.

    Approximately 5 percent of people who are over the age of 65 have an alcohol problem. Excessive alcohol use not only increases injuries, gastrointestinal illness, and liver disease, but it may also be a cause of potentially reversible dementing illness. (Alcohol and drug abuse are considered in Chapter 15.)

    Motor-vehicle accidents are the leading cause of fatal injuries in adults up to age 75. Although the number of crashes sustained by older drivers as a group is no higher than that of the driving population in general, their crash rate adjusted for the actual miles that they drive is higher than for any other age group except for people under the age of 25. All drivers, of course, should wear seat belts and avoid using alcohol before driving. More specifically, as older drivers we must be aware of adjustments in driving techniques and habits to accommodate the changes of aging. Driving schools are often able to provide an assessment of the person who has experienced a recent decline in driving skills. Driver education or retraining is offered through the American Association of Retired Persons (AARP) and the American Automobile Association (AAA). It's sensible to take a refresher course to improve your knowledge and skills. Drivers with severe visual or hearing loss, dementing illness, or various neurologic diseases should seriously consider not driving.

    Unintentional injury is the sixth leading cause of death among people who are 65 years and older. While a third of these injuries are related to falls and motor vehicle accidents, choking, burns, and drowning are also relatively common causes of death. Again, alcohol use contributes significantly to injuries due to falls, burns, and drownings.

    Regular dental checkups are important as we age. Both daily brushing with fluoride-containing toothpaste and flossing are crucial to good dental health.

    Although cholesterol remains a risk factor for coronary heart disease as we age, it is less important and less powerful a risk factor than smoking, hypertension, or lack of exercise. In fact, our risk in old age is not completely known. All of the studies evaluating cholesterol-lowering drugs have excluded or contained very few older people. Encouraging a balanced low-fat diet is beneficial not only for preventing heart disease but also for preventing cancer and other forms of disease. Specific high-risk groups, such as those with heart disease, may benefit from more aggressive cholesterol-lowering programs.

    In spite of the availability of an effective vaccine, pneumococcal infections continue to be the leading cause of pneumonia and are a significant contributor to disability and mortality. The Centers for Disease Control and Prevention estimate that more than 40,000 deaths are due to these infections each year--80 percent occurring in people over age 65. While the vaccine, commonly known as the flu shot, has been available since 1977, it is greatly underutilized; less than 20 percent of the targeted population has ever received any vaccination. A number of expert panels recommend that all people 65 years and older receive the pneumococcal vaccine. The limiting factor in demonstrating the true benefit of the vaccine is the failure to deliver it to those of use at highest risk.

    Yearly vaccination for influenza continues to be necessary because of the changes that occur in the influenza virus itself, a factor that explains the failure of protective antibodies in our blood to develop in spite of previous infection. If you have allergies to eggs or egg products you should not receive the vaccine nor should anyone who has any history of sensitivity to any part of the vaccine. Additionally, you should postpone immunization if you have a sudden respiratory infection or any illness that produces fever. During influenza epidemics, older people may be hospitalized at two- to fivefold increased rates, which poses significant health and economic problems.

    While diphtheria and tetanus are rare (in 1987 they occurred in only 25 people over the age of 60) they are associated with a high rate of fatalities. Because of this, a tetanus-diphtheria booster every ten years is recommended.

    To prevent coronary heart disease, the leading cause of death in the United States, low-dose aspirin therapy (325 milligrams of aspirin every other day) is recommended if you have two or more of the following risk factors: diabetes mellitus, a low HDL cholesterol, high blood pressure, a high LDL cholesterol, male gender, severe obesity, strong family history, or smoking. However, you should not take aspirin if you have uncontrolled high blood pressure, severe liver disease, ulcer disease, or any other condition that increases the risk of bleeding.

    An estimated 25 percent of women who are 65 and older have spinal compression fractures, and about 15 percent will have a hip fracture during their lifetime. Estrogen therapy is often recommended for women who are at increased risk for osteoporosis. (This issue is further discussed in Chapter 17.)

    By adopting preventive health behaviors, we can gain control over some factors that influence the nature and rate of our own aging. Smoking hastens the aging of the cardiovascular system; protein in the diet affects the aging of the kidney; excessive sunlight accelerates aging in the skin and the eye; exercise prolongs muscle function.

Secondary Prevention

Screening to detect early disease and initiate treatment is the chief element of secondary prevention. Table 1, compiled from a review of recent recommendations on prevention, lists the diseases, conditions, and risks that are associated with older people, along with the most commonly suggested screening intervals. Routine screening for diabetes mellitus is not recommended. Only if you have such risk factors as obesity, a family history of diabetes, or diabetes mellitus occurring during pregnancy should you be screened.

    An electrocardiogram is not an effective screening test; however, cardiac stress testing may be useful before you begin an exercise program. If you have had a heart attack, the aggressive control of risk factors such as cigarette smoking, high cholesterol, and high blood pressure is important to prevent another. In addition, treatment with beta-adrenergic-blocking drugs in the first three years following a heart attack seems to reduce mortality. These are important concerns to discuss with your doctor.

Table 1. Prevention in Older People

SCREENING RECOMMENDED FOR EVERYONE INTERVAL
Alcohol, drug, and tobacco abuse Yearly
Breast cancer Yearly
Decline in function Yearly
Deconditioning Yearly
Dental problems Yearly
Hearing problems Yearly
High blood pressure Yearly
Malnutrition Yearly
Risk of falls Yearly
Thyroid disease Yearly
Vision problems Yearly
SCREENING RECOMMENDED FOR PEOPLE AT HIGH RISK
Cervical cancer (women who have not had previous normal exams) Every 3 years
Colon cancer (family history, previous polyps or inflammatory bowel disease, previous breast, ovarian, endometrial, or colon cancer) Every 3 years
Coronary heart disease (two or more coronary risk factors, sedentary males beginning an exercise program) Every 3 to 5 years
Diabetes mellitus (obesity, family history, diabetes during pregnancy) Yearly
Oral cancer (excessive tobacco or alcohol use) Yearly
Skin cancer (previous history of skin cancer, significant sunlight exposure, precancerous changes) Yearly
Tuberculosis (residents of nursing homes, homeless people, immigrants from endemic countries, people with impaired immune function) Every 10 years
NOT RECOMMENDED FOR SCREENING BUT WORTH WATCHING FOR
Abuse or neglect
Dementing illness
Depression
Obesity
Prostate cancer
Transient ischemic attack

    Over the past 40 years cervical cancer in the United States has decreased by approximately 80 percent. There are significant racial differences in the pattern of the disease. As black women age, they experience a much higher incidence in mortality from cervical cancer than do white women. The National Health Interview Survey estimates that up to 40 percent of black women and 15 to 20 percent of older white women have never had a Pap smear. Pap smears can be stopped at age 65 if a woman has had several (at least three) previously documented normal exams.

    Breast cancer screening by means of an annual examination and mammography every one to two years is recommended by the U.S. Preventive Services Task Force. Unfortunately, there is no reliable information for deciding whether there should be an upper age limit to screening. On average, breast cancer takes about ten years to grow to about the size of a large pea (1 centimeter in diameter). In older women, breast cancers are generally slower growing and less aggressive than they are in younger women. The U.S. Preventive Services Task Force registered uncertainty as to the benefits of screening in low-risk women 75 and older whose prior mammograms had been normal. Its ultimate recommendation was that screening be discontinued at age 75, but reliable data to support this directive are unavailable. Since years of remaining life constitutes a major issue in determining the benefit of early detection, recommendations regarding screening mammography could be made on the basis of anticipated survival rather than chronologic age.

    There is not enough evidence to make a judgment about screening for colon or rectal cancer. As we get older, the potential benefit of screening is heightened by the increased likelihood of the disease, but is reduced by our diminished tolerance of the various aggressive curative and investigative procedures. Screening for colon cancer is recommended if you have the following risk factors for the disease: (1) a first-degree relative with colon cancer, (2) a personal history of endometrial, ovarian, or breast cancer, or (3) a previous history of an inflammatory bowel condition, polyps, or previous colon or rectal cancer.

Table 2. Areas of Priority for Health Promotion in Older People

Cancer screening
Depression
Falls
Hypertension
Infectious diseases
Misuse of medications
Nutrition
Oral health
Osteoporosis
Physical inactivity
Sensory loss
Smoking
Social isolation
Source: Berg R, Cassells J, eds. The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC: National Academy Press; 1990. © 1990, National Academy of Sciences. Published by the National Academy Press, Washington, DC. Reprinted with permission.

    Screening for prostate cancer is controversial because of the usually slow progression of the disease. Only 1 in 380 men with prostate cancer will die of the disease. In addition, there is a lack of evidence supporting the benefit of treatment of early disease.

    It is also not recommended that bone density in asymptomatic women be routinely measured. However, as mentioned, women who are at increased risk for osteoporosis and who are being considered for estrogen therapy might consider this measurement to help them decide whether therapy is appropriate.

Tertiary Prevention

Usually the areas of health care priorities for older people as outlined in Table 2 are identified when we become symptomatic. Osteoporosis, sensory deprivation, depression, malnutrition, unintentional injury, oral disease, taking too many medicines, urinary incontinence, and arthritis are all major health problems in elderly people that deserve to be given priority in preventive care.

    The comprehensive geriatric assessment is one way to determine current medical problems, sources of disability, and priorities for future care. It includes screening to identify problems, including the targets of tertiary prevention, and usually involves the contributions of a multidisciplinary team. This assessment is particularly important for us when rapid changes are occurring in our health status or when a change in living arrangements appears necessary. (Chapter 8 on principles of rehabilitation has more information regarding the restoration of function if you are already disabled.) Checklists that outline health promotion strategies have been shown to improve the involvement and compliance of older persons and their physicians with the current recommendations. Properly timed and effectively delivered, preventive care can be expected both to extend our life and to postpone the period of functional disability. We have a considerable amount of control over the quality of our health in old age.




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