An ounce of prevention is worth…what exactly?
The weighty issue of preventive health in the elderly.
When someone says preventive health, many things might come to mind: eating right and exercising, screening for pre-cancerous lesions, and getting a yearly flu vaccine. Doctors also often address secondary prevention measures, which are the prevention of further complications of a disease such as preventing a second heart attack or stroke. A comprehensive approach to preventive health care in adults needs all these strategies. However, the holy grail of medicine is prevention that also improves mortality. That is, effectively extending life for people because they did not get the disease we prevented.
The straight line from preventive action to actually preventing disease may still exist in the elderly. Certainly, we can say that the influenza vaccine and the pneumococcal vaccine (against a bacteria that causes pneumonia) provide protection from these diseases or their complications. Figuring out what also prevents death is increasingly complex in the world of geriatric medicine since the most powerful predictor of death is age, not a specific disease. At a certain point, if you prevent one cause of death, people will die of another.
If this is the case, the important question is what should be the focus of preventive health in elderly? Cancer, heart disease, vaccine-preventable diseases are all uncontroversial as critical diseases the elderly. But increasingly the best approach is to ask, who is the patient? As with everything else in the elderly, the individual is the important guide to knowing how to proceed.
For example, in the field of cancer screening Dr. Louise Walter of University of California, San Francisco has shown that not everyone of all ages is created equal. For those adults in the healthiest bracket for their age that have at least 10 more years to live, it would be reasonable to offer them colorectal screening that takes at least that long to have any benefit. But for a frail older woman in the nursing home, she may not need such screening as it will be unlikely to impact her life or life expectancy. And furthermore, colorectal screening – which includes a colonoscopy and medications she would need to go through the procedure—might cause her more harm than good. Lastly, the patient’s preferences should be considered, not just the guidelines. Does she want to know if she has a tumor in her colon even if it is unlikely to cause her death, or not? Increasingly, preventive health guidelines with strict age cutoffs are meaningless as the diversity of people at different ages is more powerful than age alone. Life expectancy should be a far more practical guide for a physician and patient to making decisions about what screening to do.
What can we say is universal? For everyone, young and old, being as functional and independent for as long as possible is generally a goal. To that end, the obvious applies: counseling older adults to remain as physically, mentally and socially active as possible. Physical activity helps with mood and depression, weight control, falls and all those pesky diseases that are so prevalent in the elderly—bone disease, heart disease, stroke, diabetes and cancer. Being mentally and socially active also helps maintain cognitive function. Checking hearing and vision and making sure any deficits are corrected is key to preventing falls, social isolation, depression and cognitive decline. Quitting smoking at any age is hands down the best thing you could do for your health, and this applies still in older age (though I have one patient who is 98 who understandably wants to enjoy his pipe a few times a day without me constantly nagging him to stop). Watching how much you drink as you get older is also highly advised as alcohol can affect cognition and falls. Getting an annual flu vaccine and other recommended vaccines are just as important as when people are younger, if not more important. Disease and cancer-specific prevention requires an individual approach, especially in the oldest old. Life expectancy and weighing harms and benefits with our patients should be our guide there.
1) Day LW, Walter LC, Velayos F. Colorectal cancer screening and surveillance in the elderly. Am J Gastroenterol 2011; 106:1197–1206
2) Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750-2756.