Today's older people are increasingly interested in promoting healthy aging. The terms “health promotion” and “prevention” are used almost interchangeably. Prevention runs a gamut. For the most part, we think of prevention in terms of warding off disease or delaying its onset, but prevention can also involve simply avoiding bad events or complications of care. As noted in Chapter 4, in the context of chronic disease management, proactive primary care can be seen as a form of prevention (tertiary prevention, as defined later). Prevention is typically targeted at specific diseases or conditions, but some authors caution against such a single-disease approach to prevention among older persons, arguing that competitive risks will simply raise the rates for other diseases (Mangin, Sweeney, and Heath, 2007). Likewise, some preventive efforts, like stopping smoking and exercising, can affect many diseases.
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. Ironically, the effects of prevention may be greatest in older people because the benefit of preventive activities depends on two basic factors: the prevalence of the problem and the likelihood of an effective intervention. Thus, flu shots may be less likely to work in older people if they are immune compromised, but osteoporosis prevention will be very cost-effective because the baseline levels of the problem, and of falling, are high. Plans for prevention in older people should consider the issues laid out in Table 5–1. Perhaps the most preventable problem connected with caring for older persons is iatrogenic disease.
Table 5–1. Considerations in Assessing Prevention in Older Patients |Favorite Table|Download (.pdf)
Table 5–1. Considerations in Assessing Prevention in Older Patients
- The higher the baseline risk, the greater is the likelihood that an effective preventive intervention will have an impact. Hence, some preventive strategies may be paradoxically more effective with older patients.
Competing risks/limited life expectancy
- Multimorbidity means that reducing the risk of one disease may leave older people vulnerable to others.
- Limited life expectancy influences judgments about the expected course of benefits.
Time to achieving an effect
- Interventions with long lag times for effects (as are typical in many behavioral changes) may run up against concerns about life expectancy.
Vulnerability/risk of harms
- Older people have a narrower therapeutic window (see Chap. 4).
- They may be susceptible to the side effects of prevention.
Response to intervention
- The preventive intervention may not work as well in older patients.
- Some older patients may have difficulty following the preventive regimen.
The value of the health gained
- Other problems may reduce the benefit.
The cost of the preventive activity
- Direct costs
- Indirect costs, such as anxiety, restricted lifestyle, and false-positive results
The major thesis here, as with much covered elsewhere in this book, is that age alone should not be a predominant factor ...