Health Maintenance

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  • 1. Health Promotion and Disease Prevention in Geriatrics Jorge G. Ruiz, MD, FACP Assistant Professor of Clinical Medicine Division of Gerontology and Geriatric Medicine
  • 2. Background
    • Increase in the life expectancy after 65.
      • Women: 20+ years
      • Men: 17+ years
    • Strategies for health promotion and disease prevention must consider:
      • age
      • pathologic processes
      • life expectancy
    • Approach must be invidualized
  • 3. Background
    • Many older persons are motivated
    • 65-75: most elders are enthusiastic
    • Media reports are influential
    • There is no consensus about health promotion and disease prevention strategies
    • Little evidence based medicine
    • Conflicting recommendations from diverse organizations
  • 4. Background
    • Ageist attitudes (physicians and patients)
    • Clinicians are reluctant to recommend tests with potential side effects
    • Evidences supports the benefits of health promotion and disease prevention for:
      • Cerebrovascular disease
      • Cervical CA
      • Polio, tetanus, rubella
    • Older patients: Scarce evidence (targeting)
  • 5. Background
    • Primary Prevention: preventing illness before it develops in persons who have no symptoms and who have no evidence of the disease
      • Identify risk factors and institute interventions
  • 6. Background
    • Secondary Prevention: Those interventions used to detect diseases in early and symptomatic stages and prevent them from becoming symptomatic.
      • Screening may be useful if the condition being screened for has a high mortality or morbidity, occurs commonly, can be detected easily and can be effectively treated.
  • 7. Health Maintenance
    • Primary Prevention
      • Immunizations
      • Behaviors
      • Injury Prevention
      • Chemoprophylaxis
    • Secondary Prevention
      • Hypertension
      • Cancer
      • Osteoporosis
      • Other conditions
  • 8. Immunizations
  • 9. Immunizations
    • Influenza
    • Pneumococcal vaccine
    • Tetanus
  • 10. Influenza
    • Epidemic or endemic infectious outbreaks occur annually in the US
    • Virus strains change annually because of antigenic drifts and shifts
    • CDC conducts surveillance and develops vaccine
    • 20,000 deaths occur during epidemics (most among elderly)
  • 11. Influenza
    • Elderly at greater risk:
      • COPD
      • Diabetes mellitus
      • Chronic renal failure
      • Long term care facilities
    • It causes respiratory and systemic symptoms (debilitating)
    • Common complication: pneumonia
  • 12. Influenza
    • Vaccine usually administered in October or November (antibodies in 2-3 weeks)
    • Titers decline over 2-3 months
    • Influenza: December, January, February
    • Contraindications: allergy to egg protein
    • Side effects: minor muscle aches or redness
    • Vaccine contain no live virus
  • 13. Pneumococcal Vaccine
    • Pneumonia is 4 times more common and more likely to cause death in the elderly
    • Pneumococcus (Strep Pneumoniae) is the number 1 cause of pneumonia
    • Less likely to have classic signs and symptoms of pneumonia
    • 23-valent vaccine covers most strains in the US
  • 14. Pneumococcal Vaccine
    • It provides protection for up to 8 years
    • It only needs to be given once or twice
    • In inmunocompromised persons: every 6 years.
    • Minimal side effects
  • 15. Tetanus
    • Uncommon in the US (most vaccinated)
    • Immunity wanes 10 years after vaccination or booster injection
    • Incidence and mortality are higher in the elderly
    • Booster every 10 years
    • Primary series of tetanus immunization
  • 16. Behaviors
  • 17. Behaviors
    • Cigarette smoking
    • Alcohol Use
    • Physical Activity
    • Diet
  • 18. Cigarette smoking
    • Major risk factor for morbidity and mortality in the elderly
    • Risk factor
      • Cardiovascular disease
      • Cerebrovascular disease
      • Cancer (lung, oropharyngeal, esophagus, stomach, pancreas and bladder)
      • COPD
      • Peripheral Vascular Disease
      • Renal Disease
  • 19. Cigarette smoking
    • Directly related to the amount and the type of tobacco smoked (elderly!)
    • Elderly: Stopping smoking is still beneficial
    • Older persons often unwilling to stop
    • Sentinel events related to smoking
    • Recidivism is common (many attempts)
    • Physicians should advise elderly
  • 20. Cigarette smoking
    • Strategies
      • Cessation date
      • Frequent contacts thereafter
      • Involve family and friends for support
      • Support groups
      • Nicotine patches and gum may be useful (potential cardiac side effects)
      • Bupropion even better
  • 21. Alcohol Use
    • Prevalence is unknown
    • May be common: loneliness, boredom and loss
    • Alcohol excess
      • Falls
      • Car crashes
      • Changes in mental status (dementia, behavior)
      • Peptic ulcer
      • Malnutrition
    • Ask older persons (CAGE, MAST)
  • 22. Physical Activity
    • Most elderly: sedentary/minimal activity
    • Sedentary lifestyle
      • Greater risk of all cause mortality
      • Cardiovascular disease
      • Obesity
      • Insulin resistance
      • Diabetes mellitus
      • Osteoporosis
      • Hip fracture and functional decline
  • 23. Physical Activity
    • Regular physical activity: Many benefits
    • Even very elderly
    • Elderly persons are reluctant to exercise
    • 3 times per week: 30-40 minutes
      • Warming up and stretching (5-10 min)
      • Aerobic or resistance exercise (20-30 min)
      • Cool down: walking, stretching (10 min)
      • Goal: 70% of age specific max HR (220-age) for 45 min 3-4 times/week
  • 24. Physical Activity
    • Few contraindications
      • Cardiovascular disease that causes symptoms during normal activity
    • Orthopedic problems: strains, sprains and muscle aches
  • 25. Diet
    • Many older Americans are overweight
    • >80: prevalence of protein-caloric malnutrition increases
    • Obesity is a major risk factor
      • Cardiovascular disease, cerebrovascular disease and diabetes mellitus
    • Malnutrition is a major risk factor
      • Death, infection and osteoporosis
  • 26. Diet
    • Elderly are less likely to follow strict dietary guidelines
    • Maintain their body weight within 10% of their age- adjusted normal weight
    • Reduce fat intake and eat lean and white meat and fish
    • Hyperlipidemia: benefits of controlling it among > 75 is inconclusive
  • 27. Diet
    • Eat fresh fruits and vegetables
    • Intake of calcium, fiber and vitamin D
    • Be careful with restricted diets
    • Hypocholesterolemia in the elderly: High mortality
  • 28. Injury Prevention
  • 29. Injury Prevention
    • Falls
    • Automobile crashes
    • Fires, Scalds and Burns
    • Firearm incidents
  • 30. Falls
    • 1 in 3 community dwelling elderly fall
    • 5% result in a fracture or soft tissue injury
    • Serious: Hip fracture
    • Most falls occur in the home
    • Multifactorial
    • Identify risk factors: Interventions to modify them
  • 31. Automobile crashes
    • Elderly are involved in more MVAs than any other group except new teenage drivers
    • Despite the fact that on average they drive fewer miles
    • Most crashes: twilight hours and potentially dangerous maneuvers
  • 32. Automobile crashes
    • Factors
      • Age and disease related reductions in vision
      • Slower reaction times
      • Impaired visuospatial perception
      • Use of alcohol
      • Not wearing safety belts
      • Comorbid disease interfering with function (Weakness,sensory loss and Alzheimers)
  • 33. Automobile crashes
    • Older persons are not likely to acknowledge driving problems
    • Family members may bring up the issue
    • Unwilling to relinquish driver’s license
    • Clinicians
      • Should always ask about driving
      • Counsel about wearing safety belts
      • Report trouble drivers (Florida: anonymous)
  • 34. Automobile crashes
    • Independent driver testing (AARP)
    • Occupational Therapy departments
    • Driver education classes
  • 35. Fires, Scalds and Burns
    • Elderly may live in old homes (smoke detectors?)
      • May not hear them (age and disease related hearing loss)
    • Advise elderly and their families about fire prevention
    • Upper temperature setting of many water systems: higher than is safe for elders
    • <130 °F can prevent many scalds and burns
  • 36. Chemoprophylaxis
  • 37. Chemoprophylaxis
    • Aspirin: Data supporting its use for prophylaxis of CAD/CVA is inconclusive
    • Elderly at high risk for those conditions
      • Family history of cardiovascular disease
      • Cigarette smokers
      • Hypertension
      • Diabetes mellitus
      • Previous AMI/angina
      • Hypercholesterolemia
  • 38. Chemoprophylaxis
    • Women: Evidence is inconclusive
    • Aspirin: 81-325 mg PO QD
    • Additional benefits:
      • may reduce incidence of colorectal polyps and colorectal CA
  • 39. Hypertension
  • 40. Hypertension
    • Common (>60 million)
    • Incidence increases with age: Systolic HTN
    • Major risk factors for (Diastolic-Systolic)
      • Coronary disease
      • Stroke
      • Peripheral vascular disease
      • Renal failure
  • 41. Hypertension
    • Randomized, controlled, prospective studies of older patients
      • Treating HTN significantly reduces CVA/CAD
    • >65: Check BP at every office visit at least annually
    • JNC: >3 readings >140/90 must be treated
    • USPSTF: >160/90
  • 42. Cancer
  • 43. Cancer
    • Cervical Cancer
    • Breast Cancer
    • Colorectal Cancer
    • Prostate Cancer
    • Skin Cancer
    • Ovarian Cancer
  • 44. Cervical Cancer
    • Aging:  Incidence and mortality from invasive cancer
      • 50% women have never had a PAP
      • 75% have not undergone regular screening
    • Risk factors: HPV and multiple partners
    • Older women: PAP annually at least twice
    • If results are negative: discontinue testing
  • 45. Breast Cancer
    • >50 years: Incidence  each decade
    • Risk 
      • Family history of breast CA
      • Early menarche or late menopause
      • Nulliparous
      • Breast disease (benign adenoma, previous CA
    • Screening in asymptomatic women: markedly reduced mortality rate
  • 46. Breast Cancer
    • Medicare: provides coverage for biennial MXM
    • Recommended: Annual clinical breast examinations and annual or biennial MXM
    • Discontinue screening > 75 yo?, unless life expectancy > 7 years
  • 47. Colorectal Cancer
    • >50 years: Incidence  each decade
    • Risk  :
      • Family history of colorectal CA
      • H/O adenomatous polyps
      • Familial Polyposis Coli
      • Ulcerative colitis
    • Early detection:  survival rate?
  • 48. Colorectal Cancer
    • Screening reduces mortality
      • FOBT (randomized trials)
        • High false positive rate (90% do not have cancer)
        • Further testing (colonoscopy or barium enema)
      • Periodic Flexible sigmoidoscopy
    • >65: Annual FOBT and flexible sigmoidoscopy every 3-5 years
    • If positive: Colonoscopy (Medicare)
  • 49. Prostate Cancer
    • Second to lung CA as a cause of mortality
    • Most men with prostate CA die from other causes
    • African American men:
      • twice the age-adjusted incidence of white
      • More likely Dx: advanced and more aggressive stage
      • Higher mortality
  • 50. Prostate Cancer
    • Most patients: indolent condition
    • Few patients: aggressive disease
    • Screening men >50:
      • Digital rectal examination
      • PSA
  • 51. Skin Cancer
    • Basal and squamous cell are prevalent
      • Slow growing, rarely metastasize
    • Malignant melanoma: serious
    • Risk factors:
      • Advanced age
      • Substantial cumulative sun exposure
      • Light skin
    • Periodic screening
  • 52. Ovarian Cancer
    • 4 th leading cause of cancer death in women
    • Most common: >60
    • Most women: advanced disease
    • Detection (not for early stage disease):
      • Bimanual pelvic examination
      • Transvaginal Ultrasonography
      • Transabdominal Ultrasonography
    • Screening is not recommended
  • 53. Osteoporosis
  • 54. Osteoporosis
    • 70% of fractures > 45 are related to osteoporosis
    • The earliest and most predominant fractures involve the lower thoracic and lumbar vertebrae
    • After age 65, fractures of the hip and of the arm produce greater morbidity and are associated with pain, disability, and decreased functional ability
    • In the first year following a hip fracture, a patient's expected survival decreases 15% to 20%
  • 55. Osteoporosis
    • Important risk factors for osteoporosis are:
      • female gender
      • low dietary intakes of calcium during adolescence, age, and early menopause
      • Women of Caucasian or Asian ancestry
      • Those whose mothers have had osteoporosis
    • Peak bone mass is achieved in the 3rd decade, after which bone loss begins
    • Women: bone loss is accelerated by menopause, especially premature menopause(oophorectomy)
  • 56. Osteoporosis
    • Others: Low body weight, excessive alcohol intake, and sedentary life style
    • National Osteoporosis Foundation
      • Comprehensive program to prevent osteoporosis in women and men of all ages: adequate calcium and vitamin D intake, weight-bearing exercises, a healthy lifestyle with no smoking and limited alcohol consumption, and medication when appropriate
      • A bone mineral density (BMD) test is the only way to detect bone loss before a fracture occurs
      • A BMD test is indicated when risk factors are present
  • 57. Other conditions
  • 58. Other conditions
    • Dementia: No good screening
      • MMSE low sensitivity for early disease
      • No good treatment options
    • Depression: Only high risk groups
      • History of depression
      • Family history
      • Losses: bereavement, loss of a job, financial problems or illness
  • 59. Other conditions
    • Diabetes Mellitus: 20% > 65
      • ADA: screening every 3 years
      • Intervene: FBS> 125mg/dl
      • Tight glycemic control: elderly?
    • Hearing loss: 60% >80
      • High tone frequency loss
      • Check hearing with office audiometer or screening instrument
  • 60. Other conditions
    • Vision Loss
      • Annual visual acuity test (Snellen)
      • Glaucoma and macular degeneration: ??
    • Asymptomatic Carotid Artery Stenosis
      • Auscultation: Bruit(low sensitivity/specificit)
      • Carotid Doppler: Expensive
    • Abdominal Aortic Aneurysm
      • Screening: NO evidence
  • 61. Conclusions
    • Not enough evidence about the effectiveness of health promotion and disease prevention in the elderly
    • Primary and secondary prevention may still play an important role in many cases
    • Clear evidence for some strategies (immunizations, Chemoprophylaxis, hypertension, cancer screening, etc)
  • 62. Conclusions
    • Aging is extremely variable
    • Identify patient’s goals and preferences
    • Consider patient’s overall functional status and life expectancy
    • It is never to late to implement adequate preventive strategies in elderly person
    • We need more studies