KEY POINTS
■ The fundamental standard of preventive health care, to improve health outcomes, remains the same for the elderly. In older patients, however, outcomes are not always measured with decreased mortality and increased longevity but rather by reduced disease-specific morbidity, decreased disability, and improved quality of remaining life.
■ Immunization remains the most effective method of reducing morbidity and mortality from infectious diseases, even at older ages. Maintaining current vaccinations is important throughout life, yet this is frequently overlooked in older patients.
■ Secondary preventive health screening in the elderly aims at early detection of treatable disease. The challenge is to evaluate the risk/benefit of each recommendation in light of the individual patient's overall health status, life expectancy, values, and wishes.
■ Preventive health care in older adults improves function and quality of life and decreases health care costs, important aspects of care for an aging population. Incorporating preventive activities into routine care of older adults should be part of every practice and specialty.
At age 65 years, the average life expectancy is another 18 years, and life expectancy at age 75 years is 10.8 years for men and 12.8 years for women.1 Clinicians should therefore extend preventive health care to patients of all ages, including the elderly and the oldest-old (85 years and older). The likelihood of illness and multiple chronic diseases increases with age, but the incidence and severity of disease in the elderly can be reduced with more attention to preventive health care practices. Clinicians should use every interaction with older patients as an opportunity to incorporate preventive health care measures into the encounter, regardless of setting or specialty.
SPECIAL CONSIDERATIONS FOR OLDER ADULTS
The fundamental standard of preventive health care, to improve health outcomes, remains the same for the elderly. In older patients, however, outcomes are not always measured with decreased mortality and increased longevity but rather by reduced disease-specific morbidity, decreased disability, and improved quality of remaining life. The person's health status and values should be taken into consideration when offering preventive services to an older patient.
Although a greater number of people are remaining healthy and fit to older ages, the potential benefit of many preventive interventions declines as life expectancy decreases. Preventive health care efforts should focus on increasing years of healthy living, not merely extending the quantity of years of life. Interventions that do not contribute to short-term well-being or that pose significant potential risk may not be warranted for persons with severe disability and limited function, such as those with later-stage chronic diseases (ie, dementia, chronic obstructive pulmonary disease, heart failure, and renal failure).
The US Preventive Services Task Force (USPSTF) recognizes the importance of preventive health care measures at all ages and includes specific recommendations for persons older than 65 years.2 Differentiations for age or functional status are not established; therefore, clinicians are on their own to adjust the recommendations accordingly when caring for older patients.
The Agency for Healthcare Research and Quality (AHRQ), in conjunction with USPSTF and AARP, issued guidelines to help people older than 50 years stay healthy.3 The organizations developed checklists—one for men and one for women—and brochures that encourage patients to work with their health care providers and to take a more proactive approach to preventive health care.
The guidelines lead off with five general lifestyle recommendations for people aged 50 to 80 years. These daily steps to good health have been shown to improve overall health and function, as well as prevent a number of common, specific diseases (such as hypertension and diabetes) that are responsible for high rates of morbidity and mortality among older persons.
• Tobacco use Stop smoking. Tips on how to quit are available at www.smokefree.gov.
• Physical activity Participate in 30 minutes of moderate exercise daily.
• Diet Eat a balanced diet that includes fruits, vegetables, whole grains, fat-free or low-fat dairy products, and lean meats.
• Weight Maintain a healthy weight by balancing calories from food and drink with intensity of physical activities.
• Alcohol consumption Drink in moderation. If you drink alcohol, have no more than one drink a day.3
PRIMARY PREVENTIVE CARE: IMMUNIZATION
Immunization remains the most effective method of reducing morbidity and mortality from infectious diseases, even at older ages. Maintaining current vaccinations is important throughout life, yet this is frequently overlooked in older patients. Consequently, vaccination rates among older adults remain low.4
Age-related changes reduce immune responsiveness; therefore, vaccines may demonstrate a lower level of immunity in elderly immune systems compared with the level of immunity in a younger population. This, in turn, contributes to increased susceptibility to infection, potentially making the role of vaccines more important with advancing age. The goal of immunization in older patients is to prevent severe infectious disease and the associated morbidity and mortality. Table 1 provides a recommended immunization schedule for older adults.
Current recommendations advise vaccinating every person older than 65 years against the flu annually, during autumn to early winter (September through December). This is especially important for people in group-living situations, such as nursing homes, where herd immunity reduces the spread of infectious disease. Infl uenza vaccination also reduces hospitalization rates for respiratory conditions by 27% to 39%.5