Disease prevention is treatment intended to prevent a disease from occurring or worsening. Disease prevention measures benefit independent older people with minimal or no chronic disease and older people with several noncurable but treatable diseases.
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 ), and lifestyle changes (see table ).
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 must also be considered. Guidelines for cancer screening Elder Abuse Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of older adults. Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial... read more and screening for certain other disorders Selected Screening Recommendations for Older Patients (eg, abdominal aortic aneurysm Abdominal Aortic Aneurysms (AAA) Abdominal aortic diameter ≥ 3 cm typically constitutes an abdominal aortic aneurysm. The cause is multifactorial, but atherosclerosis is often involved. Most aneurysms grow slowly (~10%/year)... read more , elder abuse Elder Abuse Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of older adults. Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial... read more , depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more ) are available.
1. Jellinger PA, Handelsman Y, Rosenblit PD, et al: American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease. Endocrine Practice 23 (4):479–497, 2017. doi:10.4158/EP171764.APPGL
2. Arnett DK, Blumenthal RS, Albert MA, et al: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation140 (11):e596–e646, 2019. doi: 10.1161/CIR.000000000000067
3. American Diabetes Association: Introduction: Standards of medical care in diabetes—2020. Diabetes Care 43 (Supplement 1): S1–S2, 2020. https://doi.org/10.2337/dc20-Sint
4. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society: Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 59:148–157, 2011.
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 professional; 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 is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... 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. A healthy diet, calcium and possibly 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, duration of diabetes, comorbid conditions, vascular complications, risks related to hypoglycemia, concomitant medications, and life expectancy. For most adults ,an HbA1C goal of < 7% without significant hypoglycemia is appropriate. However, appropriate HbA1C goals can change based on additional factors:
< 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 Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more , 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 medications, 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.
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
U.S. Preventive Services Task Force (USPSTF) Published Recommendations: The U.S. Preventive Services Task Force publishes recommendations for screening and preventive strategies for specific conditions, based on a systematic review of the evidence.
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