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Prevention of Disease in the Elderly

By Magda Lenartowicz, MD, Medical Director, Scan Health Plan

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Patient Education

Primary and Secondary Prevention

Primary prevention aims to stop disease before it starts, often by reducing or eliminating risk factors. Primary prevention may include immunoprophylaxis (vaccinations), chemoprophylaxis (see Table: Chemoprevention and Immunization for Elderly Patients), and lifestyle changes (see Table: Lifestyle Measures That Help Prevent Common Chronic Diseases).

Secondary prevention aims to detect and treat disease or its complications at an early stage, before symptoms or functional losses occur, thereby minimizing morbidity and mortality.

Chemoprevention and Immunization for Elderly Patients

Disease to Be Prevented

Measure

Frequency

Comments*

Atherosclerotic cardiovascular disease (coronary artery disease, stroke)

Colorectal cancer

Aspirin chemoprevention

Daily

For adults 60-69 with a ≥10% 10-year CVD risk, decision based on individualized risk/benefit assessment: C recommendation by UPSTF

For patients ≥ 70: Insufficient evidence for or against use of aspirin for primary prevention of cardiovascular disease or colorectal cancer: I recommendation by UPSTF

Recommended dose: Optimal dose not established, but low dose (81mg) may be just as effective as higher doses with lower risk of GI bleeding.

Influenza

Yearly

For everyone: Recommendation by CDC

Pneumococcal infection

Twice

For everyone 65: Recommendation by CDC for 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 1 yr after PCV13

Tetanus

Every 10 yr

For everyone 65: Recommendation by CDC for a tetanus and diphtheria toxoids (Td) booster every 10 yr or, if people were never vaccinated, to be given the primary 3-dose vaccine series

Patients who never received Tdap should receive 1 dose of that preparation

Zoster

Once or twice at age 60

For everyone 60: Recommendation by CDC for vaccination once or twice (depending on vaccine preparation) regardless of history of zoster or varicella

*USPSTF recommendations based on strength of evidence and net benefit (benefit minus harm):

  • A = Strong evidence in support

  • B = Good evidence in support

  • C = Balance of benefit and harm too close to justify recommendation

  • D = Evidence against

  • I = Insufficient evidence to recommend for or against

For people at high risk of influenza A (eg, during institutional outbreaks), oseltamivir or zanamivir may be started at the time of vaccination and continued for 2 wk.

Tdap—Diphtheria (D) vaccines contain toxoids prepared from Corynebacterium diphtheriae. Tetanus (T) vaccines contain toxoids prepared from Clostridium tetani. Acellular (a) pertussis (P) vaccines contain semipurified or purified components of Bordetella pertussis.

CDC = Centers for Disease Control and Prevention; USPSTF = U.S. Preventive Services Task Force.

Lifestyle Measures That Help Prevent Common Chronic Diseases

Measure

Examples of Diseases

Smoking cessation

Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer, COPD, diabetes mellitus type 2, hypertension, osteoporosis

Achievement of and maintainenance of a desirable body weight

Atherosclerotic cardiovascular disease (coronary artery disease, stroke), diabetes mellitus type 2, hypertension, osteoarthritis

Reduction of dietary saturated fat and avoidance of trans fats

Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer, diabetes mellitus type 2, hypertension

Increased intake of fruits, vegetables, and fiber

Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer (possibly), hypertension

Increased aerobic exercise

Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer

Reduction of dietary Na

Atherosclerotic cardiovascular disease (coronary artery disease, stroke), hypertension

Reduced intake of salt- or smoke-cured food

Cancer

Minimized radiation and sun exposure

Cancer

Muscle strengthening and stretching

Osteoarthritis

Moderate physical activity

Osteoarthritis

Adequate Ca and vitamin D intake and sun exposure

Osteoporosis

Regular weight-bearing exercise

Osteoporosis

Limited caffeine intake

Osteoporosis

Limited alcohol intake (to 1 drink/day)*

Cirrhosis of the liver, osteoporosis

*1 drink = one 12-oz can of beer, one 5-oz glass of wine, 1.5 oz of distilled liquor.

Screening

Screening can be a primary or secondary preventive measure. Screening can be used to detect risk factors, which may be altered to prevent disease, or to detect disease in asymptomatic people, who can then be treated early.

Multiple organizations publish screening guidelines, which sometimes differ. Whatever a guideline recommends, individual patient characteristics and preferences also must be considered. For cancer screening, see Table: Cancer Screening* Recommendations for Elderly Patients, and for certain other disorders, see Table: Selected Screening Recommendations for Elderly Patients.

Selected Screening Recommendations for Elderly Patients

Disease to Be Detected

Test

Frequency

Comments*

Abdominal aortic aneurysm

Abdominal ultrasonography

Once between age 65–75

For men who have ever smoked: B recommendation by USPSTF

For men who have never smoked: C recommendation

For women who have ever smoked: I recommendation

For women who have never smoked: D recommendation

Abuse or neglect

Inquire about mistreatment (eg "Are there any problems with family or household members that you would like to tell me about?")

At least once

For all elderly patients: I recommendation by USPSTF

Alcohol misuse

Alcoholism screening questionnaire (eg, AUDIT, AUDIT-C)

Yearly

For all adults, including those 65: B recommendation by USPSTF

For patients who are ≥ 65 and have a positive screening test: B recommendation by USPSTF for brief behavioral counseling interventions

For patients who meet the criteria for alcoholism: Abstinence recommended

ASCVD (atherosclerotic cardiovascular disease) (1)

Framingham criteria, Reynolds Risk Score (only up to age 80), Multi-ethnic study of atherosclerosis (MESA)—up to age 85

Annually

People with multiple global risk factors more frequently

These screening tools typically include measurement of serum lipid levels (eg, total cholesterol, LDL, HDL, sometimes triglycerides)

Older women: screened in same way as older men

Cognitive impairment (eg, dementia, delirium)

Cognitive impairment screening instrument (eg, Mini-Cog)

NA

I recommendation by USPSTF

Depression (major depressive disorder)

Depression screening questionnaire (eg, PHQ-2)

Yearly

For all adults, including those 65: B recommendation by USPSTF

Diabetes mellitus, type 2

Fasting plasma glucose level

Yearly

Up until age 70 for adults who are overweight or obese: B recommendation by USPSTF

For adults > 45 who are overweight, obese or have other risk factors: ADA recommends screening every 1-3 yr (2)

Fall risk

Inquiry about falls during the previous year and about difficulty with walking or balance, Get-Up-and-Go test

Yearly

Recommendation by the AGS and BGS

For community-dwelling patients ≥ 65 who are at increased risk of falls: B recommendation by USPSTF for exercise and vitamin D supplementation

Glaucoma

Intraocular pressure measurement

Yearly

I recommendation by USPSTF

Hearing deficits

Bedside hearing test

Yearly

For everyone ≥ 65: I recommendation by USPSTF

HIV

HIV test of serum, blood, or oral fluid

At least once

For everyone 15–65 and for patients > 65 with HIV risk factors: A recommendation by USPSTF

Hypertension

BP measurement

At least every 2 yr for people with BP < 120/80 mm Hg

Annually for people with higher BP and/or risk factors (eg, overweight or obese, sedentary, strong family history, African-American)

For everyone 18: A recommendation by USPSTF

Obesity or undernutrition

Height and weight measurement

BMI (kg/m2) calculation§

At least yearly

For all adults: B recommendation by USPSTF

Osteoporosis

Dual-energy x-ray absorptiometry

At most, every 2 yr

For all women ≥ 65 : B recommendation by USPSTF

Thyroid dysfunction (hypothyroidism or hyperthyroidism)

Thyroid-stimulating hormone level

NA

I recommendation by USPSTF

Tobacco use

Inquiry about tobacco use

At least once

A recommendation by USPSTF

For all patients who report tobacco use: Cessation counseling and appropriate drug therapy

Visual deficits

Snellen visual acuity test

Yearly

For everyone 65: I recommendation by USPSTF

*USPSTF recommendations based on strength of evidence and net benefit (benefit minus harm):

  • A = Strong evidence in support

  • B = Good evidence in support

  • C = Balance of benefit and harm too close to justify recommendation

  • D = Evidence against

  • I = Insufficient evidence to recommend for or against

USPSTF recommends screening only in practices with systems to ensure accurate diagnosis, effective treatment, and follow-up.

Risk Factors (American Diabetes Association): physical inactivity, high risk race/ethnicity, first degree relative with diabetes, HDL-C < 35 mg/dL and/or TG > 250 mg/dL, A1C ≥ 5.7% IGT or IFG, history of cardiovascular disease, hypertension, conditions associated with insulin resistance like severe obesity, acanthosis nigricans, polycystic ovarian syndrome

§BMI 25 = overweight; BMI 30 = obesity

AAOS = American Academy of Orthopedic Surgeons; AGS = American Geriatrics Society; AUDIT = Alcohol Use Disorder Identification Test; AUDIT-C = abbreviated AUDIT Consumption Test; BGS = British Geriatrics Society; BMI = body mass index; MESA = Multi-Ethnic Study of Atherosclerosis; NA = not applicable; PHQ-2 = Patient Health Questionnaire-2; USPSTF = U.S. Preventive Services Task Force

Cancer Screening* Recommendations for Elderly Patients

Cancer to Be Detected

Test

Frequency

Comments,

Breast cancer

Mammography

Every 2 yr

For women 50–74: B recommendation by USPSTF

For women 75: I recommendation by USPSTF; suggestion by AGS to continue screening unless life expectancy is< 10 yr

Cervical or uterine cancer

Papanicolaou (Pap) test (evidence for newer methods is insufficient)

At least every 3 yr

For women>65: D recommendation by USPSTF against screening if results of adequate recent screening have been normal and women are not at high risk

For women who have had a total hysterectomy and no history of high-grade pre-cancerous lesion or cancer : D recommendation by USPSTF against having Pap tests

Suggestion by ACOG to stop screening in women > 65 if either 3 negative Pap test results in a row or 2 negative HPV co-test results in a row within the past 10 yr, with the most recent test performed within the past 5 yr

Colon cancer

Screening test (FOBT/FIT, flexible sigmoidoscopy, colonoscopy)

For everyone 50–75: A recommendation by USPSTF

For patients 76–85: C recommendation by USPSTF (citing a very small net benefit) against routine screening ( should be individualized, taking into account patient’s overall health and screening history)

For patients > 85: D recommendation by USPSTF against screening

FOBT

FIT

DNA

FOBT: Yearly

FIT and DNA: Every 3 years

Flexible sigmoidoscopy

Every 5 yr

Sometimes used with FOBT

Colonoscopy

Every 10 yr

Every 2 yr for high-risk patients

Lung cancer

Low-dose CT

Every year

For patients 55–80 who have a ≥ 30 pack-yr smoking history and currently smoke or have quit only within the past 15 years;

Prostate cancer

PSA measurement

DRE

Individualized

D recommendation by USPSTF against screening

*Cancer screening should be carefully considered and individual risks versus benefits should be considered, particularly in patients with a ≤ 10 yr estimated life expectancy.

USPSTF recommendations based on strength of evidence and net benefit (benefit minus harm):

  • A = Strong evidence in support

  • B = Good evidence in support

  • C = Balance of benefit and harm too close to justify recommendation

  • D = Evidence against

  • I = Insufficient evidence to recommend for or against

Medicare coverage, if provided, is listed. Patients may have to pay co-payments and deductibles, depending on the test.

ACS = American Cancer Society; ACOG = American College of Obstetricians and Gynecologists; AGS = American Geriatrics Society; DRE = digital rectal examination; FIT = fecal immunochemical test; FOBT = fecal occult blood test; PSA = prostate-specific antigen; USPSTF = U.S. Preventive Services Task Force.

Screening references

  • 1. Jellinger PA, Handelsman Y, Rosenblit PD, et al: American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Dysipidemia and Prevention of Cardiovascular Disease. Endocrine Practice 23:1-87, 2017. doi:10.4158/EP171764.APPGL.

  • 2. American Diabetes Association: Standards of medical care in diabetes. Diabetes Care 40(1): S4-S5, 2017. doi:10.2337/dc17-S003.

Tertiary Prevention

In tertiary prevention, an existing symptomatic, usually chronic disease is appropriately managed to prevent further functional loss. Disease management is enhanced by using disease-specific practice guidelines and protocols. Several disease management programs have been developed:

  • Disease-specific care management: A specially trained nurse, working with a primary care physician or geriatrician, coordinates protocol-driven care, arranges support services, and teaches patients.

  • Chronic care clinics: Patients with the same chronic disease are taught in groups and are visited by a health care practitioner; this approach can help patients with diabetes achieve better glucose control.

  • Specialists: Patients with a chronic disease that is difficult to stabilize can be referred to a specialist. This approach works best when the specialist and primary care physician work collaboratively.

Patients with the following chronic disorders, which are common among the elderly, can potentially benefit from tertiary prevention.

Arthritis

Arthritis (primarily osteoarthritis; much less commonly, RA) affects about half of people 65. It leads to impaired mobility and increases risk of osteoporosis, aerobic and muscular deconditioning, falls, and pressure ulcers.

Osteoporosis

Tests to measure bone density can detect osteoporosis before it leads to a fracture. Ca and vitamin D supplementation, exercise, and cessation of cigarette smoking can help prevent osteoporosis from progressing, and treatment can prevent new fractures.

Diabetes

Hyperglycemia, especially when the glycosylated hemoglobin (Hb A1c) concentration is > 7.9% for at least 7 yr, increases the risk of retinopathy, neuropathy, nephropathy, and coronary artery disease. Glycemic treatment goals should be adjusted based on patient preferences, comorbid conditions, and life expectancy. For example, appropriate HbA1c goals might be

  • < 7.5% for otherwise healthy diabetic older patients with a life expectancy of > 10 yr

  • < 8.0% for patients with comorbidities and a life expectancy of < 10 yr

  • < 9.0% for frail patients with a limited life expectancy

Control of hypertension and dyslipidemia in diabetic patients is particularly important.

Patient education and foot examinations at each visit can help prevent foot ulcers.

Vascular disorders

Elderly patients with a history of coronary artery disease, cerebrovascular disease, or peripheral vascular disease are at high risk of disabling events. Risk can be reduced by aggressive management of vascular risk factors (eg, hypertension, smoking, diabetes, obesity, atrial fibrillation, dyslipidemia).

Heart failure

Morbidity due to heart failure is significant among the elderly, and the mortality rate is higher than that of many cancers. Appropriate, aggressive treatment, especially of systolic dysfunction, reduces functional decline, hospitalization, and mortality rate.

Chronic obstructive pulmonary disease (COPD)

Smoking cessation, appropriate use of inhalers and other drugs, and patient education regarding energy-conserving behavioral techniques can decrease the number and severity of exacerbations of COPD leading to hospitalization.

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