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Prevention of Disease in the Elderly

by James T. Pacala, MD, MS

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 ( ), and lifestyle changes (see Lifestyle Measures That Help Prevent Common Chronic Diseases). In secondary prevention, disease is detected and treated at an early stage, before symptoms or functional losses occur, thereby minimizing morbidity and mortality.

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.

Chemoprevention and Immunization for Elderly Patients

Disease to Be Prevented

Measure

Frequency

Comments* ,

Atherosclerotic cardiovascular disease (coronary artery disease, stroke)

Aspirin chemoprevention

Daily

For men 45–79 if risk of MI exceeds risk of GI bleeding and for women 55–79 if risk of ischemic stroke exceeds risk of GI bleeding: A recommendation by USPSTF

For patients > 80: I recommendation by USPSTF

Optimal dose unknown (but 75 mg po once/day may be as effective as higher doses and may have a lower risk of GI bleeding)

Influenza

Vaccination

Yearly

For everyone: Recommendation by CDC

Medicare coverage: Vaccination once during an influenza season

Pneumococcal infection

Vaccination

Once at age 65

For everyone 65: Recommendation by CDC (which also recommends one-time revaccination for people 65 if they were vaccinated 5 yr previously and were < 65 at the time of primary vaccination)

Medicare coverage: Vaccination once in a lifetime (revaccination coverage depends on patient’s status)

Tetanus

Vaccination

Every 10 yr

For everyone 65: Recommendation by CDC to maintain booster schedule or, if people were never vaccinated, to be given the primary vaccine series

Zoster

Vaccination

Once at age 60

For everyone 60: Recommendation by CDC for vaccination once, 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

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

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.

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)*

Osteoporosis

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

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: 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

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

Plasma glucose level

Yearly

For everyone with BP 130/85: B recommendation by USPSTF

For general population 65: I recommendation

For adults with cholesterol levels near the threshold for treatment: Screening for diabetes as part of assessment of cardiovascular risk

Medicare coverage: Screening every 6 mo for people with hypertension, dyslipidemia, or a history of high plasma glucose levels

Dyslipidemia

Fasting serum total, LDL, and HDL cholesterol levels; triglyceride levels optional

At least every 5 yr

More frequently for people who have coronary artery disease, diabetes, or peripheral arterial disease or who have had a stroke

For women 45 who have risk factors for coronary artery disease and for all men 35: A recommendation by USPSTF

Medicare coverage: Screening every 5 yr

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

Medicare coverage: Yearly screening for high-risk patients (anyone with diabetes or a family history of glaucoma, blacks 50, and Hispanics 65)

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

More frequently for people with higher BP

For everyone 18: A recommendation by USPSTF

Obesity or undernutrition

Height and weight measurement

BMI (kg/m 2 ) 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 and for women < 65 with a ≥ 9.3% risk of osteoporotic fracture over 10 yr as calculated by the FRAX (Fracture Risk Assessment) tool: B recommendation by USPSTF

Medicare coverage: Screening every 2 yr after age 50 or, if medically necessary, more often

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

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

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

§ 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; 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

Medicare coverage: Yearly screening

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 for a benign disorder: D recommendation by USPSTF against having Pap tests

Suggestion by AGS and ACS to stop screening in women>70 if the last 2 results were normal (if women>70 have never been screened, screening should be done, and if results of 2 tests done 1 yr apart are normal, screening may be stopped)

Medicare coverage: Screening every 1 yr for women at high risk; otherwise, every 2 yr

Colon cancer

Screening test (FOBT, flexible sigmoidoscopy, colonoscopy)

For everyone 50–75: A recommendation by USPSTF

For patients 76–85, C recommendation by USPSTF against routine screening (citing a very small net benefit)

For patients > 85: D recommendation by USPSTF against screening

FOBT

Yearly

Medicare coverage: Yearly FOBT

Flexible sigmoidoscopy

Every 5 yr

Sometimes used with FOBT

Medicare coverage: Flexible sigmoidoscopy every 4 yr or 10 yr after colonoscopy

Colonoscopy

Every 10 yr

Medicare coverage: Colonoscopy every 2 yr for high-risk patients or otherwise every 10 yr (but not within 4 yr of previous sigmoidoscopy)

Prostate cancer

PSA measurement

DRE

PSA commonly measured every 1–4 yr

D recommendation by USPSTF against screening

Medicare coverage: Yearly PSA measurement and DRE

*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; AGS = American Geriatrics Society; DRE = digital rectal examination; FOBT = fecal occult blood test; PSA = prostate-specific antigen; USPSTF = U.S. Preventive Services Task Force.

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, if needed, cessation of cigarette smoking can help prevent osteoporosis from progressing, and treatment can prevent new fractures.

Diabetes

Hyperglycemia, especially when the glycosylated hemoglobin (Hb A 1c ) 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 HbA 1c 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.

Resources In This Article

Drugs Mentioned In This Article

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  • RELENZA
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