1. Health promotion and disease prevention strategies must be individualized for older adults due to age-related changes, life expectancy, and personal preferences. 2. Immunizations against influenza, pneumonia, and tetanus are effective prevention methods supported by evidence in geriatrics. Regular physical activity and a healthy diet also promote wellness. 3. More research is needed to determine the effectiveness and optimal application of many prevention strategies in older populations due to limited evidence and the heterogeneity of aging. Preventive interventions should consider overall health status and goals of care.

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