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HEALTH MAINTENANCE FOR OLDER ADULTS

James P. Richardson

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Incorporating health maintenance into practice
Primary prevention
 
Definition
 
Infectious diseases
 
Injury prevention
 
Osteoporosis
 
Smoking cessation
 
Alcohol
 
Dyslipoproteinemia (hypercholesterolemia)
Secondary prevention:Cancer screening
 
Definition
 
Breast cancer
 
Cervical cancer
 
Colorectal cancer
 
Prostate cancer
 
Skin
Secondary prevention:Other diseases
 
Glaucoma
 
Hypertension
 
Hypothyroidism
Geriatric assessment
 
Special senses
 
Polypharmacy
 
Cognitive impairment and depression
 
Advance directives
Chemoprophylaxis
 
Aspirin
 
Multivitamins
Chapter References

The proportion of the population that is elderly continues to grow. Due to the large influx of “baby boomers” into this group beginning in 2010, this demographic group will increase in size dramatically, guaranteeing that geriatric medicine will be a large part of every family physician's practice. Today's 65-year-old has an average of 13–17 years of life left. Thus health promotion is not an activity that patients “outgrow.”
As noted in previous chapters, many health promotion activities recommended in the past have not been supported by evidence of their effectiveness. Physicians are often confused by the plethora of recommendations from government agencies, professional groups, and experts. A good source for the practitioner is the second edition of Guide to Clinical Preventive Services of the United States Preventive Services Task Force (USPSTF) (1). This report concisely reviews the evidence for 70 health promotion activities, ranking recommendations by the strength of the evidence. Besides making their own recommendations, this resource also includes the recommendations of organizations such as the American Cancer Society and evaluates whether these recommendations are supported by evidence from reliable studies. The task force now evaluates prevention topics on a continuing basis, and the literature should be monitored for future recommendations and revisions. A useful internet site that contains the task force recommendations is www.guidelines.gov.
The following recommendations are largely consistent with the USPSTF guidelines but are the author's own. These recommendations apply only to asymptomatic people without risk factors.
I. Incorporating health maintenance into practice

A.
Elderly patients are less likely than younger ones to request health promotion activities and are less tolerant of long appointments. A useful approach, therefore, is to attempt to include some elements of health maintenance activities with every visit. For example, a visit for hypertension follow-up in the fall is a good time to inquire about influenza, pneumococcal, and tetanus– diphtheria (Td) immunizations.

B.
Many studies show that physicians believe they recommend health maintenance to their patients more often than can actually be demonstrated. Reminder systems and aids have been found effective in increasing health promotion use. The most effective are those that remove the physician from the decision loop (2). In other words, physicians can provide health promotion activities by involving their nurses and other staff, or by using questionnaires to initiate discussions of health promotion. Office protocols also are effective (e.g., immunizations, making a return appointment for cervical cancer screening). For a more detailed discussion of implementation strategies, see Chapter 1.3.

C.
As with all health care in the elderly, health promotion activities should take into account quality-of-life issues and patient preferences.
II. Primary prevention

A.
Definition. Interventions that are primary types of prevention seek to prevent a given disease from ever beginning. A good example is immunizations to prevent infectious diseases.

B.
Infectious diseases. Prevention of infectious diseases is often neglected by patients and providers (2). Together, influenza and pneumonia are the fifth leading cause of death in the elderly.

1.
Influenza. Influenza vaccine should be administered in October or November in the United States to all elderly who consent and are not allergic to eggs. The vaccine is effective in reducing the incidence of influenza and pneumonia, as well as hospitalizations for these diseases.

2.
Pneumococcal vaccine. This vaccine should be given at least once to all elderly, as well as to younger patients with chronic diseases, such as pulmonary disease, chronic liver disease, and diabetes mellitus. High-risk individuals, defined as those older than 75 years or with severe chronic disease, should receive another booster after 5 years.

3.
Tetanus-diphtheria (Td). In the United States, tetanus is now a disease of the elderly. Immunity to tetanus and diphtheria can be maintained by giving Td boosters every 10 years to patients who have had the primary series of three immunizations over 6 months. However, careful inquiry should be undertaken of all elderly receiving Td boosters because many seniors, especially women, have never received primary immunization, and these individuals will not be protected with one booster (3). Administration of tetanus immune globulin is necessary to elderly with tetanus-prone (i.e., “dirty”) wounds who have never completed a primary series.

4.
Tuberculosis. Routine purified protein derivative (PPD) testing is not necessary for community-dwelling elderly who are not HIV-positive but should be administered on admission to nursing homes. Two-stage testing (repeating the PPD 1–2 weeks after the first in those with an initial negative result) is necessary because of the booster phenomenon.

5.
Prevention of sexually transmitted disease. As with younger age groups, sexually active elderly should be counseled to avoid high-risk sexual behavior and to use condoms with new partners.

6.
Routine dental care remains important in the elderly.

C.
Injury prevention. Injuries are a frequent cause of death in the elderly.

1.
Elderly patients should be counseled regarding the dangers of falls and the benefits of exercise. Avoidable causes of falls include environmental hazards, such as poor lighting or throw rugs, visual deficits, and debilitation. Physicians should counsel older adults to gradually increase their exercise capacity by walking, gardening, or doing household chores. In addition to reduced fall risk, benefits demonstrated in population studies include lower incidence of cardiovascular disease, improved mood, and lower incidence of osteoporosis.

2.
Everyone should be counseled to wear safety belts (and bicycle or motorcycle helmets if applicable), to maintain working smoke detectors, to store firearms safely, and to keep hot water temperatures below 120°F.

3.
Although screening of all older drivers is not advocated, all providers should know the local laws governing driving restrictions should they become aware that a patient is no longer a safe driver. Many hospitals now offer testing by occupational therapists that might help with this determination.

D.
Osteoporosis. Hormone replacement therapy (HRT) (estrogen and progestin for women with a uterus, estrogen alone for those without) should be considered for women at risk of osteoporosis (see Chapter 13.6 and Chapter 17.6). Calcium supplementation (daily total of at least 1,000–1,500 mg of elemental calcium) should be recommended whether or not HRT is given. While the task force did not recommend routine screening, the National Osteoporosis Foundation recommends bone mineral density testing on all white women 65 years or older (4).

E.
Smoking cessation. Benefits accrue to those who stop smoking at any age. Patients' smoking history should be obtained, and smokers should be encouraged to quit. Counseling patients to stop smoking is an effective intervention.

F.
Alcohol. As alcoholism develops in some older people late in life, screening with the CAGE (Cut down, Annoyed, Guilty, and Eye opener) questions (see Chapter 5.3) is recommended.

G.
Dyslipoproteinemia (hypercholesterolemia). Whereas secondary prevention of cardiovascular diseases with lipid-lowering drug therapy is well established, primary prevention is controversial. The National Cholesterol Education Program advocates screening elderly persons with a good life expectancy by measuring high-density lipoprotein and total cholesterol (5). Most authorities recommend against treating elderly patients without known ischemic heart disease with lipid-lowering drugs because only one trial has been done that included men and women older than 65 years and large numbers of patients must be treated to prevent one adverse outcome (6). The decision must be individualized, based on the senior's quality of life, life expectancy, other risk factors, cost, and patient preference.
III. Secondary prevention:Cancer screening

A.
Definition. Interventions that seek to detect disease before individuals become symptomatic are secondary preventive measures. Examples include blood pressure measurement to detect hypertension and prevent cardiovascular diseases and cervical smears to detect cervical cancer.

B.
Breast cancer. Half of all breast cancers in women occur in those aged 65 years and older. Breast self-examination has never been shown to be an effective tool in reducing mortality but is recommended by the American Cancer Society. A yearly clinical breast examination is also recommended. Mammography screening is more controversial because studies of mammography have included few women older than 75 years, and there is no evidence that mammography is effective after this age. Mammography combined with clinical breast examination has been proven to reduce mortality from breast cancer in women aged 50 through 69 years. The USPSTF guidelines recommend cessation of breast cancer screening at age 70. Nevertheless, because the aging breast has an increased proportion of fat, which makes it easier to examine radiologically (and therefore mammography has a higher positive predictive value in the elderly), clinical breast examination and mammography performed every 2 years can be recommended to women older than 70 with a good life expectancy who would have surgery should a suspicious lesion be found (7).

C.
Cervical cancer. A significant proportion of elderly women have never had cervical (Pap) smears. Women with cervixes who are or have been sexually active should have smears at least every 3 years. Smears may be obtained at the physician's discretion in women 65 or older who have had consistently normal smears (see Chapter 13.4).

D.
Colorectal cancer. Rectal examination is not a useful screen in the asymptomatic patient. Fecal occult blood testing done yearly has been shown to reduce mortality from colon cancer by 33% (8,9), although the utility of this test may be less in the elderly due to a higher false-positive rate (and therefore lower positive predictive value) in the elderly. Rigid sigmoidoscopy has also been demonstrated to be effective in reducing mortality from cancer in the distal colon, but the optimal frequency of this screening is not clear (10). There is insufficient evidence to recommend one test over the other.

E.
Prostate cancer. A digital rectal examination for prostate cancer has a very low yield. The prostate-specific antigen (PSA) test is elevated in the elderly not only in those with prostate cancer but in men with benign prostatic hypertrophy as well. Although PSA testing identifies significant numbers of men with prostate cancer confined to the gland, it does not appear that mortality is reduced in those in whom early prostate cancer is found. Men older than 65–70 most likely will die of a comorbid condition other than prostate cancer (11). Therefore, with the possible exception of patients who request testing and have been informed of its drawbacks, PSA screening is not recommended for elderly men.

F.
Skin. A yearly examination of all skin for patients with significant sunlight exposure or with a history of skin cancer is recommended.
IV. Secondary prevention:Other diseases

A.
Glaucoma. Routine screening by primary care physicians is not recommended. High-risk populations (blacks older than 40, whites older than 65, and those with a positive family history, diabetes, or severe myopia) may be referred to eye specialists for screening. The optimal interval for screening is not known.

B.
Hypertension. Blood pressure should be measured at least yearly.

C.
Hypothyroidism. Routine screening is not recommended, but clinicians should have a low threshold for ordering a serum thyroid-stimulating hormone level (TSH) because of its subtle presentation.
V. Geriatric assessment. Although not as strongly supported by evidence as the above recommendations, most experts recommend some or all of the following activities for the elderly (12).

A.
Special senses. Visual and hearing loss contribute to functional decline and cognitive impairment. Vision may be tested with Snellen's chart, and hearing loss may be screened by history.

B.
Polypharmacy. Simplifying drug regimens improves compliance, reduces the incidence of adverse drug reactions, and saves money. Common offending drugs are those whose indications were never clear or the indications for which have disappeared (e.g., digoxin, H2 antagonists).

C.
Cognitive impairment and depression. Both of these are common in the elderly. The Folstein Mini-Mental State Examination (13) is specific but not very sensitive for dementia. Many depression-screening instruments (e.g., Geriatric Depression Scale) are available (12).

D.
Advance directives. Although all elderly should be encouraged to record their desires in formal advance directive instruments, simply recording the patient's desires in the medical record is often very helpful to other providers and family members should the patient become unable to make his or her own decisions (see Chapter 22.5).
VI. Chemoprophylaxis

A.
Aspirin. Although the value of aspirin is well established for secondary prevention of stroke and myocardial infarction, its role in primary prevention is less clear (for further discussion, see Chapter 1.3).

B.
Multivitamins. The role of vitamin supplementation in the prevention of cardiovascular disease is still evolving, but diet supplementation with one multivitamin a day is safe and benefits those older adults with poor diets.
Chapter References

1.
U.S. Preventive Services Task Force. Guide to clinical preventive services, 2nd ed. Baltimore: Williams & Wilkins, 1996.

2.
Richardson JP, Michocki RM. Removing barriers to vaccination use by older adults. Drugs Aging 1994;4:357.

3.
Richardson JP, Knight AL. The prevention of tetanus in the elderly. Arch Intern Med 1991;151:1712 [Erratum Arch Intern Med 1991;151:2451].

4.
Physician's guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation, 2000.

5.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993;269:3015.

6.
Denke MA, Winker MA. Cholesterol and coronary heart disease in older adults—no easy answers. JAMA 1995;274:575.

7.
Costanza ME, ed. Screening recommendations of the forum panel. J Gerontol 1992;47(special issue):5.

8.
Mandel JS, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. N Engl J Med 1993;328:1365.

9.
Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594–642 [Published errata in Gastroenterology 1997;112:1060 and 1998;114:635.]

10.
Selby JV, et al. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 1992;326:653.

11.
Johansson J-E, et al. High 10-year survival rate in patients with early, untreated prostatic cancer. JAMA 1992;267:2191.

12.
Gallo JJ, Fulmer T, Paveza GJ, et al. Handbook of geriatric assessment, 3rd ed. Gaithersburg, MD: Aspen Publishers, 2000.

13.
Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189.

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