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CHAPTER 9 Preventive geriatrics
Gerald M. Mahon1, Suzanne M. Mahon2, and Joseph H. Flaherty3
1 Saint Louis University School of Medicine, St. Louis, Missouri, USA
2 Saint Louis University School of Medicine, St. Louis, Missouri, USA and Saint Louis University Trudy Busch Valentine School of Nursing, St. Louis, Missouri, USA
3 Division of Geriatrics, University of Texas Southwestern, Dallas, Texas, USA and Geriatrics, Questcare/Envision Physician Services, Dallas, Texas, USA
Introduction
Preventive geriatrics is not an oxymoron. It is, however, a challenging area of medicine for many reasons. (i) How can guidelines for prevention take into account the variability seen among older people? (ii) How can preventive geriatrics balance the dichotomy between the treatment of populations and the treatment of the individual? (iii) How can clinicians handle the unclear areas or ‘grey zones’ of preventive geriatrics? (iv) Does early detection or case‐finding equate with better outcomes?
To deal with these questions, this chapter presents a model of preventive geriatrics called the Health Maintenance Clinical Glidepath, which is primarily for office‐based practices. It addresses screening for geriatric specific areas (e.g. cognition, gait, and balance) and screening for common medical illnesses and diseases (e.g. certain cancers, heart disease).
Background
Prevention in medicine has traditionally been divided into primary, secondary, and tertiary prevention. Primary prevention is the prevention of disease before it actually starts.
The traditional definition of secondary prevention is the detection of disease at an early stage. This can be detection of asymptomatic disease by screening tests or identification of unreported problems by case‐finding. The following caution needs to be added to the definition: detection should only be done if detection is likely to improve outcomes such as mortality, morbidity, function, or quality of life. The priority and importance of outcomes need to be made based on patient preference.
Tertiary screening, using a comprehensive geriatric assessment approach, allows for the identification and intervention of established health conditions such as cognitive impairment, gait and balance disorders, malnutrition, and urinary incontinence. The goal of the intervention would be to prevent or minimize a patient’s functional decline in order to maintain their independent lifestyle, since functional decline and loss of independence are not inevitable consequences of ageing.
The Health Maintenance Clinical Glidepath
The Health Maintenance Clinical Glidepath answers the first two questions above and addresses the limitations of two types of clinical decision‐making tools: practice guidelines and evidence‐based medicine (EBM). Although practice guidelines and EBM have been important in raising the standards of healthcare in the past decade, their use in preventive geriatrics is limited. Many guidelines do not include older age groups or, if they do, are no more specific than ‘over 65 years of age’. EBM emphasizes outcomes of populations, whereas clinical practice emphasizes the outcome of the individual. One of the limitations of EBM is the discrepancy between patients in the EBM studies and clinical practice. For example, many randomized controlled trials of medication interventions for common diseases such as congestive heart failure and osteoporosis exclude patients who are frail, demented, or at the end of life.
The older we get, the more unique we become. Chronological age does not equate with physiological or functional age. Guidelines for preventive geriatrics need to take this into account. One approach is to use life expectancy and functional status to help delineate categories of older people that are more useful than those based on chronological age. Overall health status is a good predictor of life expectancy compared with age alone, and functional capacity among older people has been found to be a predictor of mortality. Four categories can be used to help guide decisions about preventive measures. Although overlap exists and functional status may fluctuate, Gillick proposed the following: Robust (life expectancy of >5 years and functionally independent), Frail (life expectancy of <5 years and significant functional impairment), Moderately Demented (life expectancy 2–10 years and may or may not be functionally impaired), and End of Life (usually a life expectancy of <2 years).1
Preventive geriatrics requires making decisions. Healthcare decisions are complex, involving society, healthcare workers, and patients. Guidelines for preventive geriatrics need to take into account the following practice principles: (i) patients’ expectations and needs, including quality of life, satisfaction, and reassurance; (ii) physicians’ need for diagnostic certainty; (iii) physicians’ comfort with risk‐taking and concerns about malpractice; (iv) the need for cost‐effective medical care; (v) variations in practice patterns, particularly with regard to subspecialty care; and (vi) the practical realities of running a practice.2
Healthcare decisions are not black and white. Thus, four levels of recommendation were developed to allow for decisions to be made on a ‘graded’ rather than an ‘all or nothing’ basis and to allow for better patient involvement in decision‐making. The four levels are also based, when available, on the strength or weakness of EBM that exists or does not exist. The four levels are ‘Do’, ‘Discuss’, ‘Consider’ and ‘* * * *’. ‘Do’ reflects the strongest recommendation. ‘Discuss’
