Health Maintenance


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