HEALTH PROMOTION AND AGING
"PREVENTIVE HEALTH SERVICES"
     Gregg Warshaw, M.D.
   Division of Geriatric Medicine
  Department of Family Medicine
University of Cincinnati hledical Center

The problems of old age pose an unprecedented challenge to health professionals.
The potential of preventive health care to contribute to the wellbeing of the
elderly, to result in economic savings due to caring for a less disabled
population, and to provide a more humane, less technological approach to
medical care, has aroused considerable interest.  Health maintenance of the
elderly, nevertheless remains a complex, controversial and emotional t0pic.l
Fundamental to the successful application of preventive strategies for the elderly
is an understanding of the scope of prevention as it applies to the elderly.2

Patterns of disease and functional limitations are related to the demography of
the elderly population.3  Life expectancy statistics by age, race and sex
demonstrate that after reaching age 65 Americans have considerable mean life
expectancy. For example, 75 year old white women can be expected to live a
mean of 12 more years; 75 year old black men can be expected to live a mean of
9 more years.4  This remarkable expectation for additional Iife emphasizes the
opportunities for disease prevention among the old.

The most common causes of death among individuals over the age of 65 are
heart disease and cancer with heart disease accounting for nearly half of all
deaths. Cancer deaths are mainly due to colon, breast, uterus, prostate cancer,
and leukemias. Other common causes of death include injuries, pneumonia,
diabetes, and pulmonary discase.4

In 1977, adults 65 years of age and over had 14.5 bed-disability days, and in
1984 15.1 days?  Chronic medical conditions are significant contributors to
functional impairment.  Common chronic impairments include arthritis,
hypertension, hearing loss, heart disease, vision loss, and diabetes.6 Recent
reviews emphasize the importance of identifying factors that increase or
decrease the probability of an "impairment" becoming a "handicap".7-9 Some
common handicaps in the elderly include immobility, inability to dress, inability
to bathe, and inability to use the toilet.  An accumulation of handicaps leading
to dep%ndence is a strong predictor of the need for long term care services.

TASKS OF PREVENTIVE IIEALTH SERVICES

Effective health maintenance of the elderly requires that a number of tasks be
performed by many sectors of society. Although this paper focusses primarily on
the job of the health care provider; the elderly themselves, their families, and
private and public health systems all contribute to health maintenance.
Adoption of a healthy lifestyle by individuals in middle age could contribute
greatly to health in later years.   Successful aging requires life-long self-
development and adaptation to loss.  Individuals who plan and respond to
expected and unexpected financial and social stress may be able to avoid the
problems of isolation and depression.


Families, friends, and other social supporters have the challenge of providing
informal and formal support while respecting the older person's autonomy.
Over-protection by support interventions that occur prior to real need may
inadvertently encourage dependency and accelerate functional loss.

Government and other purchasers of health services have the responsibility to
find effective preventive health strategies and encourage their application. For
example, Medicare limits payment for preventive health maneuvers, and routine
vision, hearing, and dental examinations.  Somer's has recently emphasized that
selective funding of preventive interventions for the elderly by Medicare may
represent an effective "cost control" strategy for the federal government. Somer's
has also described the pfOfentia1 of governmental incentives for responsible
consumer health behavior.

Combatting agism is a task that the elderly, their families, health care providers,
and the government share. There remains a widespread belief that people in
their 60's or 70's are too old or disabled for effective preventive health care.

In their progress toward a rational and effective preventive approach for
geriatric care, clinicians must clarify the complexities of applying anticipatory
strategies to this age group.  In addition strategies addressing the prevention of
specific diseases, health maintenance plans for the elderly should include: a re-
evaluation of the traditional preventive health delivery systems, personalized
health maintenance measures, reduction of iatrogenic problems, addressing the
needs of family caregivers, strategies to enhance functional status, and strategies
to strengthen social supports.

The purpose of this paper is to discuss the guidelines by which preventive health
services should be applied to this older age group; to review clinical trials in
which health maintenance packages have been appiied to the elderly population;
and to provide a guide to potential preventive health maneuvers.

PRJNCIPLES OF APPLYING HEALTH hlAINTENANCE STRATEGIES TO
THE ELDERLY

Scientific Validation of hlaneuvers

Ensuring a sound scientific basis for a  reventive health intervention has been
addressed in recent years by McKeown PI
Sackett14y15 Frame and Carlsonl6y17  , Cochrane and Holland12, Spitzerl3,
Periodic Health Examination18>19.     and the Canadian Task Force on the

Thia work has been essential in protecting the healthy population from
iatrogenic insult, preventing unnecessary costs both to the individual and to
society, and to maintain the "scientific integrity" of the professionals concerned.
It has led to careful study of the impact of disease, the efficacy of detection
maneuvers and the quality of evidence supporting the effectiveness of
intervention strategies.

The focus of this work has been on early diagnosis through secondary prevention
or screening.lj Recommendations have also been made in the area of primnr>
prevention, such as immunizations. Screening includes large public health
programs; for example, checking blood pressure at the senior center.   The
combination of several tests as a screening package is referred to as multiphasic
screening. The periodic health examination is when screening occurs as a
preventive health visit in the physicians office.  When preventive health services
occur as part of ongoing acute or chronic health care this is referred to as case

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findina.zO For example, a 75 year old man presenting with acute bronchitis also
has his blood pressure checked and is given guiac cards to take home to check
for occult blood in the stool.

These strategies focus on the detection of asymptomatic disease.  Yet, the
relevance of this work to the elderly is somewhat limited, for it has focussed on
primary and secondary prevention strategies for biomedical disorders in young
populations. This is useful insofar as old age is not a separate period of Iife but
part of a continuum, and for full effectiveness preventive measures need to start
in childhood and continue throughout adult life.  Nevertheless it does not
provide the practicing clinician with a course of action when confronted with
frail, elderly patients.

Personalize Preventive Wealth Services

The elderly arc a heterogenous population and their health care must be
personalized. In doing this, the following principles should be considered:

Recognize that Death May bq a Legitimate End Point: A patient's right to
benefit from the developmknts -Of medi`cal science is incontestible but at some
point in the life cycle, however, a patient has the right to die peacefully and
with dignity. This is particularly true for those suffering from irremediable
disease. Preventive health care of the elderly, therefore, has as its principal goal
not simply the prolongation of life but improvement of the quality of that life.

hlinimize Unnecessary Disruption to Life Style:  A number of preventive health
measures have the potential for disrupting a patient's life. Prescribing a low-
sodium or weight-reduction diet, or urging the patient to stop smoking are
examples. While these measures have a place in the management of selected
groups of patients, the clinician must appreciate that in old age, when the
chance of prolonging life is limited, the quality of that life is more relevant.
Many patients see restriction of diet or the cessation of smoking.as seriously
affecting what enjoyment they have left in life.  These emotional issues
regarding life satisfaction must always be balanced against the theoretical
advantages to health. If independently living elderly so wish, they need not
comply with the prescribed preventive health measures. Institutionalized eIderly
are less fortunate and can be prisoners to the zealous application of preventive
strategies.

Respect Patients' Autonomy:  As elderly patients age they become more frail and
may be at risk living alone. A patient's family may become sufficiently anxious
about the risk that they try to institutionalize the old person.   Despite the
espress%vish of the patient to remain in his own home.  The clinician at these
times must respect the patient's right IO self-determination.  The exception to
this is the case of the mentally incompetent patient (although the presence of
dementia does not necessarily imply incompetence).

Time the Intervention Precisely:  There is a critical intervention time, or
"window", when the various types of preventive support should be provided. A
patient's functional status may deteriorate slowly for several years until a crisis
develops, then the patient's health deteriorates rapidly. If support is provided
too late, institutionalization is often the outcome. If it is provided too early, it
fosters dependency, wastes resources, is costly, and is considered by many
patients to be an intrusion on their privacy.

Minimize Iatrogenic Insult

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There is decline in physiologic31 functioning in almost every organ system in the
elderly which results in impaired homeostasis.  Reduction of iatrogenic insult is
therefore an important goal of health maintenance.  Drug induced disease is
perhaps the most commonly seen problem, but even the hospitalization process is
not without risk for this age group.  More and more literature21,22 reveals
significant iatrogenesis from the procedures used including nosocomial
infections  f3lls within the institution and psychologic insult associated with
relocation.2J

Reduction of iatrogenic insult should not only be 3 goal of health maintenance
but should be 3 principle by which health maintenance strategies 3re applied.
For instance the Hemoccult Slide Test has been recommended for the detection
of colorectal carcinoma in those over age 50 years yet is far from ideal as a
routine test for use with the frail elderly.  In this population the majority of
positive tests may not be due to carcinoma but to asymptomatic diverticular
disease or duodenal ulcer3tion.24 This is important because the Hemoccult is not
an innocuous test.  A positive result mandates an extensive work up from
sigmoidoscopy to double contrast enema and colonoscopy.  Morbidity in the
elderly resulting from these procedures, from the required bowel preparation and
from any accomprlnying hospitalization is significant. These factors must be
weighed in the balance when considering the routine use of the Hemoccult Test
for the frail but asymptomatic elderly population.

STRATEGIES FOR APPLYING HEALTH MAINTENANCE MEASURES

Screening and Case Finding in the General Population

The conventional approach to applying preventive c3re strategies is annual or
regular screening programs.  In the elderly this has been ex!ended to identifying
symptomatic but unreported illness by case finding.  A number of reports over
the last thirty years have suggested the benefit of screening elderly populations.
Rubenstein, et al. have recently reviewed published reports of screening
programs for the elderly living in the community.25 Among elderly populations
screening has consistently identified significant numbers of active clinic31
problems. However, the clinical significance of these findings depends on the
characteristics of the population being screened, and only a few studies have
attempted to measure the effectiveness of screenin
elderly26                         or case finding among the
     and only one used a randomized design. 27  This clinic31 trial involved
295 British patients living in the community.  The screening intervention was 3
traditional medic31 history (obtained by a nurse and a questionnaire) and 3
physical exam. The study group increased its use of health and social services
but had 3 decrease in use of in-hospital days as compared to controls. There w3s
no identified impact from screening on physical or social disability.   The
reliability and validity of the scales used to mertsure outcomes in this study were
not defined.

Screening of the community living elder-1  may slightly improve mortality rates,
but the results remain  inconclusive. 28,;4;)  Screening has even less impact on
functional status with only marginal non-statistical improvements being observed
though in some of the studies the reliability and validity of the scales used to
measure the outcomes have not been well defined. Most investigators believe
their patients benefit from a screening program and report a perceived increase
in patient morale and esteem but these subjective impressions have not been
borne out when more sophisticated measurements have been used.29 At best
screening programs for the elderly have been demonstrated to have a marginal
and transient effect at best on the quality of life.

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Screening of the institution3lized elderly' has been reviewed in 3 number of
recent studies. In one study it was found that approximately half of the annual
screenin 50 examinations produced either 3 new finding Or clarification of an old
problem.   These new findings were then assessed independently for their
degree of importance by the patient's primary care physician. It w3~ estimated
that 3.4 per cent were of major importance, 26.8 per cent were of intermediate
importance, and 69.8 per cent were of minor importance.  These results provided
only modest support for endorsing annual medical examinations for nursing
home residents. In another survey of an academically affiliated Veterans'
Administration Nursing home it was likewise concluded that ongoing health care
as part of an academic geri3tricJqrogram might obviate the need for annual
screening or physical examinations.

Levinstein, et al. reviewed the yield of routinely performed
tests in 3 large, non-profit community skilled nursing unit. y; n eFh $ J$JJ;;;~;
that in their population a CBC, serum electrolytes, urea nitrogen, creatinine,
serum glucose, thyroid function tests, and a urinalysis would be beneficial to a
substantial number of patients if performed as part of routine care or 3s annual
screening test.  The identification and erradiction of asymptomatic bacteriuria
w3s a common result of this screening program, and the authors do state that the
value of treating asymptomatic bacteriuria in this population has not been
proved.  It has been pointed out that none of the recommended tests h3ve also
been recommended by the Cannadian Task Force for this age group.33

In summary, current evidence for the efficacy of screening and case finding in
general populations of community living or institutionalized elderly remains
weak.

Screening and Case Finding in Selected Patient Groups

Rather th3n screen the whole of the elderly population, an alternative is to focus
on selected patient groups.  The elderly may self-select. For instance, a postal
questionnaire has been used to allow those fit enough and with no significant
problems to exclude themselves from further study.  By using this self-report
technique, about 3 fifth of a screening workload can be avoided.34

The results of several pre-admission screening programs suggest that referral for
nursing home-type care is 3 further opportunity for the instigation of health
maintenance measures as part of a multidimensional assessment.  Apart from
bringing to light undetected disease the subsequent rehabilitation and provision
of home supports can do much to avert or delay institutionalization and allow
resettle'ment (of the patient) at a less intense level of care.

Another method is to select only those elderly patients perceived to be "at risk".
The concept of "risk" has at least two problems.  First, the term has been used
variously to imply risk of death, risk of increased morbidity, or risk of being
institutionalized, all stigmatizing and stressful to the patient. Second, attempts
to validate "at risk" groups previously defined in the world literature failed to
find any of the definitions particularly effective for case finding.35

Periodic Health Examinations

A final strategy for the application of health maintenance measures is
onoortunistic case finding
doctor-patient interactions. that is seeking out unreported illness during norm31
              This has been shown to be particularly effective
where the health care delivery system has 3 strong primary care base with

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primary care providers serving a defined population and acting as "gatekeepers"
to a variety of resources. In this way over 90 per cent of an identified elderly
patient population may make contact with the primary care base over a one year
period.36  The concept offers both a challenge and opportunity to primary care
providers particularly those operating within health maintenance organizations.

Opportunistic case finding also removes the artificial dichotomy between
preventive and traditional medical care.  Health maintenance measures would no
longer be a separate activity performed on a relatively fit population. Health
maintenance and traditional medical care thus become integrated and the
medical process serves as a major channel for the delivery of preventive health
services. Sommer's has suggested that all new Medicare enrollees be required or
encouraged to register with a primary physician.  Identification of efficacious
preventive services and fostering them through Medicare reimbursement is
required to implement this strategy.lO

POTENTIAL PREVENTIVE IIEALTH hIEASURES

Effective preventive health care of the elderly requires an appreciation of
problems outside the narrow focus of primary and secondary prevention. Health
in old age consists of three interwoven components:  the absence of disease
(including iatrogenic disease), an optimal functional status, and an adequate
support system. Preventive health services for the elderly should intend to
achieve the following goals:

1.  Prevent or palliate physical, psychiatric, and iatrogenic disorders.
2.  Prolong the period of effective activity and independent living.
3.  Ensure a support system adequate to preserve the patient's autonomy,
  independence, and quality of life at all levels of care.
4.  Avoid institutionalization as far as is practical in both humanitarian
   and economic terms.
5.  Ensure that when iliness is termina1 there is as little distress as possible
  to patient and caregivers.

6. Minimize the burden on family and other caregivers in order to
  improve their morale and prolong the period of time they are willing to
  be caregivers.

Kane and colleagues have developed a framework for developing and evaluating
preventive interventions for the elderly.37  They emphasize that the traditional
terminology of prevention is not easily applied to a patient group with chronic
diseases.  Four groups of potentially preventable clinical problems are outlined:
1) problems that can be addressed in traditional prevention terms (diseases that
fit inte the usual primary, secondary, tertiary prevention concepts), 2)behaviors
likely to produce beneficial or adverse effects on health status (risk factor
modification), 3)problems requiring attention from caregivers (case finding and
anticipatory care of common geriatric functional problems), and 4) iatrogenic
problems. Table 1 lists items relevant to the elderly in each of these four
categories. Selected items are discussed below.

TRADITIONAL PREVENTION

Clinical Problem: Bacteriuria
Proposed Preventive Measure:  Periodic urine examinations

Therapy has been shown to be effective in erradicating asymptomatic bacteriuria
in elderly women3*.  However the effect of this treatment on morbidity and

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mortality is unclear. Several studies have suggested a mortality risk associated
with bacteriuria among institutionaIized elderly.39-41  However, others have
found bacteriuria to be transient and to frequently resolve without treatment.42

Clinical Problem: Breast Cancer
Proposed Preventive Measure: Periodic Mamogram

The age-specific incidence of breast cancer, that is the number of cases per year
per hundred thousand females in each age group, shows a progressive rise with
age. A recent carefully conducted trial from Sweden showed that prognosis was
best when the age at diagnosis was b:\ween 45 and 49 years, but thereafter
survival worsened with increasing age.    The difference in relative survival
between those older than 75 and those 45 to 49 years increased from 8.6 percent
at two years, to 12.2, 20.3 and 27.5 percent after five, ten and fifteen years of
follow up respectiveIy. No data are available on the screening of the very old
for breast cancer, but case-control studies from Europe indicate a value for
mammo
age.44>4F raphic screening in reducing mortality in patients up to 74 years of

Clinical Problem: Cervical Cancer
Proposed Preventive Strategy: Periodic Pap Smear

The value of regular screening for cervical cancer by use of the Pap smear may
decrease in old age. It is suggested that when clinicians are confronted by
elderly women with a history of previous normal Pap smears they should repeat
this procedure an additional time.  If the test is negative, no further screening
seems to be required for the age-specific incidence of conversion from negative
to positive smears decreases from 0.3 per thousand in women 55 to 59 years old
to 0 for those over 8O.46 However, 15% of women aged 65 to 74 yearj?nd 38%
of women 75 years and older report never having had a Pap smear.    These
women may require periodic screening.

It is also known that urban, black and hispanic populations have a high
incidence of cervical carcinoma as do those with multiple sexual partners, prior
venereal disease and those in the lower income group. It may be that screening
of these high risk groups should be more aggressive.  In a recent survey of an
elderly New York population the prevalence rate of abnormal smears was found
to be 13.5 per thousand.48

Clinical Problem: Colorectal cancer
Proposed Preventive Measure: Six-slide occult blood test: sigmoidoscopy
ColoreEtal cancer is common in the elderly; peaking in incidence at about age
8O.49 Five year survival rates appear to be similar for older as compared to
younger victims,  Sigmoidoscopy is recommended by the American Cancer
Society (ACS) every three years after the age of 50.50 The cost and the poor
patient acceptance. of this test has been discussed.17 Its acceptance and
complication rate in older subjects has not been sufficiently studied.

The ACS and the Canadian Task Force have recommended annual stool occult
blood testing. Two large controlled trials have reported promising preliminary
resuIts.51>5* A positive test requires follow-up sigmoidoscopy and barium enema
or colonoscopy. The test only detects fecal blood, and in the elderly many false
positives will result in lower bowel examinations. The morbidity in the elderly
from these procedures, from required bowel preparation and from any
accompanying hospitalization may be significant.

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Clinical problem: Endometrial Cancer
Proposed Preventive hleasure:  Patient education to report postmenopausal
bleeding
The incidence of endometrial cancer increases with age.53 Risk factors include
obesity, estrogens, and infertility.  This cancer appears to develop over years
from endometrial adenomatous hyperplasia.
found in 80% of women with this cancer;54  Abnormal endometrial bleeding is
                      and many of these cases are detected
in early stages.55 Endometrial tissue sampling has been recommended for high
risk women.

Clinical Problem: Lung Cancer

Proposed Preventive hfeasure: Periodic chest x-ray

In the general population the ACS and the Canadian Task Force do not
recommend routine screening chest x-rays.  Reducing tobacco use is the best
method of preventing lung cancer.

Clinical Problem: Ovarian Cancer

Proposed Preventive Rleasure: Annual pelvic exam

Ovarian cancer is aggressive; early metastatic disease is common. The incidence
of this cancer increases with  age. 53  Earl  detection of this cancer can lead to
five year survival rates approaching 80%.5 x  Unfortunately, there is no evidence
that annual pelvic examinations will detect early cancers or improve survival
rates.57

Clinical Problem: Prostate Cancer
Proposed Preventive hleasure: Digital rectal exam

Prostate cancer is common among elderly men; and is the third leading cause of
cancer death among men.53  The natural history of this cancer in elderly men is
poorly understood.  Autopsy results show Stage A (occult) disease to be very
common; and how many of these Stage A cancers progress to clinically
significant disease is unclear.  Studies su porting routine rectal examinations
have not included many elderly subjects, 58 and a recent review of a screening
program with over 2000 subjects concluded that rectal examination is an
insensitive screening test for early prostate cancer.

Clinical Problem: Hypertension
Proposed Preventive Rleasure:  Periodic Blood Pressure Check

In recent years there have been several clinical trials of the treatment of
systolic-diastolic hypertension that have included patients over age 60.59y60 The
European Working Party on High Blood Pressure in the Elderly reported a
significant decrease in cardiac mortality in the treatment group, a non-
significant decrease in cerebrovascular mortality, and a no difference in overall
mortality.59,61  Other studies have demonstrated a reduction in the incidence of
stroke disease.

Hard evidence is still confined to those under 80 years of age for there has been
insufficient numbers of the very old enrolled in the existing trials from which
to draw statistical conclusions.  There is therefore still doubt about the risk-
benefit equation of treatment in the very old away from the carefully monitored
conditions of a controlled trial. It is the very old population that is most at risk
from excessive or rapid hypotensive therapy as well as from the side effects of
the medication. Compliance with therapy in the general elderly population may

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not be as good as in the relatively fit, motivated elderly populations attending
blood pressure clinics. This may be particularly true in the case of the very old
population in whom 1 in 5 will have some degree of cognitive impairment.
Effective prevention of the complications of hypertension still requires
considerable research into strategies with the old old.

The case for treating isolated systolic hypertension is not as yet proved and
awaits the result of two ongoing controlled trials.

Clinical Problem: Influenza
Proposed Preventive hleasure:  Influenza Vaccine; Amantadine

There is good evidence of the efficacy of influenza vaccine in the community
living elderly and moderately go%%-tzidence for its efficacy in the
institutionalized elderly population.      Influenza vaccination reduces
mortality, morbidity and hospitalization rates.  However vaccination rates
remain low though a number of strategies such as postal and telephone reminders
have improved compliance with this procedure.

Amantadine hydrochloride is an antiviral agent that is specific for influenza A.
Amantadine has been 70-90% effective in preventing influenza A illness in an
institutional outbreak.65  Amantadine is recommended by the C.D.C. for high
risk individuals allergic to vaccine, 3s an adjunct to late immunization of high-
risk individuals, and during nursing home epidemics.

Clinical Problem: Pneumonia
Proposed Preventive hleasure: Pneumococcal Vaccine

Studies suggest the efficacy of pneumococcal vaccination in the elderly.66 The
appropriateness of widespread vaccination programs must, however, be seen in
the context of the populations for which they arc recommended. It is essential
to consider the effect of other concomitant disease on mortality rates from
pneumococcal pneumonia. When no other conditions co-exist the mortality from
pneumococcal pneumonia is low (9/100,000 cases), but this increases a hundred
fold for those with two or more high risk associated conditions. Therefore, two
target populations may exist.  One fit group, mostly living in the community,
who respond well to antibiotic therapy and who have a good prognosis
irrespective of vaccination status.  The second group, many of whom will be
institutionalized, are seriously debilitated from concomitant disease, have a poor
prognosis, and prevention might bc better than attempted cure. It should also be
noted that it is in precisely this frail population that there are still doubts about
the efficacy of the vaccine.67

Clinical Problem: Tetanus
Proposed Preventive hleasure:  Tetanus Toxiod Immunization

Mast cases of tetanus in the United States occur in individuals over the age of
60.68 Inadequate immunization status among the elderly has been documented
and is felt to be the cause for the relatively high attack and fatality rates among
the elderly.69  However, the overall incidence rate for tetanus is very low;
0.2/100,000 for individuals over the age of 60. The cost-effectiveness of large
tetanus immunization programs for the elderly should be evaluated.

Clinical Problem: Hypothyroidism
Proposed Preventive Measure:  Periodic T4, TSH measurement

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Hypothyroidism is present in about 1 in 500 of the community-living adult
popuIation,7O but the incidence increases with age so that it is a condition
commonly encountered by those physicians dealing with the elderly.71*72

Bahemuka and Hodkinson found it in 2.3 per cent of consecutive admissions to a
geriatric department.73  Because of its frequency, its impact on physical and
psychiatric morbidity, the simplicity and low cost of the test for its detection,
and the efficacy of its treatment, periodic evaluation of thyroid function in an
aged population may be a useful health maintenance strategy.

Clinical Problem: Tuberculosis
Proposed Preventive hleasure: Periodic PPD skin testing or chest x-rays
Persons 60 years and older account for 25 - 50% of all cases of tuberculosis.74-76
Reactivation tuberculosis is a major mechanism for active disease.  With
advancing age, the frequency of false negative PPD skin tests in the presence of
active disease increases.  Chest x-rays are not currently recommended for the
purpose of screening to detect tuberculosis.77  Because of the risk of liver
toxicity INH chemoprophylaxis for elderly PPD convertors or for exposed
contacts with negative chest x-rays is controversiaI.69  Prevention of tuberculosis
outbreaks in nursing homes requires careful evaluation of PPD reactivity status
at the time of admission and aggressive infection control measures if an active
case is identified.

RJSK FACTORS OR BEHAVIORS

Clinical Problem: Hypercholesterolemia
Proposed Preventive Measures: Routine screening for blood lipids

Recent studies supporting the screening ygr7Gnd  the treatment of elevated
cholesterol levels have been encouraging. T   Lowering cholesterol levels
through diet or medications is increasingly accepted as effective in preventing
heart disease. The relevance of this work to individuals over age 70 is unclear.
The Framingham study documents that the relationship between cardiovascular
disease and cholesterol levels decreases with age.*O

Clinical Problem: Smoking Habits
Proposed Preventive Measure: Advice and assistance to quit smoking

Although smoking rates tend to fall in old age, 17.9 per cent of men and 16.8 per
cent of women of this age group in the United States still smoke.8l  Although
the principle of minimizing disruption to the patient's lifestyle must be seriously
considered, data suggest that in addition to its correlation with coronary heart
disease*> peripheral vascular disease, lung cancer, and chronic obstructive lung
disease, smoking in the elderly is also associated with decreased bone mineral
density, loss of body weight, decreased muscle strength, and accelerated lung
aging. The demented elderly who smoke also pose a fire hazard.

The benefits of stopping smoking in younger patients has been well described.
Recently Jajich has shown that stopping smoking late in life is associatge2d with a
rapid and sustained reduction in mortality from coronary disease.   Many
programs are available to assist individuals to stop smoking. Although there may
be isolated successes, their success in the elderly is generally poor.

CASE FINDING

Clinical Problem: Alcoholism
Proposed Preventive hleasure: Historical screening

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Although the data is difficult to obtain it is generally felt that alcoholism is a
common and serious clinical problem among the elderly.83  It is felt that as
many as l/3 of older people with alcoholism developed the disease in their later
years as a result of physical or psychosocial stress. These patients may go
unnoticed by health providers.  Health workers should be aware of high-risk
profiles; eg. possible" dementia", recent falling or fractures, depression.

Clinical Problem: Constipation
Proposed Preventive hleasure: Historical Screen

Constipation, a problem more often perceived than real in the community-living
elderly, nevertheless can result in psychological distress, impaction with overflow
soiling, hemorrhoids, and diverticular disease.  It may be managed by the
maintenance of physical activity and an adequate fluid intake and by additional
dietary fiber in the form of bread or supplements. Fiber may also protect
against symptomatic diverticular disease of the colon.

Clinical Problem: General deconditioning with age
Proposed Preventive Strategy: Exercise programs

There is considerable potential for the maintenance of physical function in old
age by physical exercise programs.  Physical training programs have been shown
to reduce the decline in maximum oxygen consumption that accompanies
aging,84 to increase muscle strength,85 to improve joint mobility,86 and to
improve the sense of balance.87  Imaginative yet acceptable exercise programs
need to be developed and integrated into the social life of the elderly.
Guidelines and precautions for the prescription of these programs have been
described.88  An unanswered question is whether the elderly population,
particularly those that are frail, will have the motivation to carry out such
exercise, frequently and at a sufficient level of intensity to achieve a
conditioning response.

Clinical Problem: Dementia
Proposed Preventive Measure:  Periodic screening by standard mental status test

The recognition of dementia in the elderly is important primarily to improve the
behavioral and functional problems associated with the disease and to provide
support to the caregivers. The identification of dementia at an early stage may
assume increasing importance as research into new treatment modalities expands.

Clinical Problem: Depression
Proposed Preventive Measure:  Periodic screening by questionnaire

Depression and dysphoria are common in the elderly and are amenable to
antidepressant therapy, environmental manipulation, and other measures. As
with dementia, the greatest hindrance to its management is lack of recognition.
Increased awareness of depression as a treatable entity could be improved by
identifying high risk sub-groups or by the inclusion of a short screening
instrument into the routine clinical evaluation.

Clinical Problem: Breakdown of Family Support
Proposed Preventive hleasure: Evaluate Family Stress

Families in most western societies provide over 80 per cent of all home health
care for the elderly.  In undertaking this caring role they often experience

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significant burden which may result in adverse outcomes including psychological
distress, physical illness, family disruption, increased institutionalization,
increased consumption of community resources and, if no help is provided to
them, abuse of the elderly.  It is therefore in the best interest of everyone to
avoid this breakdown of family support.  A number of strategies could be
established to minimize this burden (though evaluative research on these
strategies is still in its early stages).  Evidence is accumulating from a number
of trials and demonstration projects that providing informal support services
such as homemaker programs are of benefit not only in reducing stress but in
preventing institutionalization.

Another type of support is respite care for selected groups of caregivers under
stress. For families of the cognitively impaired , a resource is an in-home sitting
service. Day care respite may also be of value particularly for the physically
frail. Traditional in-patient respite care has been widely used for many years in
the United Kingdom; however, there are still only descriptive studies evaluating
efficacy. This efficacy is still being estimated in terms of ultimate prevention
of long term care rather than improving the morale of the families concerned.

Clinical Problems: Falls

Proposed Preventive Measure:  Anticipatory removal of environmental hazards,
medication monitoring, etc.

Falls in the elderly are associated with significant morbidity, mortality and an
increased rate of institutionalization. 89  Isaacs work from the United Kingdom
shows that it is possible to identify those at high risk of falling based on an
assessment of walking speed, extent of body sway and the extent to which the
person mobilizes. A high correlation has been shown between a simple clinical
score and more sophisticated biomedical measuring techniques in making these
assessments90

Although theoretical frameworks have been devised for the prevention of falls
and check lists exist for the elimination of home hazards, the elderly themselves
may be reluctant to make the necessary life style changes to reduce their chances
of falling.

Clinical Problem: Foot problems
Proposed Preventive Measure: Routine podiatric care

Foot problems (nail abnormalities, calluses, bunions, ulcerations, etc.) are
common among the elderly. It is clear that older people with peripheral vascular
disease and/or diabetes require attentive foot care. In addition, many elderly
are -IFunctionally unable to care for their own feet (vision, dexterity, reach,
cognition). Preventive foot care may be beneficial to many elderly.

Clinical Problem: Hearing Loss
Proposed Preventive Measure: Hearing Screening

Hearing deficits in the elderly are common.  The vast majority of patients are
suffering from presbycusis, wax in the external auditory canal, or both.  The
first part of any screen for hearing deficit should consist of the clinician's exam
and the assessment of pure tone hearing.  Screening otoscopes can reliably
identify patients for further evaluation.  Improvements and modifications in
design and construction of hearing aids have enabled a greater proportion of the
hearing impaired elderly to benefit from amplification.

Clinical Problem: Poverty and Inadequate Housing

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Proposed Preventive Measure: Income and housing programs

Many elderly are poor. Health maintenance strategies must allow for this by
providing adequate income, not just because of the correlation between poverty,
poor health, and limitation of activities, but to enable the elderly to cope with
major problems within the health reimbursement structure.  The latter include
increasing out-of-pocket expenses for medical care, the lack of funding for
hearing aids, glasses, walking aids, dental care, and so forth, and the need to
spend-down almost to poverty level before receiving any supplementation for
long-term nursing home care.  Standard housing has an indirect effect on the
health of many elderly and results in isolation, accidents in the home, and
hypothermia.

Clinical Problem: Immobility

Proposed Preventive Measure: Rehabilitation

Although exercise programs may be considered a primary preventive strategy,
rehabilitation and functionally oriented care are the main tertiary preventive
strategies aimed at minimizing disability.  Rehabilitation tends to be considered
a specialist topic conducted by therapists and physiatrists often in specialized
units remote from the mainstream of medical practice. It is also strongly biased
toward the admission of younger age groups and has a work-oriented goal. The
term functionallv oriented care is therefore used in the context of the elderly,
and it is the duty of nurses and physicians to conduct it as well as thera  ists.  In
many cases it is as effective as more specialized rehabilitative programs. B `192

Clinical Problem: Incontinence

Proposed Preventive Measure: Historical Screening

For the elderly without dementia,
incontinence,93lg4            a high cure rate should be expected for
          yet there is considerable shame and reluctance about reporting
this problem. A priority for the prevention of incontinence must therefore be to
educate this older population and their caregivers that incontinence can be
treatable.  A simple clinical algorithm is available for the assessment of the
elderly incontinent woman.  This has been shown to correlate well with
sophisticated urodynamic studies, and the approach may do much to remove the
need for invasive procedures and hence reduce iatrogenic insult.g5

The prevention of incontinence may depend on a wide range of other strategies
such as improving the patient's mobility, improving access to and stability at the
toilet, and, in the case of institutionalized patients, ensuring an adequate nurse-
to-patient ratio to permit an effective toilet-training program.

In established incontinence in demented patients, cure is less likely, but
considerable benefit may result from the correct use of behavioral strategies,
specialized garments, appliances, and indwelling catheters.  Implementing these
measures may benefit by a community-based case-finding and surveillance
program by nursing staff.

Clinical Problem: Insomnia
Proposed Preventive hfeasure: Historical Screen

As many as 30% of elderly persons complain of serious difficulty in falling
asleep or remaining asleep.  Sleep disturbance is particularly common in the
nursing home, with most residents receiving prescriptions for sedative-hypnotics.
Insomnia is commonly associated with concomitant medical problems, and
careful evaluation is required.  Nonpharmacologic treatment of insomnia can
benefit many elderly.

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Clinical Problem: Loss

Proposed Preventive hleasure: Anticipatory Counseling

Death of a spouse or loved one carries a significant risk of morbidity and
mortality for the bereaved. Several studies now show the benefit of bereavement
counseling for the elderly,96T97 and this may be considered a useful health
maintenance measure. Similar support may be required for the caregivers of the
demented elderly during the latter part of their illness.

Retirement has been estimated as the tenth most stressful event occurring over
the life cycle. However, studies suggest that less than one third of persons have
difficulties adjusting to it.  The case for the benefit of preretirement counseling
is unproved although satisfied retirees start thinking and planning for
retirement at an earlier age. 98

Clinical Problem: Nocturia
Proposed Preventive Measure: Historical Screen

Nocturia, may be precipitated by diuretics or the return of edema fluid from the
limbs at night but many elderly have an uninhibited neuropathic bladder as the
underlying pathophysiologic cause.  This may be helped by the use of an
anticholinergic agent such as flavoxate hydrochloride at night.

Clinical Problem: Relocation Stress
Proposed Preventive hleasure: Anticipatory Counseling

There is now a sizable literature on the mortality and morbidity associated with
relocation stress. Factors that seem to reduce these negative effects are the
opportunity for choice, personal preparation for the move, and a perception of
control in the decision-making process.
effect these goals.99             Simple measures have been outlined to
            When an elderly person relocates to another person's house,
social stresses can possibly be prevented by giving advice on such matters as
privacy, daily routine, financial responsibilities, and the sharing of household
tasks.

Clinical Problem: Poor Vision
Proposed Preventive hleasure: Vision Screening

About a fifth of those over 65 years of age have poor vision. This may severely
restrict daily activities, result in social isolation, produce depression, and
aggravate paranoid and delusional states.  A simple test of vision carried out by
rela?ively untrained personnel emphasizing near rather than distance vision (for
example by the use of print charts) would uncover many problems that could
then be referred to physicians for ophthalmoscopic examination.  There is
insufficient evidence at present to support routine screening for open angle
glaucoma by tonometry.t7

Apart from specific treatment such as cataract extraction or laser
photocoagufation for senile macular degeneration or diabetic retinopathy, simple
methods such as the provision of glasses or low vision aids can be of value.
Much of the visual difficulty experienced by the elderly at home can also be
relieved by improved illumination.  One study found that the provision of a 60
watt bulb in a small lamp improved lvoidual acuity in 82 per cent of the elderly
subjects attending a low vision clinic.

IATKOGENXC

n-14


Clinical Problem: Iatrogenic Insult

Proposed Preventive Measure: Multiple Strategies

The prevention of iatrogenic insult is a priority in the health care of the elderly.
Iatrogenic insult occurs throughout the complete range of medical management.
Considerable benefit would arise by altering clinical behavior to prescribe drugs
not only more skillfully but to prescribe them less, by the adoption of a stronger
case-management principle throughout the numerous consults in the acute-care
hospital, by adopting the principle of minimal interference in the medical work-
up, and by the introduction of multidisciplinary geriatric assessment.

Portions of this paper were adapted from: Kennie DC, Warshaw GA. Health
maintenance and health screening in the elderly. In: Clinical Aspects of Aging,
3rd edition. Ed: Reichel W. Baltimore: Williams and Wilkins, In Press.

t1-15


TRADITIONAL      RISK FACTORS    CASE FINDING     IATROGENIC
PREVENTION      OR BEHAVIORS

BACTERIURIA      DIET            ADL            DIAGNOSTIC
CANCER        (CHOLESTEROL)   ALCOHOLISM       TESTS
BLADDER        EXERCISE        CONSTIPATION    DRUGS
BREAST          OBESITY         DECONDITIONING   INTERACTIONS
CERVICAL        SEAT BELTS      DECUBITI         SIDE EFFECTS
COLO-RECTAL     SMOKING        DEMENTIA        INSTITUTIONS
ENDOMETRIAL    STRESS/LOSS     DENTITION        HOSPITALS
LUNG                          DEPRESSION       NOSOCOMIAL
ORAL                        FAMILY SUPPORT    INFECTION
OVARIAN                       FALLS            NURSING HOMES
PROSTATE                      FOOT CARE
SKIN                          HEARING
DIABETES                    HOUSING/INCOME
FRACTURES/                     IMMOBILITY
OSTEOPOROSIS                   INCONTINENCE
GLAUCOMA                      INSOMNIA
HEART DISEASE                    LOSS
HYPERTENSION                   NOCTURIA
HYPO/                          RELOCATION STRESS
HYPERTHERMIA                 SLEEP PROBLEMS
INFLUENZA                     VISION
MACULAR
DENGERATION
PNEUMONIA
STROKE
TETANUS
THYROID DISEASE
TUBERCULOSIS

TABLE I: POTENTIALLY PREVENTABLE GERIATRIC CLINICAL PROBLEMS

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