Clinical Geriatrics

Aging is not preventable, but frailty and some diseases that affect older adults are. Preventing, detecting, and managing certain diseases that affect the elderly and are reversible or treatable will greatly influence an older patient’s independence, quality of life, and longevity.¹ Preventive strategies should be adapted to the overall health status of each individual patient. Approximately 60% to 75% of older adults are healthy (ie, have no or minimal chronic disease and are functionally independent), approximately 20% to 35% are chronically ill (ie, still independent or minimally dependent in activities of daily living but have multiple chronic disorders and take prescription drugs), and approximately 2% to 10% are frail (ie, have multiple severe chronic disorders and are functionally dependent).² Healthcare providers should also consider whether the patient is robust, frail, moderately demented, or at the end of life when evaluating older adults for health screening and other preventive measures.³ In general, formulating strategies for disease prevention can be challenging, as recommendations continually change as additional research data become available. In addition, older adults are often excluded from randomized controlled trials on screening recommendations, adding to the challenge.

The three levels of preventive strategies to minimize functional limitations and increase the number of healthy years lived are primary prevention, secondary prevention, and tertiary prevention.³

Primary Prevention 

The goal of primary prevention is to prevent the condition from occurring, with immunization and health education being the more commonly employed approaches. Healthy or robust older adults are most likely to benefit from these interventions. Promoting healthy behavior and immunizations cannot be stressed enough for older adults. Most studies show that they make a significant difference in terms of preventing or improving an individual’s illness, as well as improving or maintaining his or her function.⁴ Counseling patients to switch to a healthier lifestyle is always appropriate, unless they are at the end of life.

The following are some of the recommended primary preventive strategies:

1. Smoking cessation: Regardless of how long the individual has been a smoker, quitting smoking has numerous benefits to various organ systems, which cannot be overemphasized.⁵

2. Physical activities and exercise: Randomized controlled studies have shown that physical activities and exercise improve function and several chronic conditions among older adults, such as coronary artery disease, diabetes mellitus, osteoporosis, and gait disorders.⁴

3. Nutrition: A diet high in fiber and low in animal fat traditionally has been considered optimal in preventing various diseases, particularly those that affect the cardiovascular and gastrointestinal systems. The so-called “Mediterranean diet” has been the focus of some studies that purport certain benefits to the older population, chiefly cardiovascular benefits.⁶ The Mediterranean diet consists of eating primarily plant-based foods, consuming healthy fats such as olive oil rather than butter, limiting salt intake and using herbs to flavor food, limiting consumption of red meat, eating plenty of fish and poultry, and exercising.⁷

4. Chemoprophylaxis: Aspirin has been shown to decrease the risk of cardiovascular diseases⁸  and colon cancer.⁹ Vitamin D has long been used to prevent osteoporosis and has recently been suggested to play a role in the treatment of dementia.¹⁰

5. Accident prevention: Several randomized studies on falls prevention have shown that modalities such as environmental modification and specific exercises (eg, Tai Chi) prevent or minimize injuries and accidents, the latter of which is the ninth leading cause of death in the elderly population.¹¹

6. Immunization: There is an age-related decline in immune response in older adults, leading to increased susceptibility to infection and reduced response to vaccination. Presently, there are four vaccinations recommended for older adults: influenza; pneumococcal; varicella zoster; and tetanus, diphtheria, and pertussis (Table 1 [click thumbnail for full view]).^12-16 Routine annual influenza vaccination is recommended for all older adults. The 2011-2012 vaccine is similar to the 2010-2011 vaccine and includes A/H1N1-like, A/H3N2-like, and B/Brisbane/60 2008-like antigens.¹² The 23-valent pneumococcal vaccine prevents invasive pneumococcal disease, but has no clear effect on pneumococcal pneumonia.¹⁷ Revaccination after 5 years may help those who are chronically ill or frail. In 2008, the Advisory Committee on Immunization Practices (ACIP) recommended the routine zoster vaccination of all persons aged ≥60 years.¹⁵ Individuals who report previous herpes zoster eruption and patients with chronic medical conditions can be vaccinated. It should not be given to persons with primary or acquired immunodeficiency. There is no recommended booster administration at this time. For 2011, the ACIP recommends administering the Tdap (combined tetanus, diphtheria, and pertussis) vaccine to adults ≥65 years of age, especially those who have close contact with infants <12 months of age.¹⁴ The Tdap vaccination can be administered immediately, regardless of the interval since the last tetanus and diphtheria (Td) vaccination, if the adult has not previously been vaccinated with Tdap, if his or her status is unknown, or in lieu of one of the 10-year tetanus boosters.