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) and chemoprophylaxis (see see Chemoprevention and Immunization For Elderly Patients), and lifestyle changes (see 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 (see see Screening Recommendations For Elderly Patients and see Cancer Screening Recommendations For Elderly Patients) 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.

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%, increases the risk of retinopathy, neuropathy, nephropathy, and coronary artery disease. The goal of treatment is an Hb A_1c concentration of < 8% for frail diabetic patients and an even lower concentration (< 7%) for patients who are not frail or who have a remaining life expectancy > 7 yr.

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.

Last full review/revision December 2009 by James T. Pacala, MD, MS