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Editors: Kane, Robert L.; Ouslander, Joseph G.; Abrass, Itamar B.

Title: Essentials of Clinical Geriatrics, 5th Edition

> Table of Contents > Part II - Differential Diagnosis and Management > Chapter 5 - Prevention

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Chapter 5

Prevention

GENERAL PRINCIPLES

The new and emerging generations of older people are increasingly interested in promoting healthy aging. Prevention should play a central role in that pursuit. It is hard to be against prevention, but there exists a fine line between endorsing prevention and excusing poor care. It would be a grave mistake to look to prevention as the primary answer to solving the problems of chronic care, or as an excuse for not actively addressing the need for systematic reform to meet this challenge. We do not want to end up blaming the victims, by suggesting that their disease is their own fault and hence not society's responsibility.

Ageism may lead people to discount the value of prevention in caring for older persons, but the evidence suggests that many preventive strategies are effective in this age group. To some extent, one's enthusiasm for preventive care for older persons may reflect concern about their future and the value of that future. Enthusiasm for prevention is based on beliefs about the following:

The efficacy of the intervention in preventing disease or dysfunction in the future. This includes an estimate of the likelihood of the patient's following the preventive regimen.
The value of the health gained. In the case of older patients, this includes concerns about the likelihood of other problems reducing the benefit.
The cost of the preventive activity. This includes both the direct cost and the indirect costs, such as anxiety, restricted lifestyle, and false-positive results.

Perhaps the most preventable problem connected with caring for older persons is iatrogenic disease. Here some of the major issues and strategies surrounding more conventional preventive activities are discussed. The major thesis here, as with much covered elsewhere in this volume, is that age alone should not be a predominant factor in choosing an approach to a patient. A number of preventive strategies deserve serious consideration in light of their immediate and future benefits for many elderly patients.

Preventive activities can be divided into three types: primary prevention, where some specific action is taken to render the patient more resistant or the environment less harmful; secondary prevention, or screening and early detection for asymptomatic disease or early disease; and tertiary prevention, or efforts to improve care to avoid later complications. All three areas are relevant to geriatric care. Table 5-1

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offers examples of activities in each category. Not all the items indicated in Table 5-1 are supported by clear research findings. In some cases such as seat belts, exercise, and social support they are based on prudent judgment.

TABLE 5-1 PREVENTIVE STRATEGIES FOR OLDER PERSONS

PRIMARY	SECONDARY	TERTIARY
Immunization Influenza Pneumococcal Tetanus Blood pressure Smoking Exercise Obesity Cholesterol Sodium Social support Environment Seat belts	Papanicolaou (Pap) smear Breast exam Breast self-exam Mammography Fecal blood Hypothyroidism Depression Vision Hearing Oral cavity Tuberculosis	Assessment Foot care Dental care Toileting efforts

In addressing prevention for older persons, it is important to bear in mind the goals pursued. The World Health Organization has provided a useful continuum, which progresses from disease to impairment to disability to handicap. Preventive efforts for older people can be productively targeted at several points along this spectrum. Efforts can seek to prevent disease, but they can also be designed to minimize its consequences, by reducing the progression to disability. This is, in essence, the heart of geriatrics.

Preventive efforts on behalf of elderly patients are special, beyond the emphasis on function. The narrowing of the therapeutic window, discussed in Chap. 4, means that older persons may be susceptible to the side effects of prevention as well as of treatment. Some risk factors that strongly predict the onset of disease in younger persons may not be appropriate for modification in older persons. Perhaps the condition has already become well established and is resistant to change, or the factor may have already exerted its influence at an earlier stage of life.

Clearly, primary prevention is the most desirable. But the nature of the changes required to achieve this end vary substantially. Some require a single

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brief contact (e.g., immunization), but others imply sustained change in behaviors. If a brief encounter can confer some form of long-lasting protection at minimal risk, such a strategy will be actively pursued.

Many risk reduction strategies, however, require major changes in behavior, many of which are pursued because they are pleasurable. Enthusiasm for attempting to change major health behaviors, especially those that that are associated with either pleasure or addiction, is limited. Thoughtful geriatricians struggle with the overall benefit of enforcing a major life style change on someone who has both survived and has a finite life expectancy, with limited opportunities for pleasure. The task is made even harder when strong economic interests advertise the very products physicians seek to discourage.

One approach to risk reduction that fits with the predominant medical model is to transform the risk into a disease and treat it as such. For example, high blood pressure becomes hypertension; high cholesterol becomes hypercholesterolemia; thin bones become osteoporosis. When effective medications become available, as is the case in each of these scenarios, the drug companies now become active allies preaching to both the medical profession and the consumers. From a societal perspective the question becomes one of cost-effectiveness. If the medications are expensive (especially over a lifetime), how much should be spent on this prevention? Many of the calculations suggest that those strategies that involve costly medications are not cost-effective, or that the strategy must be carefully targeted to those at highest risk.

Because the number of activities that are both safe and effective is small, we must rely on the other two preventive strategies, each of which comes at a cost. Screening for one or another condition is useful where the disease process can be detected in advance of the condition's clinical appearance, but this may be excessively costly if the number of treatable cases detected is low. Screening is usually judged on the criteria of sensitivity and specificity. The former refers to the proportion of actual cases correctly identified and the latter to the accuracy of labeling of noncases (normal individuals). Alas, the two factors are usually linked, so that an improvement in one comes at the cost of a decrement in the other. The decision about where to set them relative to each other depends on the expected prevalence of the problem and the consequences of a false-positive and a false-negative finding with respect to a given clinical condition.

Tertiary prevention is a central part of good geriatric care, which strives to minimize the progression of disease to disability. It requires a comprehensive effort to address both the physiologic and environmental factors that can create dependency.

While older persons have been traditionally excluded from preventive trials, that situation is changing. As it does, findings suggest that primary prevention is appropriate for older persons as well, but the problems associated with translating the results of clinical trials into practice are at least as great as with younger persons. Active treatment of hypertension (both systolic and diastolic)

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is associated with reduced cardiovascular complications. Control of systolic blood pressure is associated with preventing heart failure.

Even more broadly, the value of geriatric assessment suggests that important problems in primary care of older persons are being ignored or undertreated. Reports that a yearly visit by a nurse practitioner to unselected persons aged 75 years and older can lead to substantial functional improvement and reduced nursing home admissions raise serious questions about how well the current primary care system is working. The concept of geriatric assessment has given way to a model of geriatric evaluation and management (GEM), which allows for the geriatric team to assume responsibility for the patient's care for a period sufficient to permit stabilization of the patient's condition and, in some instance, therapeutic trials. The problem still remains that when the patient is returned to the care of his or her primary care physician, the benefits of this rehabilitation may be lost unless provision is made to sustain the therapeutic changes. In the absence of this continuity, the investment represented by geriatric assessment may be threatened.

Clinicians' enthusiasm for prevention will be tempered by their ability to be paid for this work. Medicare's coverage of preventive services is modest. Table 5-2 shows the extent of this coverage.

TABLE 5-2 PREVENTIVE SERVICES COVERED BY THE MEDICARE PROGRAM AS OF JANUARY 2002

SERVICE	YEAR FIRST COVERED	GROUPS COVERED	FREQUENCY OF SERVICE	COST-SHARING SERVICE REQUIREMENTS*
IMMUNIZATIONS
Pneumococcal	1981	All beneficiaries	As needed (probably once per lifetime)	None
Hepatitis B	1984	Beneficiaries at intermediate or high risk of contracting hepatitis B	As needed (probably one per lifetime)	Copayment after deductible
Influenza	1993	All beneficiaries	Every year	None
SCREENING SERVICES
Cervical cancer Papanicolaou (Pap) smear	1990	All female beneficiaries	Every 2 years	Copayment with no deductible
Breast cancer mammography	1991	Female beneficiaries age 35 to 39	One baseline	Copayment with no deductible
		Female beneficiaries age 40 and older	Mammogram this period every year
Vaginal cancer pelvic exam	1998	All female beneficiaries	Every 2 years	Copayment with no deductible
Colorectal cancer fecal occult blood test	1998	Beneficiaries age 50 and older	Every year	No copayment or deductible
Colorectal cancer sigmoidoscopy	1998	Beneficiaries age 50 and older	Every 4 years	Copayment after deductible
Colorectal cancer colonoscopy	1998	All beneficiaries	Every 10 years**	Copayment after deductible
Osteoporosis bone mass measurement	1998	Estrogen-deficient female beneficiaries at clinical risk for osteoporosis as well as other qualified individuals	Every 2 years	Copayment after deductible
Prostate cancer prostate-specific antigen test and/or digital rectal examination	2000	Men age 50 and older	Every year	Copayment after deductible
Glaucoma	2002	Beneficiaries medically determined to be at high risk for glaucoma	Every year	Copayment after deductible
* Applicable Medicare cost-sharing requirements generally include a 20 percent copayment after a $100 per year deductible. Each year, beneficiaries are responsible for 100 percent of the payment amount until those payments equal a specified deductible amount, $100 in 2002. Thereafter, beneficiaries are responsible for a copayment that is usually 20 percent of the Medicare approved amount. For certain tests, the copayment may be higher. The costs of the laboratory test portion of these services are not subject to copayment or deductible. The beneficiary is subject to a deductible and/or copayment for physician services only. The exam is covered once every 12 months if the beneficiary has had an abnormality within the prior 3 years or is otherwise determined to be a high-risk candidate for cervical cancer. The doctor can decide to use a barium enema instead of a sigmoidoscopy or colonoscopy for beneficiaries age 50 and older. The frequency of service is the same as the sigmoidoscopy or colonoscopy it substitutes for. The copayment is increased from 20 to 25 percent for services rendered in an ambulatory surgical center. ** Beneficiaries medically determined to be at high risk may receive a colonoscopy every 2 years. The statute defines other qualified individuals as those who have vertebral abnormalities or primary hyperparathyroidism, or who are receiving long-term glucocorticoid steroid or osteoporosis drug therapy. CMS permits coverage of a bone mass measurement at any time sooner than 2 years if the service is medically necessary. Source: GAO Report: GAO-02-422 Medicare Beneficiary Use of Clinical Preventive Services, April 2002.

EFFECTIVENESS OF PREVENTION IN OLDER PEOPLE

In evaluating the efficacy of preventive activities for older persons, we must confront a dilemma. Because older people were systematically excluded from many trials of prevention strategies, there are few hard data on which to base judgments. At the same time, there are strong feelings from both sides about the value of prevention. Active advocates for wellness among elderly people urge strenuous efforts to promote major life changes. They are allied with those who view many of the accoutrements of aging as acquired and hence capable of modification. They cite data showing that muscle strength and endurance can be regained with active training even at advanced ages.

Another group argues that older people have already reached a stage in life where they have demonstrated a capacity to cope. They would accept many of the consequences of aging and note that the demonstrated gains are less strongly associated with major improvements in morbidity and function than with values derived from testing.

The US Preventive Services Task Force attempted to assess available scientific information on the efficacy of preventive efforts for persons at all ages (US Preventive Services Task Force, 1996). Table 5-3 summarizes the major recommendations from the Task Force and other sources for screening activities for those age 65 years and older. Many of these recommendations are based on expert judgment in lieu of hard data. For example, in the case of foot care, although there are no formal studies to confirm the effects, clinical experience

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strongly suggests the benefits of podiatry in improving the ambulation of many elderly patients. Not only diabetics should receive attention to their feet; each elderly person should be carefully asked about foot pain and discomfort and checked for bunions and corns.

TABLE 5-3 SUMMARY OF PREVENTIVE RECOMMENDATIONS FOR OLDER ADULTS

MANEUVER	RECOMMENDATION (SOURCE)
Screening*
Blood pressure	Every exam, at least every 1 2 years (USPSTF, AHA)
Physician breast exam	Annually >40 (ACS, USPSTF)
Mammogram	Annually >40 (ACS) or every 1 2 years, age 50 69 (USPSTF, ACP); Continue every 1 3 years, age 70 85, in willing/appropriate patients (AGS, USPSTF)
Pelvic exam/Papanicoloau (Pap) smear	Every 2 3 years after three negative annual exams; can then or discontinue after age 65 69 (ACS, USPSTF, CTF, AGS)
Cholesterol	Adults every 5 years (NCEP, ACP, USPSTF)
Rectal exam/fecal occult blood test	Annually >50 (ACS, AHCPR, Win)
Sigmoidoscopy	Every 5 years >50 years of age or colonoscopy/BE every 10 years (ACS)
Visual acuity test	Periodically in older adults (various)
Test/inquire for hearing impairment	Periodically in older adults (various)
Mouth, nodes, testes, skin, heart, lung exams	Annually (ACS, AHA)
Glucose	Periodic in high-risk groups (USPSTF); every 3 years (ADA)
Thyroid function	Clinically prudent for elderly, especially women (USPSTF)
Electrocardiogram	Periodically>age 40 50 (AHA)
Glaucoma screening	Periodically by eye specialist > age 65 (USPSTF)
Mental/functional status	As needed; be alert for decline (USPSTF)
Osteoporosis (bone densitometry)	If needed for treatment decision (USPSTF)
Prostate exam/prostate-specific antigen	Annually > age 50 (ACS); NR especially > age 70 (USPSTF, ACP)
Chest x-ray	NR/as needed (USPSTF)
Prophylaxis/counseling
Exercise	Encourage aerobic and resistance exercise as tolerated (AHA)
Tetanus-diphtheria vaccine	1 series then booster every 10 years (ACP, USPSTF)
Influenza vaccine	Annually > age 65 or chronically ill (ACP, USPSTF)
Pneumovax	23-Valent at least once > age 65 years (ACP, USPSTF)
Calcium	800 1500 mg/d (various)
Aspirin	Men > age 50, 80 325 mg/d or on alternate days (various)
Vitamin E, red wine	?
* Screening recommendations apply only to asymptomatic individuals; specific clinical circumstances may necessitate different testing and treatment schedules. Where no upper age limits are listed, screening should continue until approximately age 85 or when the patient is not a treatment candidate because of limited active life expectancy/quality. NR = Not recommended for routine screening in asymptomatic individuals, though may be useful when clinically indicated.
Source: From Goldberg and Chavin, 1997. Reproduced with permission of the author and updated by the author on the Internet (URL: http://www.members.aol.com/TGoldberg/prevrecs.htm ). Based on recommendations from American College of Physicians (ACP), American Cancer Society (ACS), American Geriatrics Society (AGS), American Heart Association (AHA), Canadian Task Force on the Periodic Health Examination (CTF), National Cholesterol Education Program (NCEP), U.S. Preventive Services Task Force (USPSTF), American Diabetes Association (ADA), Winawer SJ, Fletcher RH, Miller L: Colorectal screening clinical guidelines and rationale. Gastroenterology 112: 59 62, 1997 (Win); and the authors' interpretations of the literature.

Appropriate treatment can do a great deal to keep such patients ambulatory and stable. The US Task Force avoided the debate about false-positive results with regard to screening for glaucoma by recommending that the decision be made by an ophthalmologist, but the importance of vision in the overall functioning of the elderly patient argues strongly for attention to this area. In a similar vein, the potential for improving function by replacing cataracts with implanted lenses mandates greater attention to visual problems as well as concern about the excess use of surgery. However, the functional benefit is not realized by cognitively impaired persons. More recent practice has shifted diabetes care attention from the usual concerns about eyes and feet to a greater appreciation about the importance of cardiovascular disease. Because of the vascular effects of diabetes, close attention should be paid to the lipid profiles of diabetics.

Some preventive interventions seem intuitively worthwhile, but occasionally data raise irksome questions. For example, vaccination against influenza is strongly recommended for older persons. Indeed, over the last several years the rate of such immunization has increased dramatically. However, ironically the rate of hospitalizations among older persons for influenza and pneumonia has also gone up during the same period, raising perplexing questions about the value of this widely lauded preventive measure.

Pneumococcal vaccines are now in widespread use, and many consider them to be useful in the care of elderly persons at risk, especially those in institutions, but there remains an active controversy about their cost-effectiveness. Tuberculosis remains a problem among older people, especially those in institutions. Special care must be taken in interpreting a lack of reaction to tuberculin skin tests in elderly persons because of the risk of anergy.

In addition to specific recommendations for preventive actions, a number of areas can be usefully examined as part of routine care. Table 5-4 offers examples of such geriatric health maintenance activities. It is important to recognize that these recommendations, as well as those from the Task Force, are intended to be carried out as part of regular primary care. No special visits for prevention are implied.

TABLE 5-4 GERIATRIC HEALTH MAINTENANCE ITEMS WORTH INCLUDING IN A ROUTINE SCREENING PROGRAM

Historical information
    Tobacco
Physical examination
    Height and weight
    Blood pressure
    Hearing and vision
    Gait and fall assessment
Diagnostic tests
    Mammography
    Papanicolaou smear in underscreened women
    Flexible sigmoidoscopy
Interventions
    Aspirin therapy to prevent coronary artery disease (CAD)
Immunizations
    Influenza
    Tetanus

Source: Modified from Scheitel et al., 1996, with permission.

Particularly in our current system, where Medicare Part B does not pay for many preventive services, it is important to appreciate that much can be done in prevention without special visits for that purpose. Most, if not all, of the procedures can be performed by an appropriately trained nonphysician.

In some cases, care must be taken to avoid penalizing older persons on the basis of stereotypes. For example, the US Preventive Services Task Force was skeptical about the usefulness of breast self-examination in elderly women. Moreover, physicians tend to be less enthusiastic about treating older patients with breast cancer.

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The value of screening depends on the availability of an effective intervention and the likelihood that the intervention will change the clinical course. There is reason to believe that some cancers may perform differently in older persons. Although the incidence (and certainly the prevalence) increases with age, the rate of growth may be slower. Thus there is great controversy around the efficacy of active screening for prostate and breast cancer in older persons. The recent reanalysis of data from clinical trials of mammography illustrates

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just how confusing this literature can be. One analysis suggested that screening with mammography after age 69 leads to a small gain in life expectancy and is modestly cost-effective (Kerlikowske et al., 1999).

At the same time, some areas are well served by increased clinical attention. Greater physician sensitivity to identifying depression in older persons can detect an often remediable condition. Detection of mental problems is greatly enhanced by structured screening data. Awareness of the likelihood of alcoholism can lead to recognizing a problem that can be corrected.

There is more controversy about the desirability of increasing the recognition of cognitive deficiency. Although standardized testing can detect cases that might otherwise be masked in older persons who have skillfully compensated for their loss, it is not immediately clear that there is great benefit in such early uncovering. Given the relatively small proportion of dementia cases that have reversible etiologies, screening for dementia would not seem to pass the first test of screening. However, some geriatricians suggest that the modest benefits of anticholinesterase therapy can gain at least months of function and postpone institutionalization, thus justifying an aggressive approach to screening. Others suggest that increasing the period of time when a person knows they have dementia may be a mixed blessing at best.

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Routine screening for geriatric populations tends to uncover problems that are already known. Among a group of elderly persons coming for a health screening, 95 percent had at least one positive finding. Approximately 55 percent were referred to a physician for further evaluation and 15 percent were treated for the finding. Routine annual laboratory testing of nursing home residents has received mixed reviews. A modest panel including a complete blood count, electrolytes, renal and thyroid function tests, and a urinalysis may be useful.

Behavior change represents at once the most promising and the most frustrating component of prevention. While some may argue that you can't teach an old dog new tricks or that ingrained habit patterns are hard to break, there is no evidence to support such pessimism. Quite to the contrary, anecdotal data about elderly people taking up exercise programs and changing their dietary habits provide reason for more optimism. The critical issue here is the degree to which such changes will sufficiently modify risk factors to justify the disturbance.

In general, moderation seems safest. For example, data from the Alameda County study suggest that not smoking, modest physical activity, moderate weight, and regular meals are associated with lower mortality risks among older populations. As shown in Fig. 5-1, older persons' health habits are generally as good as or better than those of younger people. Although our data are scant, the degree of enthusiasm for active modification will likely vary with the topic addressed.

FIGURE 5-1 Personal health habits of people at different ages.(From U.S. Senate, 1991.)

The best preventive strategies for older persons are those associated with the least risk. The findings from the Treatment on Nonpharmacological Interventions in the Elderly (TONE) study, suggesting that weight loss and sodium restriction could effectively lower blood pressure in older persons, is a good example of such

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an approach. Reducing dietary salt intake was shown to lower blood pressure in another study as well. Along the same lines, antioxidant vitamins have been suggested by epidemiological evidence as a means of reducing cardiovascular disease. Several studies have shown protective benefits from using vitamin E to prevent Alzheimer's disease, although the definitive data for either has not yet been seen. A recent review suggests that taking broad vitamin supplements is probably a good idea for most older people (Fletcher and Fairfield, 2002). Hormone replacement therapy (HRT) in women was widely hailed as having multiple benefits including delaying osteoporosis, lowered cholesterol, and prevention of Alzheimer's disease. However, more recent findings suggest that many of these benefits were exaggerated, and that HRT (at least a combination of estrogen and progesterone, the treatment recommended to avoid risks of uterine cancer) may actually increase risks of heart disease, Alzheimer's disease, and stroke, as well as of cancer. The discontinuance of a major trial because of modest but significant risks in several areas makes it unlikely that HRT will play a major role in any preventive program. Its role in treating postmenopausal symptoms is still under evaluation, and will likely become a decision based on risk aversion.

OSTEOPOROSIS

A good example of the conflicted nature of prevention in older persons is the case of osteoporosis. Effective treatments are now available to delay the onset or halt the progression of this disease, which can lead to fractures and disability. Understanding the management of osteoporosis requires thinking systematically about the clinical goals. In this regard, the intellectual exercise is similar to that around hypertension. The real consideration is not necessarily attacking the primary disease but its ultimate effects. In the case of osteoporosis, the adverse outcomes are fractures of various types. However, once attention shifts to the actual outcomes of importance new strategies emerge. For example, if the goal is to prevent hip fractures, wearing hip protectors may be as effective, perhaps more so, than improving bone density, because hip fracture is the combined effect of falling and osteoporosis. Indeed, several studies point to the preventive value of wearing hip protectors, although it is not easy to convince older patients, especially those with cognitive impairment, to wear such devices.

The last decade has seen the emergence of a new class of drugs to treat osteoporosis effectively and with modest side effects, but these drugs are expensive, especially over a lifetime. The first line of defense against this disease is a regimen of calcium, vitamin D, and weight-bearing exercise; but this inexpensive and safe approach may be insufficient or hard to sustain. In these instances, drugs may be indicated (although the use of the big three should be continued).

The prime targets for osteoporosis screening are postmenopausal women, but the disease can also affect men. Screening is done by bone mineral density testing.

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The World Health Organization standard for osteoporosis is a value of 2.5 standard deviations (SD) (often referred to as a T score) or more below the young adult mean value, but the National Osteoporosis Foundation recommends treating when T scores are 2 SD below the young adult mean value.

HRT is effective in delaying the course of osteoporosis, but the effects last only as long as the treatment. Given the new evidence of multiple disease risks associated with HRT, this option has effectively been removed from the osteoporosis treatment repertoire.

The class of bisphosphonates shows great promise in increasing bone mass and reducing fracture rates. The major side effects are gastrointestinal and the drugs must be taken on an empty stomach in an upright position. New weekly dosing regimens promise to reduce the side effects and the cost. The ultimate duration of this therapy is still not established. There is some evidence of a sustained effect for up to a year. A number of bisphosphonate products are emerging each year into this lucrative market, each with claims of improved benefits. In addition, other approaches are being actively explored. Nasally administered calcitonin has been tested, but sufficient advantages over bisphosphonates to justify the cost have not yet been established. An intriguing finding has been that the statins, used to treat high cholesterol, have appeared to show a positive effect on bone mass density. This therapeutic effect has not yet been tested in randomized trials. Table 5-5 compares the effectiveness of the available bisphosphonates and other potential treatments. Both bisphosphonates seem to prevent fractures by increasing bone density. Although parathyroid hormone is the most potent approach, it is not widely used because of the cost and administration problems, as well as potential side effects.

TABLE 5-5 RELATIVE EFFECTIVENESS OF VARIOUS OSTEOPOROSIS TREATMENTS

	MEAN % CHANGE IN BONE MASS DENSITY AT 12 18 MONTHS		RATE OF FRACTURES
	LUMBAR SPINE	FEMORAL NECK	VERTEBRAL	NONSPINE	HIP
Alendronate (10 mg)*	+5	+3
Risedronate (5 mg)*	+3	+2
Raloxifene (60 mg)	+3	+2
Calcitonin (200 IU)*	+1
Parathyroid hormone (20 mg)	+9	+4
Hormone replacement therapy	+4	+1		(Ind)	(Ind)
* FDA-approved agent for treating postmenopausal osteoporosis. No longer considered a realistic option. Difference between drug and placebo.
Direct evidence from randomized trials.
(Ind)Indirect evidence from observational studies.
Source: Information provided by Kristine Ensrud, MD, MPH.

GENERIC APPROACHES

An effort to develop a more comprehensive approach to health promotion in a group of older people met with less success. The first lesson to come out of the project was that older persons have their own agenda about what is important to them and what they believe will benefit them. Even after they reached a compromise agenda that included elements both subjects and health professionals felt were valuable, the changes in functioning were not greater than those for the control group.

One area that has received considerable attention, and perhaps created confusion in the minds of both older persons and their clinicians, is exercise. Overall, there is widespread belief that exercise will benefit the individual. However, exercise is not a unidimensional activity. There are various types, and each is directed at a specific target. Table 5-6 summarizes the major types of exercise and the intended benefits of each type. Different approaches to exercise should be pursued to achieve specific goals. Although its role in osteoporosis prevention

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remains controversial, exercise is generally recommended as a safe approach, with more possible benefits than risks. Less than a third of older persons report regular exercise, to say nothing of vigorous activity. Although evidence suggests that active aerobic exercise is necessary to reduce risk of cardiovascular accidents, even modest amounts of exercise will improve strength, keep joints more limber, promote a sense of well-being, and improve sleep. Recent work has indicated that even severely compromised nursing home residents can benefit from carefully supervised and graded strength-training exercise. Both the direct benefits (e.g., improved muscle strength and activity tolerance) and indirect effects (e.g., being treated with more esteem) allowed residents to function more autonomously (Fiatarone et al., 1994).

TABLE 5-6 TYPES OF EXERCISE

TYPE	PURPOSE/EXPECTED BENEFIT
Aerobic/anaerobic	Cardiovascular conditioning
Resistance/weights	Strength, tone, muscle mass
Antigravity	Prevent osteoporosis
Balance	Prevent falls
Stretching	Flexibility

Exercise appears to improve both overall well-being and older persons' sense of self-worth. Likewise, occupational therapy has been shown to produce beneficial results for a group of independently living older adults (Clark et al., 1997). Modest efforts at exercise can yield substantial rewards in terms of improved function and reduced use of long-term care.

Epidemiological data suggest that even among persons in their 70 s, cessation of smoking will reduce mortality to levels of nonsmokers in a sufficiently short time to justify actively encouraging quitting. Smoking cessation has rapid benefits for risks of both vascular and lung disease.

There is growing enthusiasm for controlling even modest levels of both diastolic and systolic hypertension among the elderly. The European Working Party on High Blood Pressure in the Elderly showed that treatment was associated with a significant reduction in cardiac mortality, a nonsignificant reduction in cerebrovascular mortality, but no reduction in overall mortality. The results from the Systolic Hypertension in the Elderly Program (SHEP) suggest that lowering isolated systolic hypertension can lead to reduced rates of fatal and nonfatal endpoints for stroke, coronary heart disease, and cardiovascular disease.

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It is important to distinguish carefully between the value of uncovering elevated blood pressure and the need to control it over a sustained period. Most older persons with hypertension are aware of it; the challenge is to maintain them in a safe range without producing significant side effects. Hypertension is very common among the elderly. Black females have the highest rates, and among white males the rate approaches 40 percent.

The effects of dietary changes are less certain. Weight loss for obese persons makes sense in terms of reducing cardiovascular load and in the management of adult-onset diabetes and hypertension, but hard data suggest that the benefit may be oversold, certainly for the former. The efficacy of changing diet, especially to reduce the amount of fat consumed, has not yet been clearly established.

Cholesterol and low-density lipoproteins (LDLs) are risk factors for heart disease for general populations, but have not been specifically tested in the elderly. However, elevated high-density lipoproteins have been shown to provide a protective factor for strokes in older people. More than 30 percent of white females have high-risk cholesterol levels (greater than 268 mg/dL). Cholesterol-lowering therapy works in older persons, as well as in the middle-aged, who were generally included in such trials. Recommendations for using lipid-lowering drugs in older patients with a history of cardiac or vascular disease are countered by other claims that cholesterol is not a significant risk factor in older persons. At the same time, only approximately 50 percent of older persons put on lipid-lowering medications remain on the regimen after 5 years. The preponderance of support now seems to favor more aggressive treatment of elevated LDL cholesterol, even in quite elderly persons (Aronow, 2002). However, many older patients do not remain on the statin therapy regimens long enough to benefit from them (Benner et al., 2002).

In areas such as weight, cholesterol, and blood pressure, the clinician must weigh the benefits of intervention against the costs (risks). There is a compelling argument that overzealous activity in the name of prevention may cost more in quality of life than it gains in quality years. Some have suggested that the survivor effect should be taken more seriously. Persons who survive to old age may have demonstrated a biological ability that deserves more respect. At the very least, any determination to change lifestyle at this stage of life should be made by the patient after suitable counseling. Nonetheless, older persons should not be denied the opportunity to actively consider the benefits of primary prevention. The growing body of evidence about at least the art of the possible imposes on clinicians a responsibility to provide them with such information.

One area of behavior with great theoretical promise but little immediate practical application is social support. There is some evidence to suggest that those older persons with strong social support systems, or at least perceived support, are at less risk for adverse events, but it is not yet clear how to build such a support system for those without one naturally. Social support likely plays at least two distinct roles: (1) Having (or perhaps just believing one has) a strong support system

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may reduce the risk of adverse events (through a yet-to-be-elucidated mechanism that likely involves stress). (2) For persons who are disabled and require assistance, having a real support system may prove the difference between staying in the community and needing to enter an institution. It is difficult to assess the availability of that support system in advance.

The perception, even the promise, of such support does not guarantee that the necessary support will be consistently and conveniently available when it is needed. Even well-intentioned family members may find the task too daunting to be able to maintain it.

PREVENTING DISABILITY

Although discussions of prevention tend to focus on the prevention of disease, the context of geriatrics with its emphasis on functioning urges a broader approach. When caring for older patients, equal attention must be paid to seeking means to keep them as active as possible. While there may be little that can be done to prevent the occurrence of a disease in an elderly person, much can be done to minimize the impact of that disease. Impairments cannot be allowed to become disabilities. Recent work in studying disability has raised new questions about the possible differences between transient and persistent disabled states. Studies that followed older people closely showed that many of them move in and out of transient states of disability. Hence, measures of disability over long periods may contain elements of both permanent and transient disability. This distinction is important because efforts to prevent disability may be falsely positive if they reflect transient conditions that would have improved on their own.

A major component of the efforts to avoid this transition are contained in geriatric assessment programs. The general approaches of such programs are reviewed in Chap. 3. It is important to note that these programs have been very varied in their composition. Table 3-1 in Chap. 3 summarizes the major randomized controlled trials using different approaches to assessment.

Work on demonstrated performance, especially when combined with timed measures is promising. This additional component provides a way to achieve more variability and may lead to better prediction. It offers a means to detect more subtle change.

The overarching goal of geriatric practice is the improvement, or at least the preservation, of patients' function. In general, function can be thought of as being determined by three principal forces: (1) the patient's overall physical health; (2) the environment; and (3) the patient's motivation. Much of the discussion in this book deals with ways to maximize the patient's health status by proper diagnosis and treatment. Such steps are necessary but not sufficient for good geriatric care. It is essential to appreciate that a person's environment can play a critical role in affecting his or her functioning. Just imagine for a minute what it would be like

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to be in a country where you did not speak the language or even understand its symbols. Although your capabilities are intact, you cannot function effectively. By a similar token, even after therapy has achieved its maximal effect, a patient's environment can be crucial.

Environment in this case refers to both the physical and psychological setting. It is fairly easy to imagine the physical barriers to functioning. Narrow doorways, poor lighting, and stairs can all serve as barriers.

Occupational therapists can be especially helpful in assessing the patient's environment to suggest modifications and adaptive equipment. The Appendix contains a simple environmental assessment form useful in uncovering hazards.

The psychological barriers are more subtle, but perhaps more important. They refer to the way patients are treated and, especially, the extent to which they are encouraged to do as much for themselves as they can. We noted earlier that a risk-averse environment can engender excessive dependency; so, too, can the pressure to be productive. As long as time is at a premium, care providers will be motivated to do things for patients, rather than encouraging them to perform those tasks themselves, especially if the latter course takes considerably longer. In the name of efficiency, we may be creating dependency. The efforts to encourage self-sufficiency are precisely what is usually called rehabilitation, even when it occurs in a plain wrapper.

The third element of functional effects is the patient's motivation. Today's older patients place especially high trust in their physicians, whom they view as figures of authority. Thus, one of the most subtle but nonetheless important aspects of this approach to prevention the prevention of inactivity and despair is the physician's attitude. For the patient, a gain in function or an ability to deal with a chronic problem is essential. It is surely no mean feat. Such behavior should be encouraged and rewarded. Indifference may be enough to discourage the patient from trying.

Other programs can be mobilized in the patient's behalf. Self-help groups are available in many communities to offer support with chronic illness, including stress management and drugless pain-control techniques. Social activity can play an essential role in maintaining function. Pets have proved to be very effective in improving morale and maintaining function.

Special efforts may be necessary to deal with members of the patient's family. Their concern over potentially dangerous accidents may lead them to become overprotective and thus exaggerate the condition of dependency.

IATROGENESIS

Probably the most important preventable problems faced by older persons today are those associated with treatment. Many iatrogenic problems result from the care that has been provided. In some cases, these problems can be traced to

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oversights and omissions. In other cases, overzealous care can be blamed. Some of the problem is attributable to lack of expertise in managing older persons, but a substantial portion is caused by the inevitable problems of trying to titrate therapy in an environment that is considerably less resilient to error. The more aggressive the treatment, the greater the chance that it will produce adverse effects. As noted in Chap. 4, the therapeutic window (i.e., the space between a therapeutic dose and a toxic dose) narrows with age. As the response to therapy decreases, the susceptibility to toxic side effects increases. These changes are attributable to many factors, including the ability to metabolize drugs, changes in receptor behavior, and an altered chemical environment produced by other simultaneous drugs.

This narrowing of the therapeutic window is perhaps most easily recognized in the pharmacological treatment of older patients. In the face of reduced capacity for metabolizing and excreting many drugs, the older patient can develop high blood levels on normal dosages. Changes in receptors may alter sensitivity to chemicals in either direction.

Many older people are at risk of drug problems. A study of community-dwelling elders found that 20 percent of older people taking medications had inappropriate elements, such as potential drug disease interactions and excessive duration of use. Another study found that more than 20 percent of older persons were taking drugs that an expert panel had identified as inappropriate for this age group. For example, several studies have shown that thrombolytics may have serious adverse consequences when used in elderly patients with acute myocardial infarctions. Although they are actively recommended for younger victims, their use in older persons must be monitored very closely.

Use of numerous drugs transforms the elderly patient into a living chemistry set. Because of their prevalence and importance, drugs are discussed separately in Chap. 14. In this chapter we focus attention on some of the more subtle ways in which other types of treatment can adversely affect older people. In general, many drugs can be discontinued safely. One caveat, however: in the fear of overmedicating older patients, doctors may be tempted to discontinue drugs that were begun at an earlier time. While such a reevaluation is prudent, the decision to discontinue should be made carefully. One study showed that stopping long-term diuretic medications in elderly patients resulted in an exacerbation of heart failure symptoms and a rise in their blood pressure (Walma et al., 1997).

On a more philosophical plane, one can think about aging as a continuously changing relationship between an organism and its environment. As noted in Chap. 1, aging is typified by a decreased capacity to respond to stress. A person's environment can do much to reduce or create stress. Whereas a mature adult is likely to adapt to or alter the environment, the aged individual is greatly affected by changes of setting. In infancy, a person is readily influenced by his or her environment. One of the signs of maturation is the person's ability to function independently of that environment and ultimately to influence that environment. Indeed, one of the attributes that distinguishes humans from

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other animals is precisely this capacity to shape the environment. With increased age, the delicate balance shifts again to the point where advanced age often means that the individual is heavily affected by the environment. It is hardly surprising, then, that the elderly patient is vulnerable to the variety of stresses imposed by modern medical care. Table 5-7 lists some of the iatrogenic problems elderly patients may suffer.

TABLE 5-7 COMMON IATROGENIC PROBLEMS OF OLDER PERSONS

Overzealous labeling

Dementia

Incontinence

Underdiagnosis

Bed rest

Polypharmacy

Enforced dependency

Environmental hazards

Transfer trauma

SPECIAL RISKS OF HOSPITALS

Hospitals are dangerous places for any patient, as reflected in a report from the Institute of Medicine documenting the prevalence of medical errors (Kohn et al., 2000). Most of us are resilient enough to enter an acute care hospital and suffer the vicissitudes of care with the expectation that we will emerge better (certainly in the long run). The calculation of benefits received for risks undertaken needs to be more carefully thought through with older patients.

Just a little thought reveals the litany of familiar hazards of hospitalization from the risk of nosocomial infection to getting the wrong drug to the stress of major surgery or the danger of certain diagnostic procedures. One meta-analysis estimated the high rate of adverse drug reactions in hospitalized patients in general at almost 7 percent (Lazarou et al., 1998). All these are imposed on the general hazards of bed rest discussed in Chap. 10, Table 10-2. Table 5-8 offers some examples of potential hazards in the hospital. They include problems of both overtreatment and undertreatment.

TABLE 5-8 THE HAZARDS OF HOSPITALIZATION

Diagnostic procedures

Cardiac catheterization

Arteriography

Therapeutic procedures

Intravenous therapy

Urinary catheters

Nasogastric tube

Dialysis

Transfusion

Drugs

Medication error

Drug drug interaction

Drug reaction

Drug side effect

Surgery

Anesthesia

Infection

Metabolic imbalance

Malnutrition

Hypovolemia

Bed rest

Hypovolemia and hypertension

Calcium metabolism

Fecal impaction

Urine incontinence

Thromboembolism

Nosocomial infection

Falls

Elderly patients are more likely to experience an untoward event during a hospital stay. In part, this is because they present with more physical problems; however,

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they are also more vulnerable. Table 5-9 lists patient characteristics associated with increased risk of hospital iatrogenic complications. Of these, only the first two, source of admission and condition on admission, remained significant when other factors were controlled. Because elderly patients are more likely to come from nursing homes and to be in poor condition on admission, they should be considered at high risk for iatrogenic complications.

TABLE 5-9 RISK FACTORS FOR IATROGENIC HOSPITAL EVENTS

Admission from nursing home or other hospital

Physician's assessment of overall condition on admission

Age

Number of drugs

Length of stay

In a study of patients hospitalized on a general medical service, the incidence of functional symptoms unrelated to diagnosis was over four times higher among

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patients age 70 years and older than among younger patients. Younger patients were more likely to be treated for symptoms of confusion, but older patients were more likely to be treated for problems of not eating and incontinence (Gillick, et al., 1982). Table 5-10 provides a simple rapid screening test for identifying older patients at risk of functional decline in the hospital. Delirium can be a serious problem in elderly hospitalized patients (see Chap. 6 for a discussion of this condition).

TABLE 5-10 RISK FACTORS FOR FUNCTIONAL DECLINE IN ELDERLY HOSPITALIZED PATIENTS

Age 75+

Missing > 15 of the first 21 MMSE items

Dependence in 2 + IADL prior to admission

Pressure sore

Baseline functional dependency

History of low social activity

Abbreviations: IADL, independent activities of daily living; MMSE, Mini-Mental State Examination.

Sources: Adapted from Inouye SK, Charpentier PA: Precipitating factors for delirium in hospitalized elderly persons. JAMA 275: 852 857, 1996; and Sager MA, Rudberg MA, Jalaloddin M, et al: Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc 44: 251 257, 1996.

The elderly patient's vulnerability extends to a more subtle level. Admission to a hospital means entering an unfamiliar world. Moreover, the patient enters the hospital at a time of great stress. The anxiety of unknown consequences exists in addition to the physical stress of the illness.

The hospital presents physical and organizational barriers to which the patient must adapt. Not only the geography but the routines are different. The things we

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rely on to preserve our sense of identity our clothing, our personal effects are among the first things taken away. It is hardly surprising, then, that many elderly persons who are able to function in their familiar surroundings become disoriented and often agitated in the hospital. Just as a blind person can move flawlessly in familiar surroundings, an older person may have developed a host of adaptive mechanisms to function in his or her home situation, overcoming problems of memory loss and impaired vision.

Transferred into the sterile, rigid hospital room, such an individual may decompensate. The syndrome of sundowning, whereby older patients in the hospital become agitated and disoriented as dusk falls, is likely a function of visual or hearing impairments, diminished sensory stimuli, and resultant disorientation.

The older person accustomed to coping with nocturia may wander at night in the dark to where the bathroom at home ought to be and wet the floor. In the crisis of urinary urgency, the patient may be unable to scale the side rails and make it to the bathroom in time. To label an individual who suffers such environmentally exacerbated accidents as incontinent is to inflict double jeopardy.

We fail to appreciate the dangers of bed rest for the elderly people. Bed is actually a very dangerous place for an older person. Besides the risk of falling out of bed, enforced immobility can produce many harms. Complications of bed rest are summarized in Table 5-11 and detailed in Chap. 10.

TABLE 5-11 POTENTIAL COMPLICATIONS OF BED REST IN OLDER PERSONS

Pressure sores

Bone resorption

Hypercalcemia

Postural hypotension

Atelectasis and pneumonia

Thrombophlebitis and thromboembolism

Urinary incontinence

Constipation and fecal impaction

Decreased muscle strength

Decreased physical work capacity

Contractures

Depression and anxiety

The hospital breeds dependency. Even with younger patients, hospital personnel are accustomed to performing basic functions for the patient. Use of the

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bathroom is by prescription only. Bathing is often a supervised event. Patients are transported from one location to another. Although most of us as patients may have enjoyed being indulged for a while, we soon begin to rail against the imposed dependency. In older patients who need to be urged, encouraged, and cajoled into doing as much for themselves as possible, such an atmosphere can be especially debilitating.

Encouraging patients to act independently necessitates patience and time; unfortunately, both are scarce in the acute care hospital. It is much faster and easier to do a task for a person who performs slowly and uncertainly than to take the time to encourage that person to do that task independently. Moreover, the result of a professionally performed task is usually neater and more in keeping with hospital standards. Thus, well-meaning staff bowing to the pressures for efficiency may be inclined to do things for elderly patients rather than urging the patients to do as much as possible for themselves. This well intentioned behavior fosters dependency at a time when independent function is crucial.

The hospital is notoriously averse to risk taking. Hospital policies are designed to err on the side of caution. Such behavior can further compromise the independent functioning of older patients. Patients who are not allowed to bathe themselves or who are wheeled rather than walked are likely to become less motivated to use their full capacities. Any fears about their ability are likely to increase.

In light of the multiple adverse consequences that may be associated with hospitalizing older people, we might pause to ask why we have not done more to make hospitals more hospitable for them.

Ironically, we have invested great care in minimizing the trauma of hospitalization for children. Creativity in architecture and programs has gone into making pediatric wards as nonthreatening and homelike as possible. Although children are rarely hospitalized and geriatric patients are frequently hospitalized, no similar investment of creativity has been devoted to making the hospital less stressful for frail elderly patients. We know enough about perceptual and functional problems of aging to recognize that even simple architectural modifications can make a hospital stay easier. Use of primary colors, windows at lower heights, better-designed furniture, use of textures and patterns, and better design of rooms can all help the older patient retain maximum functioning capacity.

Special units for managing geriatric patients are beginning to emerge. Staffed by an interdisciplinary team composed of nurses, social worker, physician, and physical or occupational therapist, these units apply techniques of multidimensional functional evaluation to assess the capacity of the geriatric patient.

Likewise, the reports of geriatric assessment units that took patients who had completed a course of acute care hospitalization and were otherwise destined for a nursing home and dramatically altered both their clinical state and their long-term care course, even reducing mortality rates, suggest that much more can be done for older persons while they are in a hospital. Such geriatric units can uncover treatable conditions, provide rehabilitation to improve functional

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capacity, and develop a plan of care that will allow elderly patients to remain in the community.

An iatrogenic danger to the elderly patient thus lies in underdiagnosis, especially of mundane but critical conditions involving hearing, vision, and dentition. In addition, even more clinically important problems such as thyroid disease or aortic aneurysms may be overlooked unless a careful examination is performed.

LABELING

Perhaps even more dangerous than the cases of underdiagnosis are those of overdiagnosis. The physician who too readily labels a disoriented patient as senile or demented, or who classifies a urinary accident as incontinence, may be sealing the fate of that patient unnecessarily. These two diagnoses are strongly associated with an increased likelihood of nursing home admission and thus should not be made lightly.

Physicians admitting patients to nursing homes are responsible for assuring both themselves and their patients on several scores:

The patient truly needs care in such a setting and cannot reasonably get such care elsewhere.
The institution is capable of providing the needed care.
The patient is prepared for a transfer to the nursing home.

Too frequently, hospital discharge to the nursing home compounds the trauma. Discharge planning is often begun too late. There is insufficient time to find the best facility for the patient's needs or to allow the patient and the patient's family a sufficient role in making the decision for nursing home placement.

Good discharge planning includes at least five critical steps:

Adequate identification of those at risk of needing special arrangements on discharge.
Assessment to identify problems and strengths.
Determination of the risks and benefits associated with alternative modalities of care.
Determination of the most suitable vendor among the modality of care selected.
Transmission of adequate information to assure a successful transition.

Patients and their families should play an active role in steps 3 and 4. Ideally, they should make the choice after the information has been provided by professionals. In practice, this is rarely the case.

Adequate information about the risks and benefits of alternative modalities is not presented (it may not be known). No encouragement or assistance is provided to help patients and families determine precisely what outcomes they seek to maximize. Little time is allowed to weigh the complexities of the choice. When

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it comes to choosing among vendors of a given service, real choices may not exist because of the constraints of payment arrangements, including managed care.

As discussed in Chaps. 15 and 16, the nature of nursing home care is changing. The pressure for earlier discharges from hospitals has created a new demand for what has been termed subacute care in essence, care that was formerly provided in hospitals.

SUMMARY

Many useful steps can be taken to improve and protect the health of elderly patients. The elderly patient represents a different risk:benefit ratio than the younger patient. Actions well tolerated in others may produce serious consequences in the old. Bed is a dangerous place for the older patient; confinement to bed rest should be avoided whenever possible.

The physician must guard against several potential iatrogenic problems with elderly patients. Diagnostic labels implying incurable problems (such as dementia and incontinence) should not be used until a careful search for correctable causes has been undertaken. Special attention should be given to the tendency to create dependency through well-intentioned care. By keeping in mind the need to maintain the patient's functioning, the physician can remain sensitive to the effects of the environment to enhance or impede such activity.

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