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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #19, #37

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LEARNING OBJECTIVES

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Learning Objectives

  • Provide a framework for evaluating the benefit of preventive measures in older adults.

  • Identify which populations benefit most from cancer screening.

  • Review management strategies for asymptomatic chronic diseases.

  • Identify health behaviors most beneficial for older adults.

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Key Clinical Points

  1. Appropriate prevention strategies in older adults involve taking into account estimated life expectancy and time to benefit for a preventive intervention.

  2. Person-centered approaches to prevention and screening require frank discussions of benefits and harms in the context of the patient’s values and preferences.

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INTRODUCTION

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Prevention and screening hold the promise of maintaining health by intervening before an illness can cause symptoms. Some preventive interventions, such as influenza vaccination, have truly minimal risks and public health benefits. However, many other interventions, such as cancer screening tests, impose risks and burdens on patients that should be considered when deciding whether to target those tests to individuals. For interventions with minimal risks, targeting is less important since many patients will benefit and few (or none) will be harmed. In contrast, for interventions with some risks or burdens, targeting is critical since some patients may be more likely to be harmed than helped by the preventive intervention.

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In this chapter, we will present the evidence for several preventive interventions in older patients. First, we will focus on preventive interventions that impose some risks and burdens on patients, starting with a framework for targeting these preventive interventions and then focusing on the benefits and risks of each preventive intervention in greater detail. These interventions include cancer screening as well as treatment for asymptomatic chronic conditions such as hypertension or diabetes. Second, we will review the evidence for interventions with minimal risks. These interventions include behavioral and lifestyle modification as well as immunizations.

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Screening for geriatric syndromes such as falls and incontinence are discussed in detail in their respective chapters.

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FRAMEWORK FOR INDIVIDUALIZING PREVENTION

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One challenge of appropriately targeting prevention in older adults is that few studies of preventive interventions have enrolled persons older than 75 years. The absence of age-specific data requires clinicians to extrapolate data about the benefits and harms of preventive interventions in younger persons and apply it to older persons. Furthermore, even if trials suggest that the effectiveness of a preventive intervention is similar in younger and older populations, challenges remain about how to apply data from trials to an individual older person. Trials show the average effectiveness of an intervention, but they generally do not address individual patient characteristics, such as comorbid conditions or functional status, which may change the likelihood of receiving benefit or harm from a preventive intervention. Given these challenges, the need to individualize prevention and screening decisions is especially important for older people, because individuals become increasingly heterogeneous in ...

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