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 (vaccinations), chemoprophylaxis (see Table: Chemoprevention and Immunization for Older 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 Older 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 cardiovascular disease 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 gastrointestinal bleeding |
|
Influenza |
Yearly |
For everyone: Recommendation by CDC† |
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Pneumococcal infection |
Twice |
For everyone ≥ 65: Recommendation by CDC for 23-valent pneumococcal polysaccharide vaccine (PPSV23); additional dose of 13-valent pneumococcal conjugate vaccine (PCV13) at least 1 year before or 1 year after PPSV23 based on shared decision making with patients, particularly in those with malignancy and other disorders causing immunocompromise For older adults who have received pneumococcal vaccination when < 65 years, see Centers for Disease Control and Prevention: Pneumococcal Vaccination |
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Tetanus |
Every 10 years |
For everyone ≥ 65: Recommendation by CDC for a tetanus and diphtheria toxoids (Td) booster every 10 years 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 |
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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 |
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* USPSTF recommendations based on strength of evidence and net benefit (benefit minus harm): |
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† 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 weeks. |
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‡ 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. |
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CDC = Centers for Disease Control and Prevention; USPSTF = U.S. Preventive Services Task Force. |
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Lifestyle Measures That Help Prevent Common Chronic Diseases
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 Older Patients, and for certain other disorders, see Table: Selected Screening Recommendations for Older Patients.
Selected Screening Recommendations for Older 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 older 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 years (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 |
Blood pressure measurement |
At least every 2 years for people with blood pressure < 120/80 mm Hg Annually for people with higher blood pressure and/or risk factors (eg, overweight or obese, sedentary, strong family history, African-American) |
For everyone ≥ 18: A recommendation by USPSTF |
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Obesity or undernutrition |
Height and weight measurement BMI (kg/m2) calculation§ |
At least yearly |
For all adults: B recommendation by USPSTF |
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Osteoporosis |
Dual-energy x-ray absorptiometry |
At most, every 2 years |
For all women ≥ 65 : B recommendation by USPSTF |
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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 |
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* Recommendations vary slightly among different professional societies and groups. USPSTF recommendations based on strength of evidence and net benefit (benefit minus harm): |
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† USPSTF recommends screening only in practices with systems to ensure accurate diagnosis, effective treatment, and follow-up. |
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‡ 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 |
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§ BMI ≥ 25 = overweight; BMI ≥ 30 = obesity |
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AAOS = American Academy of Orthopedic Surgeons; ADA = American Diabetes Association; 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 |
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Cancer Screening* Recommendations for Older Patients
Screening references
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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
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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
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:
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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.
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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.
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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
Arthritis (primarily osteoarthritis; much less commonly, rheumatoid arthritis) 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. Calcium 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 (HbA1C) concentration is > 7.9% for at least 7 years, 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
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
Older 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 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 leading to hospitalization.
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
oseltamivir |
TAMIFLU |
zanamivir |
RELENZA |
Aspirin |
No US brand name |
