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CHAPTER 13 PREVENTIVE HEALTH MAINTENANCE

CHAPTER 13 PREVENTIVE HEALTH MAINTENANCE
Practice of Geriatrics
SECTION III PREVENTION/REHABILITATION IN GERIATRIC PRACTICE
CHAPTER 13 PREVENTIVE HEALTH MAINTENANCE
Mark Joseph Magenheim, M.D., M.P.H.
Methodologic Criteria for Screening
Application of Preventive Assessment Recommendations
Goals of Preventive Assessment of the Elderly
Specific Recommendations
Summary
Attention to clinical preventive services has increased in the past decade, as managed care, managed demand, and health maintenance programs have expanded. As managed care (control of access to providers) has been supplemented (or even replaced) by managed demand (control of access to services), implications for the geriatric population are becoming problematic in that needed services may not remain readily available. In this more restrictive environment, preventive health services have a higher priority. For the elderly, the focus of clinical prevention is primarily on maintaining functional ability rather than on identifying new disabilities, although both activities are important. Health assessment of the elderly includes review and follow-up of health issues primarily from the perspective of the patient as well as from that of health professionals and payers. Successful health assessment of elderly patients depends on keen observation, sound applied logic, and full use of the “sixth sense.”
Screening is central to preventive health assessment of the elderly. As a point of reference, screening is defined generally as “the presumptive identification of unrecognized disease or defect by the application of tests, examinations, or other procedures which can be applied rapidly to sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. Persons with positive or suspicious findings must be referred to their physicians for diagnosis and necessary treatment.”1
Two forms of health screening are commonly recognized: (1) epidemiologic community surveys, which are used to identify or describe a population that has not sought medical assistance and (2) case-finding among those who have sought medical assistance. Within the category of case-finding, interventions are either provided incidentally to individuals who have not sought screening directly (as when office staff check the blood pressure of every adult at each office visit), or, alternatively, they are provided to populations who have sought screening assistance for self-identified purposes to maintain or improve personal health (as when individuals check their own blood pressure at home or at shopping malls or in drugstores). One difference between these two forms of case-finding is that the first type is offered in a health care setting by a health services provider, whereas the second type is initiated in a non-health care setting by the health services consumer.
Screening strategies, benefits, costs, and outcomes vary according to the objectives, test features, and points of view of the screening program and its participants. This chapter focuses on provider-initiated screening in the context of preventive health assessment for case-finding of functional impairments or conditions. The aim of this form of professionally based prescriptive screening is early detection of important conditions or diseases for which efficacious and efficient interventions exist to prevent or postpone disability and premature death.2 For the elderly, the goal of prescriptive screening is to improve the quality of life by enhancing functional capacity and reducing disability.
Early efforts at preventive health assessment and screening of the elderly were conducted in the form of epidemiologic community surveys rather than as office-based case-finding. In general, these findings did not show enough benefit to justify mass community screenings. Even when such services were conducted by mobile units or in the homes of the elderly by physician-extenders with back-up laboratory services, the results were not cost-effective.3,4,5,6,7,8,9,10,11,12,13 and 14 Results of Lowther’s pioneering studies showed that “the end result of all our early diagnostic activities has thus been an improvement in 23% of the whole group and … it is unlikely that many general practitioners will be able to accept this further burden in the near future.”4
Currie and his associates in Scotland reported that “the results of the [Glasgow] survey were perhaps incommensurate with the effort expended since most of the unreported morbidity was trivial, …and community health screening of the elderly may be very time-consuming and expensive in time and money.”5 Results of other studies of office-based and special population case-finding among the elderly have been weak owing to limitations of study design and lack of efficacy. Freedman and colleagues report that the low incidence of serious illness (2.8%) among 682 elderly patients screened in Newcastle “revealed that the vast majority of positive symptoms and physical signs were either already known to the patient’s general practitioner or were of no real significance to the health and well-being of the patient …including previously undiagnosed mental and emotional illness.”13
One of the most rigorous evaluations of preventive health maintenance screening was the randomized controlled trial done by Tulloch and Moore in 1979.14 In 295 elderly patients assessed over 2 years, results “in both screened and unscreened groups showed that patients were well adapted in most cases to their problems so that the quality of life of these old people was relatively unimpaired.”14 No significant impact on socioeconomic, functional, and medical disorders affecting health was made, risk rating in the two groups differed only marginally, and screening and surveillance had little impact on health status or vulnerability to stress as represented by risk rating. McKeown’s landmark review corroborated the conclusions of many of these rigorous pioneering studies from the United Kingdom.15
In North America, studies by Breslow and Somers, Somers and associates, Frame and Carlson, Frame and Kowulich, the Canadian Task Force on the Periodic Health Examination, and the U.S. Preventive Services Task Force of the U.S. Department of Health and Human Services have shown that rigorous, comprehensive health maintenance guides are useful when they emphasize age-related risk assessment targeted to specific groups and conditions.16,17,18,19,20 and 21 Although health maintenance recommendations for many conditions are still under development,22,23,24,25 and 26 a number of preventive health assessment protocols have now been adequately validated to warrant routine use in clinical practice.27,28,29,30,31,32,33,34,35 and 36 As with all screening recommendations, specific protocols for screening the elderly need to be based on general principles and evidence-based, scientifically grounded methodologic criteria.
METHODOLOGIC CRITERIA FOR SCREENING
Screening standards were set forth in 1961, and general principles were adopted by the World Health Assembly in 1971.37,38 and 39 Practical methodologic criteria and guidelines developed during the past 25 years now include the following:
Burden of Disease or Disability

1.
Is the condition an important health problem for the individual and for the community? (What is the prevalence and the types and magnitude of suffering among those affected?)
Etiology and Clinical Course

2.
What is the natural history of the condition from the latent stage to overt disease or disability? (Is there an early asymptomatic stage?)

3.
Will early detection alter the course of the condition?

4.
Is effective treatment for the condition available if it is identified before or at an early symptomatic stage?
Efficacy of Screening

5.
Is there a suitable screening test to detect the condition at the latent or early symptomatic stage?

6.
Is the screening test likely to do more good than harm?

7.
Is the test valid for the condition being assessed?

8.
What is the effect of the condition’s prevalence in the population on the predictive value (yield) of the screening test?
Effectiveness of Preventive Assessment

9.
Is the screening test acceptable to patients, to health professionals, and to payers of the preventive health assessment?

10.
What is the labeling effect of a positive test result?

11.
What is the level of compliance with screening protocols among patients, professionals, and payers? (That is, do patients and clinicians adhere to recommended screening procedures? Do insurers pay for such services? Do prevention incentives exist, and do they work?)
Community Effectiveness

12.
Are diagnostic facilities available, accessible, and affordable for those with positive results on screening tests?

13.
Is treatment available, accessible, and affordable?

14.
What is the level of compliance with treatment among patients, health professionals, and payers of treatment services?

15.
Is there suitable coverage? (That is, do those in need receive effective services and treatments after screening?)

16.
What is the impact of effective diagnosis and treatment on the burden of suffering, in magnitude, type, or other costs?
Efficiency (Economic Evaluation)

17.
Is screening cost effective when compared with other means of diagnosis and treatment? (What is the relative benefit of preventing, arresting, or curing the problem early?)

18.
Is screening for condition A cost effective compared with screening for condition B in terms of screening efficacy and effectiveness?

19.
Is diagnosis and treatment of condition A cost effective compared with diagnosis and treatment of condition B in terms of community effectiveness and the population’s burden of suffering?

20.
What are results of cost-utility analyses of screening and treatment alternatives? (That is, do screening and early detection lead to an improvement in end results as measured by quality-adjusted life-years, or is it merely “staging-migration”?)
Consistent use of these criteria helps to promote rational evaluation of screening and preventive assessment protocols and fosters effective clinical policies and practices. Although the “spectrum of evidence” is still incomplete, it is nonetheless important to conduct a critical review of any proposed health screening technique, procedure, or method intended for the elderly to develop and implement appropriate periodic assessments and to avoid inefficacious, ineffective, and potentially harmful interventions. The recommendations for preventive assessment of the elderly in this chapter focus on burden of suffering, natural history (etiology and clinical course), efficacy, and effectiveness. Issues of community effectiveness and economic analysis, although relevant, are beyond the scope of this chapter. In the following section, the condition of essential hypertension among the elderly is used as an example to show how these guidelines and methodologic criteria can be applied to determine appropriate specific preventive recommendations for this common problem.
APPLICATION OF PREVENTIVE ASSESSMENT RECOMMENDATIONS
Essential hypertension is a common geriatric problem that can be used as an example for applying rules of evidence to preventive assessment guidelines.
Step One: Burden of Disease or Disability
Approximately 5% to 35% of North American adults have an elevated diastolic and/or systolic blood pressure depending on age, sex, and race. (The wide range of prevalence is itself a useful measure of the difficulty of determining the true burden of disability.) The peak prevalence of diastolic hypertension (more than 95 mmHg) is 16% in males and 19% in females at 55 to 64 years, and the peak of isolated systolic hypertension (more than 160 mmHg) occurs in about 28% of males and 33% of females aged 75 to 79. Results are inconsistent for those over age 80.
Determining the true prevalence of hypertension among those over 65 years old is difficult because of frequent misreporting and misclassification in this group, and the burden of suffering among elderly hypertensives is problematic because of the usually asymptomatic nature of the condition and the adverse side effects of treatment. However, target organ damage occurring as a consequence of untreated hypertension poses a huge burden to society, to individual patients and their families, and to the health care system. Disability and premature death from congestive heart failure, myocardial infarction, coronary heart disease, cerebrovascular accidents, and atheromatous brain infarction due to untreated hypertension remain major health problems.
Step Two: Etiology and Clinical Course
Information about the etiology of essential hypertension is limited, but data on the clinical course of the condition are substantial. Among those aged 65 to 74, data consistently show significantly higher rates of congestive heart failure and death from cardiovascular disease in diastolic hypertensive women compared to age-matched nonhypertensive women. Risks associated with isolated systolic hypertension in those 65 to 79 years and for those over age 80 are now quite well documented.40
Efficacy studies of compliant patients under 65 years old with treated hypertension have shown an 83% reduction in mortality and 92% reduction in morbidity among those with severe diastolic hypertension (more than 115 mmHg before treatment), a 67% reduction in events among those with moderate diastolic hypertension (105 to 114 mmHg), and a 17% reduction in mortality in those with mild hypertension (90 to 104 mmHg). Optimal control can be achieved after 5 years for two thirds of young adults needing hypertensive therapy, but control among the elderly is inconsistent.
The results of the VA Cooperative Study and the Hypertension Detection and Follow-up Program (HDFP) for elderly patients unequivocally demonstrated benefits of therapy for those aged 60 to 74 with moderate (105 to 114 mmHg) or severe (over 115 mmHg) diastolic hypertension. Efficacy of treatment was not demonstrated for those over age 60 with mildly elevated diastolic (less than 104 mmHg) or isolated systolic hypertension. Reliable results have been reported from the Systolic Hypertension in the Elderly Program (SHEP) study,41 but consistent findings for those aged 75 and over have been limited in most studies to date.
Newer methods of antihypertensive treatment and questions about the efficacy of stepped care have further complicated management of this problem among the elderly. Negative side effects include postural hypotension, urinary incontinence, confusion, sedation, abrupt changes in blood pressure, hypokalemia, depression, fatigue, weakness, and anorexia. The case for treatment thus needs to be established clearly before subjecting an elderly patient to the rigors of daily antihypertensive therapy.
Although there is a high burden of suffering among untreated hypertensives with a diastolic pressure of more than 105 mmHg, the evidence for intervening in elderly patients with mild diastolic hypertension or isolated systolic hypertension is not as firm. These forms of high blood pressure are the most common among those aged 65 or over, and treatment recommendations for this group have recently been better validated. Although they are based on good evidence from well-designed studies, preventive assessment and health maintenance guidelines for mild hypertension in the elderly are not yet conclusive.41
Step Three: Efficacy of Preventive Assessment
The foremost technical aspect of screening, which determines efficacy, is the establishment of test validity. Validity here refers to the ability of the test to identify individuals with the condition correctly (sensitivity) and to identify individuals without the condition correctly (specificity). The extent to which screening test results conform to those derived from an acknowledged gold standard of diagnostic accuracy provides a measure of sensitivity, specificity, and overall test validity. Table 13-1 shows these concepts of determining validity algebraically.

TABLE 13-1 RESULTS OF SCREENING TEST ILLUSTRATING SENSITIVITY AND SPECIFICITY

As shown in Table 13-1, it is possible to place each screened individual into cells labeled (a), (b), (c), or (d) and to compute the respective percentages in each cell. In this hypothetical example, the hypertension screening program is being conducted in a community of 1000 adults where population screening has not previously been available. We assume that measuring devices are reliable and that the blood pressure readings taken are diagnostically accurate and are not affected by observer bias. Given the suitability of the screening test and good information on the benefits of early detection and treatment, we now wish to determine the validity of the screening test.
In the perfect screening test (i.e., one with 100% sensitivity, 100% specificity, and no false-positive or false-negative results), all diseased subjects would be in cell (a) and all nondiseased subjects would be in cell (d). In actual practice, however, this is neither attainable methodologically nor desirable. (To achieve “perfection,” the tests would have to be exceedingly costly and inefficient, and the potential benefits derived from early screening of asymptomatic persons would be lost.)
Instead of perfection, the goal of preventive assessment in the form of screening for case-finding is to achieve the highest levels of both sensitivity and specificity consistent with other screening criteria deemed essential for the given condition. To achieve this balance, the approach taken in case-finding is to “trade off” the sensitivity and the specificity of a test. Operationally, this is done by setting a level in advance that must be met for a test outcome to be deemed “positive.” This “criterion of positivity”42 is determined clinically and statistically as that point on the spectrum of measurement (from “definite health” to “definite disease”) that affords optimal sensitivity and specificity for the condition in question—at the lowest cost, pain, inconvenience, and risk. The criterion of positivity is affected by value preferences for “health,” “acceptable risk,” cost-benefit ratios for different points on the full spectrum of measurement, and the prevalence of the condition of interest. As shown later, different cut-off points can lead to substantial variations in the screening results obtained.
Using validated standards, our example (Table 13-2) uses a fifth-phase Korotkoff level of 105 mmHg as the cut-off point for diastolic hypertension. Patients labeled hypertensive (those who have a diastolic reading of 105 mmHg or greater on screening) would be referred for definitive diagnosis and treatment (the so-called gold standard). From the results of our screening program (shown in Table 13-2), we conclude that the screening test for hypertension appears to be very good at correctly identifying individuals with diastolic hypertension (sensitivity = 95.0%) and without diastolic hypertension (specificity = 95.0%). At this cut-off level of 105 mmHg in an unselected population, this test shows good predictive value for positive test results (88.0%) and very good predictive value for negative test results (98.0%). This means that the post-test likelihood of correctly identifying an individual as hypertensive or as nonhypertensive based on this screening test alone is quite good. We also conclude that the prevalence of diastolic hypertension (more than 105 mmHg) among these 1000 persons is 280/1000 or 28%, which is within the expected range based on the results of other surveys. Thus, we conclude that this screening test appears to be valid.

TABLE 13-2 EXAMPLE FOR CALCULATING SCREENING TEST SENSITIVITY AND SPECIFICITY FOR DIASTOLIC HYPERTENSION (³105 mmHg)

Let us now apply the same screening test to a population of 1000 persons over age 65 who live in a retirement community in the Sun Belt. In Table 13-2 we determined that our hypertension screening program had a sensitivity of 95% and a specificity of 95% and that the prevalence was 28% in this general population. Although the test characteristics do not change in different populations (test sensitivity and specificity remain unchanged), what happens to test validity if the prevalence changes?
First, we begin with previous information that the prevalence of undetected diastolic hypertension among those over age 65 in this Sun Belt population may be only 8% because most people in this population already know their blood pressures and are in fact under medical care. Combining this figure with the known sensitivity of 95% and specificity of 95% gives the results shown in Table 13-3.

TABLE 13-3 CALCULATION OF EXPECTED DIASTOLIC HYPERTENSION SCREENING OUTCOMES (PREVALENCE OF 8 PERCENT, TEST SENSITIVITY OF 95 PERCENT, AND SPECIFICITY OF 95 PERCENT)

Working backward, we start with a total population of 1000 and an expected prevalence of 8% in the population of interest. The resulting N of a + c (prevalence) equals 80 (8% of 1000). The total population (a + b + c + d) of 1000 less the expected prevalence a + c (80) equals 920 nondiseased (which equals b + d). Using the known percentages for sensitivity (95%) and specificity (95%), we then calculate values for all the remaining cells. From Table 13-2, we know that the sensitivity and specificity remain unchanged, and thus the percentages of false-negatives and false-positives will also remain the same. However, when we compare the predictive values of the same screening test in these two settings (but with prevalences of 28% and 8%, respectively), the results are quite different.
The predictive value of a screening test refers to the likelihood that the subject with a positive test result actually has the disease of interest (positive predictive value) or that a subject with a negative test result does not have the disease of interest (negative predictive value). The calculation of predictive value is derived by computing the ratio of true outcomes to all outcomes for both negative and positive test results, based on Bayes’ probability theorem.43 Expressed mathematically, the predictive value of a positive test result is TP/TP + FP (or a/a + b, where TP = true positive and FP = false positive), and the predictive value of a negative test result is TN/TN + FN (or d/c + d, where TN = true negative and FN = false negative). From Table 13-2, the positive predictive value is 266/302 × 100 or 88.0%, and the negative predictive value is 684/698 × 100 or 98.0%. As shown in Table 13-3, the positive predictive value is 76/122 × 100 or 62.3%, and the negative predictive value is 874/878 × 100 or 99.5%.
Comparison of these values shows us that a difference in prevalence can have a major impact on the predictive value of a screening test. In the first example (see Table 13-2), the predictive value of a positive test result was more than 88%. Thus, 88 persons of every 100 with a positive test result would be true positives, and 12 would not be true positives. In the second example shown Table 13-3, the predictive value of a positive test result was less than 63%. Here, only 62 elderly persons of each 100 with a positive test result would be true positives, and 38 screened persons with a positive result would in fact not be hypertensive.
The problem of limited predictive value is even greater when prevalence is very low (below 3%, for instance). As Vecchio has shown, the predictive value of a single diagnostic test in unselected populations is markedly affected by the prevalence of the condition and by the pretest “likelihood of positivity.”44 Thus, even when test sensitivity and test specificity are high, there may still be an unacceptably large number of false-positive results when prevalence is low. This relationship is displayed in Figure 13-1, and it has been confirmed for many disorders, including diabetes mellitus and lung, breast, and cervical cancer. In addition to these limitations, many biases can affect preventive assessment efforts, such as unmasking (signal detection) bias, diagnostic suspicion bias, lead time (starting time) bias, volunteer bias, exposure-suspicion bias, diagnostic access bias, mimicry bias, previous opinion bias, and Neyman (prevalence-incidence) bias. Biases produce screening results that differ systematically from “the truth,” and the extent to which bias is controlled increases overall validity of screening and case-finding.

Figure 13-1 Relationship between prevalence of disease and predictive value, with sensitivity held constant at 95% and specificity held constant at 95%. (Adapted from Vecchio TJ: Predictive value of a single diagnostic test in unselected populations. N Engl J Med 274:1171, 1966.)

Step Four: Effectiveness of Preventive Assessment
Blood pressure screening is well accepted by patients, providers, and the health care system. However, labeling of individuals as hypertensive often leads to new problems such as lowered self-esteem, higher work absenteeism, lower productivity, and “sick role” behavior. These phenomena have occurred among untreated hypertensives and among mislabeled normotensives. Such problems can thus be attributed to the labeling process itself and are not necessarily due to the disease process of hypertension (which is asymptomatic in most patients) or to the side effects of treatment. Diagnostic labeling is especially important in assessing the elderly.
Compliance also affects clinical outcomes. Compliance for keeping appointments following screening for blood pressure ranges from 50% to 83% and is affected by the demographics of the patient, features of the screening test, clinical setting, condition of interest, perceived therapeutic regimen, patient-therapist interaction, and sociobehavioral aspects of the patient and the therapist. Even the most rigorous and valid screening test (one with high sensitivity and high specificity as well as a high predictive value) may lack adequate effectiveness if it is unacceptable to patients or practitioners or if compliance is too low.
Step Five: Community Effectiveness
This process is concerned with the availability, accessibility, and validity of definitive diagnostic services and with the efficacy and effectiveness of therapies for individuals with positive results on screening or preventive assessment tests. For hypertension, interobserver and intraobserver variations in measuring blood pressure limit the accuracy of this diagnosis, and this is further complicated by controversy about what constitutes hypertension that warrants treatment among persons over the age of 65 years.
Although the efficacy of treatment is well established for some forms of hypertension in some populations, diagnostic inaccuracy, clinical disagreement, and lack of compliance by patients and providers markedly reduce the effective coverage and impact of appropriate services and treatment of hypertension among the elderly.45
Step Six: Efficiency (Economic Evaluation)
The final (and usually the most difficult) step in analyzing the evidence on preventive assessment is an evaluation of its cost-effectiveness. For hypertension, cost-effectiveness was analyzed early by Weinstein and Stason.46 Their cost estimates of hypertension screening and care per year of increased quality-adjusted life expectancy (impact) were lowest when services were provided in the form of office-based case-finding rather than as community-wide screening.
Logan and colleagues published a pioneering cost-effectiveness analysis of nurse practitioner care of hypertensives at work sites with physician office care. They found that nurse care was more effective and less costly.47 Cost-benefit and cost-utility analysis of treating hypertension has not yet been well analyzed, nor has the cost-effectiveness of treating hypertension been compared with that of treating other disorders.
Economic analysis of hypertension screening or care among the elderly is further complicated by the finding that different high blood pressure cut-off levels markedly affect the results of cost-effectiveness analysis. It has been demonstrated that procedures that are cost effective for screening hypertension at age 30 are not cost effective when they are used for screening at age 60. As Weinstein pointed out, “These analyses underline the principle that even though screening (for hypertension) is relatively inexpensive, the large attrition between detection and ultimate blood pressure control severely compromises its cost-effectiveness…. [P]rograms to screen for hypertension are indicated on cost-effectiveness grounds only if adequate resources are available to ensure that detection is translated into effective long-term blood pressure control.”46
GOALS OF PREVENTIVE ASSESSMENT OF THE ELDERLY
In the context of the foregoing general screening principles and methodologic criteria, what goals are reasonable for prescriptive preventive geriatrics? The United Kingdom has advocated screening the elderly “to preserve physical health, to maintain mental health, and to preserve social standing and circumstances,”3 and to discover minor disabilities that can limit coping ability and enjoyment of life. Other screening goals have included establishing comprehensive baselines, devising forms and systems to promote periodic health assessments as integral elements of office practice, fostering teamwork, and developing information about elderly problems.
Others support screening to detect early problems among those with locomotor difficulties, those recently discharged from the hospital, those bereaved or living alone, those with financial troubles, and those over age 80 regardless of health status.14 The World Health Organization advises geriatric screening “to keep the elderly in good health and happiness in their own houses for as long as this is possible,” and Breslow and Somers define health monitoring for those 60 to 74 years old to prolong optimum physical, mental, and social activity and to minimize handicaps from chronic conditions. For those over age 75, health goals are to prolong effective activity, to live independently, to minimize inactivity and discomfort, to avoid institutionalization, and, when illness is terminal, to ensure minimal distress and maximum emotional support to dying patients and their families.16
The Report of the U.S. Preventive Services Task Force in its 1996 Guide to Clinical Preventive Services devotes over 900 pages and thousands of references to support appropriate recommendations that meet the methodologic criteria outlined in this review.21 Based on these and other rigorously conducted studies, mainly in the United States and Canada, specific recommendations can be made at this time for appropriate periodic health assessment of the elderly; these are summarized in the following sections.
SPECIFIC RECOMMENDATIONS
These guidelines are based on the general principles described earlier. Preventive assessment of the young elderly (those aged 65 to 74 years) focuses mainly on health problems that can be eliminated or controlled, and assessment of those over age 75 emphasizes reducing problems that impair function but for which cure or optimal control is less likely. Further, tests and procedures should be limited to those that meet standards of sufficient validity and that are acceptable and likely to make a difference to the person’s overall health status. Although some scientific evidence that allows fully informed decision-making about office-based elderly screening and follow-up is available for some conditions found in the elderly, other evidence is often lacking at the level of the individual patient. Thus, definitive recommendations for preventive assessment of the elderly for a number of conditions and problems remain incomplete.
In categories for which information is incomplete, guidelines are based on the best available data using the methodology of the U.S. Clinical Preventive Health Services Task Force and others.20,21,27,29,31,33,48,49,50,51,52 and 53 When a recommendation is either absent or equivocal, individual clinical judgment based on general screening principles, guidelines, and methodologic criteria is suggested.
Table 13-4, Table 13-5 and Figure 13-2 display periodic health assessment and health maintenance recommendations for the elderly based on the foregoing general principles, criteria, and quality of the evidence. Table 13-4 lists conditions for which direct intervention and follow-up are warranted (many such interventions can be efficiently and effectively conducted by supervised nonphysician health personnel). Home follow-up (often in conjunction with community resources), where available, is often necessary and appropriate in many instances. With elderly patients, the medical practitioner’s role includes a large element of coordination of services to maintain health and to preserve independent functioning.

TABLE 13-4 RECOMMENDED HEALTH ASSESSMENT AND HEALTH MAINTENANCE ACTIVITIES FOR ELDERLY PATIENTS

TABLE 13-5 CONDITIONS REQUIRING FURTHER RESEARCH TO DETERMINE APPROPRIATENESS OF SCREENING AND CASE-FINDING IN ASYMPTOMATIC ELDERLY

Figure 13-2 Health maintenance flow sheet for older adults (65 to 90 years of age).

Table 13-5 contains a list of conditions that require further research to determine whether preventive assessment among the elderly is warranted (either as screening or as case-finding) and if so, in what form, how often, for how long, and to what end. Problems listed in Part A do warrant periodic assessment at this time, but problems shown in Part B do not presently warrant either screening or case-finding based on the methodologic criteria and quality of the evidence now available.
Figure 13-2 is a health maintenance flow sheet for elderly patients. This recommended schedule of preventive interventions is based on current knowledge and principles consistent with methodologic criteria for preventive assessment in general. Modifications of Figure 13-2 and of Table 13-4 and Table 13-5 are anticipated as more information becomes available through advances in clinical prevention research in the areas of periodic health assessment and health maintenance of the elderly.
Listed below are principles and guidelines for preventive assessment of the elderly.

1.
Use of nonphysician health personnel is central to sound preventive assessment and health surveillance of the elderly.

2.
Preventive assessment of the elderly is acceptable and preferable when it is conducted in health facilities or the home rather than in the community at large.

3.
Regular episodic “health maintenance” activities intended to preserve function and prevent or reduce impairment are more appropriate than exhaustive, expensive, and often ineffective searches for new diseases or diagnoses, especially in persons over age 80.

4.
Systematic checklists and office flow sheets are expeditious methods for monitoring screening results and the health status of elderly patients.

5.
Technologic advances enhance elderly preventive assessment, but use of procedures or methods that have not been validated should be limited until they have been evaluated.

6.
The periodic health examination has a relatively low sensitivity for the detection of major disorders that have lethal outcomes, and extensive health surveillance programs for the elderly are not currently justifiable on methodologic grounds.

7.
The frail elderly in the community are especially susceptible to the “inverse care law.” That is, those in greatest need and for whom preventive assessment and surveillance have the highest potential benefit are most likely to be missed or to default. Active case-finding and close follow-up of elderly with particularly high risk (the lonely, the recently bereaved, and the poor) are especially important health intervention priorities.

8.
Lifetime health monitoring is a useful process in the spectrum of risk-based preventive assessment. Extension of this approach among the elderly is particularly worthwhile when it is conducted in accordance with guidelines of the U.S. Preventive Services Task Force, the American Academy of Family Physicians, the American College of Physicians, and the Canadian Task Force on the Periodic Examination.20,21,48,49,53

9.
Research aimed at further defining and delineating the efficacy of specific preventive assessment interventions based on sound clinical and epidemiologic principles continues to be needed because of the urgency of the “geriatric imperative” in the United States.

10.
The ultimate dictum of primum non nocere (“first, do no harm”) is highly germane in preventive assessment of the elderly. Holland’s insight in 1974 remains true today: “In the middle-aged and elderly, simple tests for vision and hearing and tests to identify people in need of chiropody or walking aids may be far more effective than more complex biochemical and laboratory-oriented procedures in improving the ‘quality of life.’”50
Although more scientifically based recommendations either for or against specific preventive assessments in the elderly are becoming validated,25,26,27,28 and 29 the quality of much evidence at this time remains inadequate to justify high-level intervention.22,23 and 24 However, “therapeutic nihilism” is also a risk in that appropriate interventions might not be undertaken based solely on one’s age rather than on the full range of factors relevant to the individual patient and his or her wishes.54
SUMMARY
The challenge, then, is to find the right balance between the value of screening the elderly through periodic health assessments to identify and correct or minimize treatable problems on the one hand, and, on the other hand, to avoid the very real problem that clinically or biochemically inapparent (and most often insignificant) “abnormalities” may lead to overzealous investigation and overtreatment of the elderly at high cost, inconvenience, and risk.55,56 Conversely, reflex ageism that denies otherwise appropriate interventions based on age discrimination alone also warrants cautious monitoring.57 In the end, sound clinical judgment is always necessary. Especially for those caring for the elderly in times of critical change in health care structure, finance, and accessibility, it is also irreplaceable.
CHAPTER REFERENCES

1.
Commission on Chronic Illness: Chronic Illness in the United States, Vol. 1. Prevention of Chronic Illness. Cambridge, Harvard University Press, 1957, p. 45.

2.
Sackett DL: Screening in family practice: Prevention, levels of evidence, and the pitfalls of common sense. J Fam Pract 1987;24:233–234.

3.
Whitby LG: Screening for disease: Definitions and criteria. Lancet 1974;2:819–822.

4.
Lowther CP, Macleod RDM, Williamson J: Evaluation of early diagnostic services for the elderly. Br Med J 1970;3:275–277.

5.
Currie G, MacNeil RM, Walker JG, et al: Medical and social screening of patients aged 70-72 by an urban general practice health team. Br Med J 1974;2:108–111.

6.
Milne JS, Maule M, Williamson J: Method of sampling in a study of older people with a comparison of respondents and non-respondents. Br J Prev Soc Med 1971;25:37–41.

7.
Powell C, Crombie A. The Kilsyth questionnaire: A method of screening elderly people at home. Age Ageing 1974;3:23–28.

8.
Burns C: Geriatric care in general practice. A medico-social survey of 391 patients undertaken by health visitors. J R Coll Gen Pract 1969;18:287–296.

9.
Tomlinson JM: Setting up a geriatric survey in general practice. Update 1976;8:277–281.

10.
Taylor GF, Eddy TP, Scott DL: A survey of 216 elderly men and women in general practice. J R Coll Gen Pract 1971;21:267–275.

11.
Steel K, Williams F, Fairbank M, Knox K: Laboratory screening in the evaluation and placement of geriatric patients. J Am Geriatr Soc 1974;22:538–543.

12.
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