Approach to preventive care in the elderly

Areas to address

Age, life expectancy, and concept of frailty: Estimating remaining years of life helps guide your recommendations for preventive screening and treatment plans. Estimating life expectancy is not an easy or precise science, yet clinical decisions are made daily regarding this issue.

There are multiple tools to predict patient life expectancy. The US National Center for Health Statistics provides a table based on only sex, race, and age.¹ Statistics Canada also provides a similar table based on sex and age.² There are other tools that use further individual characteristics and that are more accurate.³

Both comorbidity (the presence of 1 or more medical illnesses) and functional status (independence or dependence in basic or instrumental activities of daily living) affect life expectancy.⁴ Frailty is an emerging concept that can help guide clinical decision making.⁵ In Canada, the Clinical Frailty Scale, developed from the Canadian Study of Health and Aging, also predicts life expectancy (Figures 1 and 2).^4,6

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Figure 1.

Clinical Frailty Scale

IADL—instrumental activity of daily living.

Reproduced with permission from Rockwood.⁶

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Figure 2.

Kaplan-Meier curves, adjusted for age and sex, for study participants over the medium term (5–6 y), according to their scores on the Clinical Frailty Scale: Some scores were grouped. A) Probability of survival. B) Probability of avoidance of institutional care.

Reproduced with permission from Rockwood et al.⁴

Using the Clinical Frailty Scale, Mrs M.B. is found to be in category 3, “managing well” (Figure 1).⁶ Category 3 is associated with approximately an 80% probability of survival to 60 months (5 years). Category 3 is also associated with approximately a 90% probability of avoidance of institutional care at 5 years (Figure 2).⁴

Risks and benefits of screening or treatment: Risks often increase along with an increase in frailty and comorbidity. Conversely, benefits often diminish as life expectancy decreases.

Values and preferences of your patient: Preventive management plans should take into account the patient’s perspective and be mutually agreed upon. This is especially true when there is no specific guideline to follow.

Primary care preventive considerations

We created an acronym for primary care preventive considerations based on our clinical experience and called it CCFP, short for cancer, cardiovascular disease, falls and osteoporosis, and preventive immunizations.

Cancer: Adults aged 65 or older have a 16-fold greater risk of dying from cancer than younger people do.⁷ The American Cancer Society,⁸ the US Preventive Services Task Force, and the Canadian Task Force on Preventive Health Care (CTFPHC) offer guidelines for screening for breast, cervical, colorectal, and prostate cancer. The CTFPHC guidelines can be accessed online (http://canadiantaskforce.ca/ctfphc-guidelines/overview) and their recommendations are in agreement with most other agencies, but owing to the lack of research and evidence for screening tests beyond the age of 74 years, most agencies believe this age group’s screening needs to be individualized based on age and life expectancy, risks and benefits, and patient values and preferences. The general consensus is that screening mammography is unlikely to benefit women who have a life expectancy of less than 5 years.⁹ The US Preventive Services Task Force recommends against screening with colonoscopy beyond 85 years of age.¹⁰ Recently the CTFPHC has recommended against screening with colonoscopy altogether at any age. However, the CTFPHC does support screening with fecal occult blood testing or fecal immunochemical testing every 2 years and sigmoidoscopy every 10 years from 50 to 74 years of age.^11,12 A discussion on screening, including the patient’s core values and a review of potential risks and benefits, will be critical for optimal patient-centred care.¹³

For patients older than 74 years, screening mammography might provide benefit if life expectancy is longer than 5 years.⁹ Mrs M.B. chooses to undergo mammography.¹⁴ Mrs M.B.’s Papanicolaou tests have had normal results since the age of 50 until she was 68, and she has indicated that her husband is her only sexual partner. You decide that she does not need to have any more Pap tests as she is older than 69 years.¹⁵ After discussing risks and benefits of sigmoidoscopy and, considering the time it takes for carcinomatous polyps to develop, you do not recommend it. As she likely has more than 5 years of life expectancy, you recommend fecal occult blood testing.^11,12 Mrs M.B. agrees and mentions she was hoping that colonoscopy or sigmoidoscopy would not be necessary.

Cardiovascular disease: Screening for type 2 diabetes by measuring fasting plasma glucose level should be performed every 3 years in individuals 40 years of age and older. In the elderly, intensive lowering of hemoglobin A_1c (HbA_1c) might not reduce cardiovascular events and could increase hypoglycemic events and mortality.¹⁶ Choosing Wisely Canada, endorsed by the Canadian Geriatrics Society and the College of Family Physicians of Canada, recommends a target HbA_1c level less than 7.5% for healthy elderly patients but less than 8.5% in those with a limited life expectancy of less than 5 years.¹⁷ However, the risks and benefits of tight glucose control in the elderly are still being evaluated.¹⁸

Previous Canadian Diabetes Association guidelines recommended acetylsalicylic acid (ASA) antiplatelet therapy for all patients with diabetes older than 50 years of age, but more recent meta-analyses of randomized controlled trials have pointed to a lack of evidence for ASA in these patients.^19–21

Hypertension occurs in more than two-thirds of adults older than 65 years of age.²² The randomized controlled trial HYVET (Hypertension in the Very Elderly Trial) showed that total mortality and cardiovascular events were reduced by treatment of hypertension in those 80 years of age or older with a systolic blood pressure of at least 160 mm Hg at baseline.²³ The same study concluded that blood pressure targets for patients older than 80 years should be 150/80 mm Hg to prevent hypotensive events.

For secondary prevention of cardiovascular events, 4 drug classes have been shown to reduce mortality in older adults: angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers; β-blockers; statins; and antiplatelet agents. The greatest benefit was found with the use of statins.²⁴

However, for primary prevention of cardiovascular events, there is a lack of convincing evidence to recommend routine screening for and treatment of hypercholesterolemia with statins in those older than 80 years of age.^25,26 Low cholesterol levels have actually been associated with death in the frail elderly residing in long-term care.²⁷

You recommend ongoing HbA_1c testing for Mrs M.B. to monitor her glucose levels but do not recommend screening for high cholesterol levels. You also recommend ongoing blood pressure monitoring. You discuss the benefits and drawbacks of using of ASA and decide not to start antiplatelet treatment.

Falls and osteoporosis: Osteoporosis screening with dual-energy x-ray absorptiometry measurement of bone mineral density should be considered for adults aged 65 and older and those older than 50 years of age with risk factors.²⁸ Assessment tools, such as the CAROC (Canadian Association of Radiologists and Osteoporosis Canada) system and FRAX (Fracture Risk Assessment Tool of the World Health Organization) can be used to determine 10-year fracture risk.²⁹ Those at high (> 20%) and moderate (10% to 20%) risk of fracture in 10 years might benefit from bisphosphonate treatment. All individuals should be counseled regarding adequate daily elemental calcium (1200 mg) and vitamin D (1000 IU) intake through diet and supplements.^11,29 The American Geriatrics Society and British Geriatrics Society recommend asking about falls every year. Our personal experience is that elderly patients tend not to mention this problem to their family doctors until very advanced stages.

You learn that Mrs M.B. has had 2 falls in the past 6 months with no injuries and they were both accidents when she tripped at home. You recommend osteoporosis screening, as it has not been done in the past 3 to 5 years. You also recommend a gait assessment by a physiotherapist and home hazard assessment by an occupational therapist. Based on previous screening, Mrs M.B. is at moderate 10-year risk of fracture, so you recommend treatment with bisphosphonates, calcium, and vitamin D after educating her about ways to prevent falling.

Preventive immunizations: Health care providers should encourage all of their older patients to receive an annual influenza vaccination, as this has been shown to reduce influenza-related hospital admissions by 42%.³⁰ A single pneumococcal vaccination in those older than 65 is also recommended. This should be at least 5 years after any pneumococcal vaccinations received at or before age 65 for a specific medical condition.³¹ Older adults have twice the incidence of tetanus infections; the fatality rate is also higher.³² This finding is likely owing to a missed vaccination rather than an inadequate response to it, as the vaccine provides sufficient immunity to older adults.³³ The herpes zoster vaccine is also recommended for patients aged 50 and older, as it reduces both the incidence and severity of herpes zoster disease in older adults.³⁴ There is no upper age limit for vaccination, but a patient’s physical fitness and other contraindications should be considered.

You recommend annual influenza vaccination to Mrs M.B. You also recommend pneumococcal and herpes zoster vaccinations (as she has not had these yet) and check on her tetanus immunization status. You also plan for formal cognitive testing at the next visit to see if she has any further memory decline.