Considerations for Health Promotion and Disease Prevention in Older Adults

James P. Richardson, MD, MPH, AGSF, FACPM

Disclosures

May 17, 2006

According to Mark Twain, the 19th century American novelist and social observer, "The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not."[1] This is certainly as succinct a view of most of our patients' feelings about health promotion as any clinician is likely to find. As difficult as it is for our patients to adopt healthy habits, clinicians looking for guidance regarding health promotion activities for older adults have to surmount just as many obstacles.

Promoting the health of older adults is not simply a matter of taking existing guidelines and extrapolating them. Older adults, defined here as those at least 65 years of age, are more likely to suffer from chronic illness and impairments in function, are more likely to take multiple medicines, and, on average, are more likely to die than younger adults. Because of these factors, health promotion and disease prevention activities often are forgotten or overlooked. On the other hand, overzealous healthcare professionals sometimes inappropriately apply recommendations developed for young or middle-aged adults to frail older adults with limited life expectancy, such as frail nursing home residents.[2]

Another pitfall is the failure to distinguish between recommendations for primary and secondary prevention. As a reminder, primary prevention is aimed at preventing disease before it occurs (eg, prevention of pneumococcal pneumonia through immunization). Secondary prevention detects disease before it is usually found (eg, mammography to detect breast cancer before a mass becomes palpable). One example might be recommending aspirin as primary prevention for cardiac disease to a frail older adult with a history of upper gastrointestinal bleeding. Although the risk of recurrent bleeding might be acceptable to a patient who has suffered a myocardial infarction (secondary prevention), the risk might be too great, depending on other cardiac risk factors, to recommend as a primary prevention measure.

Clinicians looking for preventive health guidelines for older adults derived from well-done studies may well end up scratching their heads. Studies of preventive interventions seldom have included older adults. For example, randomized trials of mammography to screen for breast cancer have included few women older than age 70 at entry;[3] this is true for other conditions as well. Other potential problems include the failure of recommendations from specialty groups to give upper age limits for interventions.[4]

Adding even more to the confusion is the fact that the government insurance program that covers almost all older adults in the United States -- Medicare -- did not recognize the value of these interventions until recently. Medicare coverage of preventive services has expanded dramatically over the years. Please see the table at the end of this column for a list of preventive services covered by Medicare.

Medicare has not been the only skeptic. It's difficult to persuade patients to adopt health promotion interventions when they believe that a "complete physical" is the most important component. Oboler and colleagues[5] surveyed 1203 adults in Boston, Denver, and San Diego. Two thirds believed that an annual physical was necessary; 90% felt that blood pressure should be measured, and that the heart, lungs, abdomen, reflexes and prostate should be examined. With the exception of blood pressure measurement, there is little evidence that any of these other examinations promote health or detect disease.[6]

There is hope for the busy practitioner, however, in the form of the United States Preventive Services Task Force (USPSTF).[7] Formed in 1984, the goal of the Task Force was to reduce confusion among clinicians regarding effectiveness of preventive medicine interventions. The Task Force assembles experts from different fields to evaluate the evidence of effectiveness of interventions. These are rated from A (good evidence that intervention is effective) to D (good evidence that intervention should be excluded). An I recommendation means that the evidence is insufficient to recommend for or against the service; the service may or may not be useful, but has not been studied in sufficient detail for the Task Force to make a recommendation. Medicare coverage of health promotion adheres closely to the recommendations of USPSTF.[8]

For complete evaluations and recommendations of the Task Force, the reader is referred to their Web site, www.preventiveservices.ahrq.gov/, which can be searched easily by topic, and it has a version that may be downloaded to a personal digital assistant (PDA). A few topics of particular interest to those who care for the elderly follow below. For more information about these topics, the reader is referred to the references or to the Task Force Web site.

Almost half of all breast cancers occur in women aged 65 or older. Mammography has been shown to reduce mortality from 20% to 35% in women aged 50 to 69 years of age,[3] but no studies have enrolled women older than 75 years of age.[7] The USPSTF recommends screening women with mammography up to age 70, but notes that women with comorbid conditions that may limit life expectancy are unlikely to benefit. Others recommend that screening be considered for women over age 70 with a life expectancy greater than 10 years, after counseling the patient about the benefits and harms of screening.[3]

The American Geriatrics Society recommends that providers offer mammography to women with at least 5 years of life expectancy to age 85.[9] Beyond age 85, screening should be reserved for those in "excellent health" or for those patients who feel strongly that they will benefit from such screening.

Although screening for cervical cancer with cervical smears has not been subject to randomized controlled trials, observational studies strongly suggest that the decline in cervical cancer mortality has resulted from increased screening. Physicians caring for older women cannot assume that these patients have had screening, however. Unlike younger women who "grew up" having cervical cancer screening, many older women have never had a Pap smear.

The USPSTF recommends screening women who have not been previously screened or when information about their past history of screening is unavailable. For adequately screened women, screening may stop after age 65.[7] American Cancer Society guidelines recommend that women can stop undergoing screening after age 70 if they have had 3 or more technically satisfactory negative cervical cytology tests within the last 10 years.[4]

Screening for prostate cancer, regardless of the patient's age, remains controversial for several reasons. To date, no prospective trials have shown decreased morbidity and mortality from screening for prostate cancer. Both digital rectal exam and prostate specific antigen tests have low positive predictive value. In addition, the probability that further invasive testing will be necessary after PSA screening is high. Men older than age 65 who have not been previously screened will probably die of another disease.

The USPSTF concluded that the evidence is insufficient to recommend for or against screening with PSA.[7] The American Cancer Society guidelines recommend annual screening for men beginning at age 50 who have at least 10 years of life expectancy, after a discussion about the "benefits, limitations, and harms" of testing.[4] Concerns about life expectancy and comorbidities should weigh more heavily in decisions to screen men older than 65 years of age. Two large randomized controlled trials, one in Europe and one in the United States, should offer help to physicians when results become available around 2009.[10]

The Task Force recommends routine vision screening with a Snellen chart and screening for hearing impairment by history or referral.[7] The clinical experiences of geriatricians and others who care for older adults support these practices.

Although the prevalence of dementia increases from about 5% at age 65 to as high as 40% at age 85,[11] the USPSTF found insufficient evidence to recommend for or against screening for dementia.[7] The Task Force did recommend that clinicians evaluate patients whenever cognitive impairment is suspected based on direct observation (eg, noncompliance, difficulty following directions) or concerns raised by family members or caregivers.

Clinicians wishing to provide preventive healthcare to older adults have several challenges, but current guidelines from the USPSTF provide reasonable starting points for many diseases. The concepts of life expectancy and quality of life should also guide healthcare providers in discussions with their patients. In areas where there is uncertainty, such as screening for prostate or breast cancer, shared decision making is appropriate.

Medicare Coverage of Preventive Services
"Welcome to Medicare" physical exam (Initial Preventive Physical Examination [IPPE]): a 1-time exam focused on prevention to occur within the first 6 months of Medicare Part B coverage. This examination consists of:

  • Review of modifiable risk factors

  • Review of risk factors for depression

  • Review of functional ability

  • Height, weight, blood pressure measurements, and visual acuity screen

  • Electrocardiogram and interpretation

  • Education, counseling, and referral based on the results of the previous services, including referral for other preventive services covered by Medicare

  • Breast cancer: baseline mammogram between ages 35 and 39, then screening mammograms every 12 months after age 40

  • Cardiovascular disease: fasting total cholesterol, high-density lipoproteins, and triglycerides every 5 years for asymptomatic persons

  • Diabetes screening, including fasting blood glucose, oral glucose tolerance test with 75 grams for nonpregnant adults, or a 2-hour postglucose test alone (Medicare will cover 1 of these tests for those without a diagnosis of diabetes or prediabetes once every 12 months.)

  • Cervical and vaginal cancer: screening pelvic exam every 24 months (every 12 months for women at high risk for cervical or vaginal cancer)

  • Colon cancer screening: fecal occult blood test once every 12 months, after age 50; flexible sigmoidoscopy every 4 years; screening colonoscopy once every 10 years, but not within 48 months of screening sigmoidoscopy (every 24 months if at high risk); barium enema may be substituted for sigmoidoscopy or colonoscopy every 48 months (every 24 months if at high risk)

  • Immunizations; influenza vaccine annually for those 65 or older; pneumococcal vaccine at least once after age 65 and may be repeated after 6 years for those at highest risk (eg, patients with leukemia, multiple myeloma, asplenia); hepatitis B vaccine (for patients at increased risk, eg, with end-stage renal disease)

  • Osteoporosis: bone mineral density measurements every 24 months for women

  • Prostate cancer: digital rectal exam and prostate specific antigen once every 12 months after age 50

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....