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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 57:M338-M342 (2002)
© 2002 The Gerontological Society of America

Editorial It's Never Too Late

Health Promotion and Illness Prevention in Older Persons

John E. Morleya and Joseph H. Flahertya

a Division of Geriatric Medicine, Saint Louis University, and GRECC, Veterans Administration Medical Center, St. Louis, Missouri

John E. Morley, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104 E-mail: morley{at}slu.edu.

MORE than 20 years ago, James Fries (1) suggested that healthy lifestyle habits could result in a compression of morbidity. In this issue of the Journal, together with his colleagues, he provides evidence that healthy lifestyle habits postpone and reduce morbidity (2).

Frailty represents a major comorbidity in older persons (3)(4). In general, most organ systems demonstrate an age-related decline of about 0.5% per year (5). In physically active older adults both V.O2 max (6) and muscle power (7) decline at the rate of 0.5% per year. Overall decline in physical activity (8) as well as the specific decrease in muscle power (9), lower limb function (10)(11), and balance (10)(12) are all key factors on the road to frailty. Exercise programs should be designed to increase muscle power (13). Regular light exercise for 30 minutes a day will maintain muscular strength but not necessarily increase cardiovascular fitness (14). Although some authorities feel exercise programs will improve long-term function (15) and quality of life (16), others have pointed out that there is a paucity of data to make an evidence-based conclusion that exercise improves function in the long term (17).

Rubenstein and colleagues (18) found that a group exercise program for 90 minutes three times a week improved endurance, strength, and function in older individuals. It also decreased falls. A resistance exercise program decreased dysphoria in seniors (19). Stewart and colleagues (20) designed an individual physical activity program designed to increase older persons' lifetime activities. This program resulted in a substantial increase in physical activity that was maintained for more than a year. Clearly, increasing physical activity represents an important lifestyle intervention to decrease the prevalence of frailty. Physicians need to encourage patients to take part in physical activity. Programs such as that designed by Stewart and colleagues (20) should be provided at health centers.

Besides declining physical activity with aging, the other major cause of sarcopenia leading to frailty in males is testosterone deficiency (21)(22). Testosterone levels decline with age (23)(24). This decline has been shown in epidemiological studies to be an important factor in the decline in muscle mass and muscle strength with aging (25) and with functional impairment (26). Testosterone replacement in hypogonadal older males increased both muscle mass (27)(28), strength (29)(30), and bone mineral density (31). Testosterone also may enhance cognitive function (23). Decline in cognitive function is also a factor in the pathogenesis of frailty (32). Older men should be screened regularly for hypogonadism utilizing the androgenic deficiency in aging men (ADAM) questionnaire and a measurement of bioavailable testosterone when the ADAM is positive (33).

Cardiovascular disease has been demonstrated to be a factor in the development of frailty, and one of the major risk factors associated with cardiovascular disease is tobacco use (34). For smokers, compared with nonsmokers, the incidence of myocardial infarction may be increased as high as sixfold in women and threefold in men (35)(36). Risk of recurrent infarction in smokers may decline by as much as 50% within 1 year of smoking cessation and may normalize to that of nonsmokers within 2 years (37). In agreement with the "It's never too late" motto, the benefits of smoking cessation on cardiovascular disease are seen regardless of how long or how much the patient smoked previously (37), and the benefits are equivalent in older compared with younger patients (38). An additional frailty-prevention benefit of smoking, cessation is an improvement in exercise tolerance (39). Although the evidence continues to mount that depressive symptoms are associated with increased cardiovascular risk (40)(41), even among older patients (42), it is unclear whether depression is a marker for cardiac disease or is somehow linked to a neuropsychoimmunology pathway yet to be fully identified (43). Interestingly, one of the major risk factors for death among depressed persons is smoking (44). Whatever the biochemical or pathophysiological link is that fully explains these associations, it cannot be argued that smoking cessation is not beneficial, and with the current pressures to "use or not use" high-tech, high-cost interventions to prevent or treat cardiovascular disease, it is good timing that Kaplan and colleagues report in this issue of the Journal that regular visits to health care professionals are associated with a lower likelihood of smoking (45).

Hypertension (46)(47) and diabetes mellitus (48)(49) also represent major reversible risk factors for cardiovascular disease in older persons. Aerobic exercise lowers resting blood pressure in older adults (50). Although cholesterol lowering in the oldest-old remains controversial based on its putative effects on cognition (51), it needs to be considered in all older persons following a myocardial infarction (52). Cardiovascular risk factors represent an important area for secondary prevention. All patients who smoke should be advised to stop at each visit.

Nutrition advice for the older patient should focus on weight maintenance (53)(54). Two excellent screening tests have been published recently in the Journal (55)(56). In addition, it has been shown that physicians fail to recognize older persons with osteoporosis (57). All persons, regardless of ethnicity or sex, should be assumed to be at risk of osteoporosis until proved not to be by measurement of bone mineral density (58). The majority of older persons should be advised to take calcium and vitamin D (59)(60). Bisphosphonates should be given to older persons with osteoporosis to prevent the poor outcomes seen following hip fractures (61)(62). Because of the high risk of dehydration in older persons (63), they should be encouraged to ingest at least 4 to 6 glasses of fluid per day (64). The regular use of other vitamins in either physiological or pharmacological doses is controversial, but should be considered in all malnourished individuals (65). There is some evidence that vitamin E will decrease infection in older persons (66). As pointed out by Amarantos and colleagues (67), "good nutrition promotes health related quality of life by averting malnutrition, preventing dietary deficiency disease and promoting optimal functioning" (p. 54).

Disability prevention includes the active management of pain (68). Chronic pain results in decreased physical activity and depression (69)(70). Appropriate pain management improves outcomes during resistance exercise programs (71) and function in persons with arthritis (72)(73).

Health promotion and illness prevention range from simple but highly effective interventions, such as influenza vaccination, which are easily carried out in the office (74), to screening for depression (75) or general screening in the home (76). Geriatricians need to be active promoters of the concepts of preventive medicine and a healthy lifestyle for older persons.

When the geriatrician undertakes a health promotion program, it is important to remember that in education "less is more." Thus, for each individual patient the physician needs to prioritize the one or two areas from which the patient will benefit most and concentrate on encouraging the patient to alter this one lifestyle factor. Once this has happened, the patient should be congratulated and the positive behavior reinforced for a number of visits before another intervention is attempted.

Geriatricians have recognized that all older persons are not the same with regard to appropriate interventions. The interventions for healthy elderly persons should differ from those for frail older persons, those with dementia, and those at the end of life. Keeping this in mind and being aware of the limitations of practice guidelines (e.g., rigid, usually based only on age) and the paucity of applicable evidence-based medicine (EBM), intervention studies usually do not include frail, older persons, those with dementia, and those at the end of life. Full-time practicing geriatricians from Gerimed of America, a medical management company specializing in primary care geriatrics, and academic geriatricians from Saint Louis University developed outpatient clinical GlidepathsTM. The development process was based on a literature review. After identification of common outpatient illnesses/problems/syndromes faced by physicians, evaluation and management strategies were developed for four categories of older patients (Robust, Frail, Demented, and End of Life). These categories were defined based on functionality and life expectancy. The recommendations then underwent critical review by academic geriatricians based on available EBM and practice guidelines. In particular, attention was paid to areas where EBM was lacking. The final step in development was to review the GlidepathsTM using a modified Delphi process to reach consensus among an expert panel consisting of 15 private practice and academic geriatricians, cardiologists, endocrinologists, and an urologist (77)(78)(79)(80). Based on one of the 24 GlidepathsTM, the Health Maintenance GlidepathTM, a simple form was developed that the patient is able to fill out, called the "Passport to Aging Successfully" (Fig. 1). The patient is then empowered to discuss with the physician any health promotion items that have not been addressed.



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  		Figure 1. Saint Louis University Health Maintenance "Passport to Aging Successfully" for patients. This is available for patients at www. thedoctorwillseeyounow.com. Reprinted with permission from Gerimed® and Saint Louis University Division of Geriatric Medicine.

 
It is hoped that the two articles (2)(45) in this issue of the Journal will stimulate geriatricians and other health professionals to put a premium on health promotion and illness prevention programs for older persons. Influenza and pneumococcal vaccinations, physical exercise programs, balanced nutrition advice, advice to cease smoking, appropriate treatment of pain to allow full expression of physical activity, treatment of male hypogonadism, screening and treatment of osteopenia, and early detection and treatment of hypertension and diabetes mellitus will go a long way to improving health care of older persons. The "HEALTH PROMOTIONS" mnemonic (Table 1 ) is provided as a tool to help physicians remember to cover primary and secondary prevention in their office practices.


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  		Table 1. The "HEALTH PROMOTIONS" Mnemonic To Help Physicians Remember To Do Primary and Secondary Prevention

 


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