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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