Disease prevention is treatment intended to prevent a disease from occurring or worsening. Independent, older people with minimal or no chronic disease, as well as older people with several noncurable but treatable diseases, benefit from disease prevention measures.
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 Overview of Immunization Immunity can be achieved Actively by using antigens (eg, vaccines, toxoids) Passively by using antibodies (eg, immune globulins, antitoxins) A toxoid is a bacterial toxin that has been modified... read more (vaccinations), chemoprophylaxis ( see Table: Chemoprevention and Immunization for Older Patients Chemoprevention and Immunization for Older Patients ), and lifestyle changes ( see Table: Lifestyle Measures That Help Prevent Common Chronic Diseases 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.
Screening Screening Tests Test results may help make a diagnosis in symptomatic patients (diagnostic testing) or identify occult disease in asymptomatic patients (screening). If the tests were appropriately ordered on... read more 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 Older Patients Cancer Screening* Recommendations for Older Patients , and for certain other disorders, see Table: Selected Screening Recommendations for Older Patients Selected Screening Recommendations for Older Patients .
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 43(Supplement 1): S1-S2, 2020. https://doi.org/10.2337/dc20-Sint
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 older adults, can potentially benefit from tertiary prevention.
Arthritis (primarily osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes, including bone hypertrophy (osteophyte formation). Symptoms... read more ; much less commonly, rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that primarily involves the joints. RA causes damage mediated by cytokines, chemokines, and metalloproteases. Characteristically... read more ) affects about half of people ≥ 65. It leads to impaired mobility and increases risk of osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more , aerobic and muscular deconditioning, falls Falls in Older People A fall is defined as a person coming to rest on the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically, events caused by acute disorders... read more , and pressure ulcers Pressure Injuries Pressure injuries are areas of necrosis and often ulceration (also called pressure ulcers) where soft tissues are compressed between bony prominences and external hard surfaces. They are caused... read more .
Tests to measure bone density Dual-energy x-ray absorptiometry (DXA) Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more can detect osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more before it leads to a fracture. Calcium and vitamin D supplementation, exercise, and cessation of cigarette smoking can help prevent osteoporosis from progressing, and treatment can prevent new fractures.
Hyperglycemia Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more , especially when the glycosylated hemoglobin (HbA1C) concentration is > 7.9% for at least 7 years, increases the risk of retinopathy Diabetic Retinopathy Manifestations of diabetic retinopathy include microaneurysms, intraretinal hemorrhage, exudates, macular edema, macular ischemia, neovascularization, vitreous hemorrhage, and traction retinal... read more , neuropathy Diabetic Neuropathy In patients with diabetes mellitus, years of poorly controlled hyperglycemia lead to multiple, primarily vascular, complications that affect small vessels (microvascular), large vessels (macrovascular)... read more , nephropathy Diabetic Nephropathy In patients with diabetes mellitus, years of poorly controlled hyperglycemia lead to multiple, primarily vascular, complications that affect small vessels (microvascular), large vessels (macrovascular)... read more , and coronary artery disease Overview of Coronary Artery Disease Coronary artery disease (CAD) involves impairment of blood flow through the coronary arteries, most commonly by atheromas. Clinical presentations include silent ischemia, angina pectoris, acute... read more . 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 years
< 8.0% for patients with comorbidities and a life expectancy of < 10 years
< 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.
Older patients with a history of coronary artery disease Overview of Coronary Artery Disease Coronary artery disease (CAD) involves impairment of blood flow through the coronary arteries, most commonly by atheromas. Clinical presentations include silent ischemia, angina pectoris, acute... read more , cerebrovascular disease, or peripheral vascular disease Peripheral Arterial Disease Peripheral arterial disease (PAD) is atherosclerosis of the extremities (virtually always lower) causing ischemia. Mild PAD may be asymptomatic or cause intermittent claudication; severe PAD... read more 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).
Morbidity due to heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more is significant among older adults, 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 Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more leading to hospitalization.