Monday, February 8, 2010

Prevention of Disease in Elderly

Health promotion and disease prevention targeted at older persons must be aimed to lengthen life and focus on improving or maintaining the quality of a person’s remaining life. Primary and Secondary prevention are the focus of this chapter. Primary prevention consists of efforts to prevent disease (eg, counseling, immunizations, and chemoprophylaxis). Secondary preventions is identification of a disease or disorder in the asymptomatic persons over diagnosis in symptomatic persons cannot be overemphasized.
An important concept is that of active life expectancy (ALE), the problem period of life free of disability with independence in activities of daily living. Functional status and independence play important roles in defining both health and quality of life. Furthermore, functional status encompassing activities of daily living or instrumental activities of daily living is a powerful predictor of mortality and other health outcomes. It is the responsibility of the clinician to incorporate his or her knowledge of a patient’s comorbid illnesses, functional status, active life expectancy, and preferences into the decisions about which preventive health measures to offer a given patient. The choice of preventive health interventions is important, but how one conducts prevention is probably more important to effective prevention programs.

PRIMARY PREVENTION

Counseling

Tobacco
The hazards of smoking in the elderly are no different from that in the young and the rates of total mortality among current smokers aged 65 and older are up to 10 times what they are for persons who have never smoked. Even minimal counseling by health care providers has been shown to help the patient stop smoking, and the health benefits clearly extend to quitting in old age.

Exercise
Physical activity not only reduces coronary heart disease risk, but also can improve musculoskeletal conditions, bone density, and risk of falls and fracture, and it enhances a sense of well-being for older persons.

Diet
A majority of the elders consume diets that fail to meet the minimum recommended daily allowances (RDA). Preliminary data suggest that daily supplementation with a multivitamin may improve immune function and result in fewer infection-related sick days for older persons. Especially among bed ridden elderly and women, vitamin D insufficiency has been detected and may contribute to reduced calcium absorption. Nonetheless, low-fat, high- fiber diet is a reasonable recommendation for older persons.

Alcohol
Psychological counseling of older patients about their alcohol intake can result in changes in drinking behavior. Furthermore, elders are felt to be at particularly high risk for alcohol abuse because of physiologic changes in alcohol distribution and metabolism, the concurrent use of variety of medications, the presence of comorbid illness, and an increased risk of falls and accidents. Thus, it seems reasonable to inquire about a patient’s alcohol intake and intervene when a concern is identified.

Medications
Three-quarters of elders regularly use prescription medications and nonprescription medication; 15% take five or more prescription medications daily. The potential for adverse drug reactions and drug interactions clearly increases with the number of drugs taken and probably increases with age, and thus counseling to avoid unnecessary medications may be beneficial.

SECONDARY PREVENTION

Coronary Heart Disease
All patients with known coronary heart disease and at high risk for coronary heart disease should be screened for dyslipidemia. Intervention with these groups using cholesterol-lowering agents is widely recognized as efficacious. Although the hypothetical effect of cholesterol reduction on coronary heart disease end points in asymptomatic persons aged 65 and older is substantial, there is no direct evidence from clinical trials to support mortality benefit. In the absence of such data, physicians must use their judgment, making individualized recommendations that should incorporate a patient’s preference, functional status, comorbid illness, and active life expectancy.

Stroke
Cerebrovascular disease is the third leading cause of death for older persons. Carotid endarterectomy (CEA) offers documented benefit to patients with significant (at least 70%) symptomatic stenosis of the carotid artery. Hypertension is a major risk factor for stroke, and screening older persons for hypertension (isolated systolic or diastolic) is recommended. The treatment of atrial fibrillation with warfarin has been conclusively shown to decrease risk of stroke and thus screening for atrial fibrillation on physical examination is a must in all elderly patients.

Cancer

Cervical Cancer
Approximately 16,000 new cases of invasive cervical cancer are diagnosed each year, and about 5,000 women die of this disease annually. Thus, screening for cervical cancer with Pap smears can be safely continued in women till age of 65 only in the absence of recent risk factors and previous cervical disease if the woman has had a minimum of three recent adequate (endocervical cells present) normal cervical smears.

Breast Cancer
The incidence of breast cancer rises with age and does not level off until age 85. Annual clinical breast examination in conjunction with mammography every 1 to 2 years has been unequivocally shown to be beneficial for women aged 50 to 69. For women aged 70 to 74 the data are limited and conflicting, and there are no data for women aged 75 and older. Again, the clinician should use the patient’s preference and knowledge of the patient’s comorbid illness, functional status, and active life expectancy to make an individualized recommendation.


Colon Cancer
Colorectal cancer increases in incidence throughout old age. The efficacy of fecal occult blood testing (FOBT) as a screen for colon cancer has been well proved in various trials. It is reasonable to recommend screening with FOBT and/or sigmoidoscopy for all elderly patients.

Other Screening Maneuvers

Hearing
Hearing problems are one of the most prevalent conditions. The high prevalence of hearing problems in older populations indicate that a recommendation for routine screening by a specialist using an audiometer is recommended.

Visual Acuity
The incidences of glaucoma, cataracts, and visual problems increase with age. Given that refractive problems are so common in older populations and the prevalence of these conditions increases with age, it is recommended that regular screening be conducted by an specialist for persons aged 65 and older.

Functional Assessment
There are no controlled trials on the use of functional assessment as a screen for older populations. It has been recommended that functional assessment of physical function (activities of daily living, instrumental activities of daily living, and mobility) and cognitive is worthwhile. Many persons with cognitive deficits have irreversible dementias, but even in these cases, the primary care physician can substantially influence the quality of a patient’s life by early identification. Thus, ideally a family physician should routinely enquire regarding the prevalent functional status of his elderly patients.

Arthritis
Osteoarthritis and rheumatoid arthritis, which affect about half of persons> 65 years, lead to impaired mobility and increase the risk of developing osteoporosis and pressure sores. Hence, special care along with physiotherapy must be routinely advised for the same.

Vascular Disease
Elderly 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 management of risk factors (e.g., hypertension, smoking, diabetes, atrial fibrillation, hyperlifidemia).

PREVENTION OF FRAILITY
This refers to a loss of physiologic reserve that makes a person susceptible to disability from minor stresses. Common features include weakness, weight loss, muscle wasting, exercise intolerance, frequent falls, immobility, incontinence, and instability of chronic diseases.
Exercise and a healthy diet are recommended for preventing or reducing frailty. Older adults who engage in regular exercise (e.g., walking) exhibit up to a 50% reduction in morbidity and have less functional decline compared to those who are sedentary. A healthy diet may reduce the risk of many disorders that contribute to frailty, including certain cancers (breast and colon), osteoporosis, obesity, and malnutrition.

PREVENTION OF ACCIDENTS
The elderly are vulnerable to injury from falls. A falls prevention program should be implemented for persons who are at high risk of a fall or who have already fallen. Routine referrals to orthopedicians for evalvation of bone status are recommended. A family physician should evalvate for various problems like visual impairment, walking disabilities and imbalance at every visit so that they can be adequately tackled and treated, thus preventing falls.

MULTIPLE DRUGS (POLYPHARMACY) AND USE OF INAPPROPRIATE DRUGS
Taking several drugs concurrently and having several chronic diseases markedly increase the risk of drug-drug or drug-disease adverse interactions. The risk of such interactions is high among patients who are malnourished or who have renal failure. Additionally, certain drugs pose especially high risk of adverse reactions in the elderly. Family physician must take care of the same.

PREVENTION OF PSYCHOSOCIAL PROBLEMS

Depression screening is recommended because depression is common among the elderly. Screening is relatively easy using several readily available depression scales and indices. For at-risk individuals, social worker assistance to increase social contacts may prevent morbidity and postpone death. For those who are depressed, appropriate intervention with counseling or drugs is warranted. Remaining productive, engaging in leisure activities, and feeling needed by someone enhance self-worth. Obtaining a pet, contributing to household chores, or performing volunteer work or other activities that confirm a sense of social connectedness may help prevent psychosocial problems (and physical disability). The choice of preventive measures is guided by the general condition of patients. Caregivers should be watchful for even subtle functional changes in elderly patients and promptly report them to health care practitioners. If a patient has multiple unmet needs, especially when coupled with functional decline, a general practitioner should consider seeking the care of a geriatric interdisciplinary team.

Source: Care of the Elderly in General Practice: A Guide to Geriatric Care

By: AP Jain, Amit D Bhatt

Preview: Dr,AB Dey

5 comments:

marshall said...
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marshall said...

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Jorge Fernando said...
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Radhika Ganesh said...

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Chronic Diseases Prevention

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