INTERVENTION

Primary & Secondary

Prevention
Annisa Wuri Kartika

Preambule.

Chronic diseases account for 7 of every 10 deaths;

affect the quality of life of 90 million Americans.
1993 vs. 2001: US adults reported:
Deterioration in:

physical health
mental health
ability to do their usual activities

Increase in unhealthy days

5.2 to 6.1 days

Adults 45-54 years old had consistently greater

deterioration than younger or older adults.
http://apps.nccd.cdc.gov/HRQOL/TrendV.asp?State=1&Measure=5&Category=1

Health Status of Older Adults

88% - at least one chronic condition
50% - at least two chronic conditions
34% experience some activity limitation
26% assess health as fair or poor
CDC-MIAH 2004; CDC/NCHS Health US, 2002

41% of older African Americans

Leading Causes of Death, Age 65+

(2001)
Heart Disease

32%

Cancer

22%

Stroke

8%

Chronic Respiratory 6%
Flu/Pneumonia

3%

CDC-MIAH 2004; CDC/NCHS Health US, 2002

Chronic Disease

Modifiable Lifestyle Risk factors

Smoking
Physical inactivity
Inadequate diet
Alcohol abuse
Social isolation

Guiding Principles
Make Prevention a Priority
Start with the Science Evidence
Work for Equity and Social Justice
Foster Interdependence
Aging network
Health care
Public health
Long term care
Mental health
Research
* James Marks, MD

PRIMARY PREVENTION
_Healthy Ageing_

Healthy ageing
WHO defines health as:

a state of complete physical, mental and social wellbeing

and not merely the absence of disease or infirmity
WHO defines active ageing as:

the process of optimizing opportunities for health,

participation and security in order to enhance quality of

life as people age allowing people to realize their
potential for physical, social and mental well-being
throughout the life course
WHO (2001) suggests a major determinant of healthy
ageing is living an independent life for as long as
possible

Healthy Older People View

Can have health problems and still age well
Keeping active (mentally and physically)
Enjoying life
Keeping engaged
Positive attitude
Meaningful engagement
Good relationships with family and friends
Physical activity important

Active Ageing Framework

Health
Prevention of chronic

disease and disability

Reducing risk factors and
increasing protective factors
throughout the life course
Health and social services
Education and training to
caregivers.

Cont,.
Participation
Life long education and learning opportunities
active participation in economic development
formal and informal work and voluntary

activities
full participation in family & community life
Security (social, financial and physical) & rights

Evidence for Healthy Ageing

Keeping active
Social and meaningful participation
Eating well
Environments that support health
Mental wellbeing
Good relationships with family

and friends
Optimism

Benefits to Older Adults

Reviewed in A New Vision of Aging
Longer life
Reduced disability
Later onset
Fewer years of disability prior to death
Fewer falls

Improved mental health

Positive effect on depressive symptoms
Possible delays in loss of cognitive function

Lower health care costs

http://www.cfah.org/programs/aging

Social Ecologic Model of Healthy Aging

Public Policy
Community
Organizational
Interpersonal
Individual

McLeroy et al., 1988, Health Educ Q; Sallis et al., 1998, Am J Prev Med

Cont,
The health and well-being of older adults will be

improved only if we work from a broad perspective.

Comprehensive planning and partnerships at all

levels are required.

Harassing individuals about their bad habits has

very little impact.

Changes at the individual level will come with

improvements at the organizational, community and

Level of Prevention
Primary prevention involves measures to prevent

an illness or disease from occurring, for example,

immunizations, proper nutrition, and regular fluoride
dental treatments.
Secondary prevention refers to methods and
procedures to detect the presence of disease in the early
stages so that effective treatment and cure are more likely
( Routine mammograms, hypertension screening)
Tertiary prevention is needed after the disease or
condition has been diagnosed and treated. This is an
attempt to return the client to an optimum level of health
and wellness despite the disease or condition.

Primary Prevention
Ideal health promotion behaviors at the level of

primary prevention, include:

smoking cessation and
limited alcohol consumption,
good nutrition,
exercise,
adequate sleep,
safe lifestyles, and
updated immunizations.

Cont,.
One of the greatest barriers surrounds misconceptions

about the benefits of health promotion for older

adults.
Another barrier lies in the challenge of separating the
normal changes of aging from pathological illness.
For example, joints normally stiffen as one ages, causing the older

adult to use the joint less for fear that the stiffness may worsen

A final barrier to improving the health promoting

activities of older adults is their own motivation to

change. In fact, this is the most important factor in
improving health

Older adults are

never too old to

improve their
nutritional level,
start exercising,
get a better
nights sleep, and
improve their
overall health
and safety.

Health Promotion As Primary Prevention

On their face, both health promotion and primary

prevention seek to avoid the untoward consequences

of illness, accidents, environmental stressors, and
less than ideal personal habits
Health promotion must be concerned with wellbeing, not just the absence of disease or infirmity.

Health promotion of the elderly

Health promotion is the process of enabling

people to increase control over & improve their

health by developing their resources to maintain or
enhance well being.
Health promoting is an action for health using

knowledge, communication & understanding

Objectives of health promotion

Increase quality and years of healthy life

Maintain function
Eliminate health disparities and independency
Improve (enhance) quality of life
Extend life expectancy premature mortality
caused by chronic& acute diseases

Health Promotion (Strategies)

Education
Physical activity programs
Volunteering
Age friendly cities

Health Education
Most common form of health promotion
Relies on health literacy
Delivery methods

Health professional
Peer education
Mass media

Physical activity programs

Physical activity guidelines
Group based programs

Benefit of social component

Higher participation rates
Increased physical activity
Barriers ageism, ageist stereotypes, built
environment, hard to reach groups

Volunteering
Volunteering is generally defined as unpaid work for

or through an organization
Benefits:
Morbidity
Functional health
Self reported health
Life satisfaction
Possibility of maintaining physical and cognitive
activity
Strong personal and emotional support
Opportunity to contribute to others
Not all volunteering has equal benefit

Age Friendly Cities

Started in 2005 by WHO, 33 cities
Inclusion of older people in planning and

development (focus groups)

Global Age Friendly Cities Guide
Global Network
to help cities see themselves from the perspective of
older people in order to identify where and how
they can become more age-friendly

Sampel
Medan
Payakumbuh
Balikpapan
Makasar
Jakarta pusat
Depok
Bandung
Semarang
Surakarta
Yogyakarta
Surabaya
Malang
Denpasar
Mataram

Component of health promotion

1.
2.
3.
4.
5.
6.
7.

Exercise
Nutrition
Rest & sleep
High risk behavior
Spiritual well-being
Psychosocial well-being
Periodic medical check up

1- Exercise
Physical benefits
Consumption of body fat
Improve cardio-vascular capacity
( by blood flow----- keep tissue
healthy
3) Control hypertension& blood sugar
4) Improve respiratory function
5) Improve joint flexibility
6) Improve pattern of sleep & rest
7) independency
8) Improve sense of well being &
relaxation
9) Maintain minds function
10) Promote sense of normality
11) Peristaltic movement
1)
2)

Psychological benefits
1.
2.
3.
4.
5.

Improve mood state

Improve self-image
Reduce stress
Enhance sleep
Improve depressive
state of elderly

Role of the nurse during exercise

I- Assessment done at the beginning of exercise
program include:
1. History & physical examination (CVS, resp,
musculoskeletal & neurological system)
2. Renal & liver function tests
3. ECG,& exercise stress test
4. Assess range of motion & use of assistive devices.
5. Assess environmental hazards
II-Set a regular time to exercise each day

III- Before starting exercise the nurse should advice the

elderly about:
1. Document baseline resting function status (ht &resp rate,
bl.sugar)
2. 10 minutes warms up stretching exercise
3. Drink water before and after exercise is important as
water will be lost during exercise
4. Clothes worn during exercise should allow for easy
movement and perspiration.
5. Athletic shoes provide both support and protection
6. Outdoor exercise should be avoided in extremely hot or
cold weather.

IV . During exercise
Monitor heart & resp. rate
Stop exercise if elderly has fatigue , chest pain or

heart & resp. rate

After exercise:
10 minutes cooling up at end of exercise
Monitor pulse rate during cooling for returning
to resting ht. rate

2- Nutrition
It is neglected especially those living alone or
with low income.

Factors affecting nutritional status:

1)
2)
3)
4)

Age related changes

Psychosocial factors
Economic factors
Cultural factors

Nutritional requirement of elderly

1- Calories
Caloric requirement diminished by 10% in age 51-75 years

and by 20-25% in age more than 75 years. (man = 1960

cal, woman = 1700 cal)
N.B: Fat yield 9 cal/gram, CHO and protein yield 4
cal/gram, mineral and water yield no calories
2- Protein requirement
0.8 g/kg body wt
A balanced diet of a healthy elderly should contain 12-14%

of total caloric intake.

During infection, stress, trauma protein to 1.6 or 1.5 g/kg

body wt

3-Fat requirement
Fat either saturated or unsaturated
Total fat intake limited to 30 % or less of total energy

intake
Saturated fat limited to 10-15% of total energy intake
Dietary cholesterol intake limited to 300mg/ day or less

4- Carbohydrates requirement
CHO is essential for maintaining normal bl. glucose level &

preventing protein break down.

50% of total calories---- CHO
Complex CHO as vegetables, grains, fruits
Complex CHO has vit, minerals, fibers which help in bowel
elimination& bl. cholesterol level.

5-Fluid intake
Elderly at high risk for dehydration due to:
1.
2.
3.
4.
5.

6.

7.

Thirst sensation
Inadequate fluid intake (2000-3000 cc/day) required
Some medications, such as for high blood pressure or antidepressants, and diuretic
Some medications may cause patients to sweat more
Frail seniors have a harder time getting up to get a drink when
theyre thirsty, or they rely on caregivers who cant sense that
they need fluids
As we age our bodies lose kidney function and are less able to
conserve fluid (this is progressive from around the age of 50,
but becomes more acute and noticeable over the age of 70)
Illness, especially one that causes vomiting and/or diarrhea,
also can cause elderly dehydration

6- Vitamins & mineral requirements

Calcium for

mineralization of bone & has

a role in blood & cardiac
function.
Daily requirement 1200
mg./day if there is no
contraindications
Vitamin D needed for
calcium absorption &
metabolism.

Nurse Role
Assessment involves: nutritional history, physical

examination, anthropometric measurements, biochemical

evaluation, cognitive & mood evaluation
Health history related to nutrition
Anthropometric measurement
Client and family education

Dietary guideline for old persons

Eat a variety of food - Maintain a healthy weight
Choose a diet low in fat,
- Use sugar & salts in moderate

saturated & cholesterol

Choose a diet plenty of - Drink 200-3000cc/daily
vegetables, fruits & grain products

3- Rest& sleep
Person spend 1/3 of his life in sleep
Sleep is time for cell growth & repair
Elderly need 5-7 hrs at night

Importance of Rest& sleep:

1) Conserve energy
2) Provide organ respite (rest)
3) Restore the mental alertness & neurological
efficiency
4) Relieve tension

Nursing measures adopted to promote sleep

1.
2.
3.
4.
5.
6.
7.
8.
9.

Engage in exercise program

Avoid exercise within 3-4 hour of bedtime.
Spend time out door in the sunlight each day but avoid
period between 12 Md to 3 PM sunshine exposure.
Engage in relaxing activities near bedtime
Avoid tobacco at bedtime
Avoid drink any caffeinated beverages before mid
afternoon.
Limit fluid intake after the dinner hour if nocturia is a
problem.
Limit daytime naps to 30 minutes or less.
Avoid using the bed for watching TV, writing bills,
and reading.

4- High Risk Behavior

It is behavior that damage physical health.

It includes:
Over the counter medication (multiple
medications )
Smoking
Caffeine

Smoking
Nicotine & toxic substances in cigarette has impact on de-

toxication process in the body-cell damage & variety of

diseases as cancer, respiratory, CVD, risk of osteoporosis
Cessation of smoking improves cerebral blood flow&

pulmonary function
Interventions to stop smoking usually surround behavioral
management classes, and support groups are available to
community-dwelling older adults.
Nicotine-replacement therapy and anti-depression
medications are also helpful in assisting the older adult to
quit smoking.

Multiple Medication
Older people consume many medication adverse drug reaction
The most common over the counter medication: Analgesics,

laxatives & antacids followed by cough products, eye wash&

vitamins.

Caffeine
Found in coffee, tea, soft drinks, chocolate
It is mood elevator
It stimulates sympathetic nervous system
motor activity
muscle capacity & alertness
Rapid pulse
calcium excretion

5- Spiritual Well- being

Spiritual Well-being is the

practice and philosophy of

the integral aspects of
mental, emotional and
overall wellbeing.
Spiritual Well-being is a
state in which the positive
aspects of spirituality are
experienced, incorporated
and lived by the individual
and reflected into ones
environment.

Signs of spiritual
distress:
Doubt
Despair
Guilt
Boredom
Expression of anger
toward god

6- Psychosocial Well- being

* Psychosocial changes may alter an individual
relationship with others.
* Physical well-being depend on:
Psychosocial wellbeing
Social structure
Personal relationships

7- Periodic medical examination

Importance of Periodic medical examination:
1. Assess elderly level of well-being
2. Detect early signs of disease
3. Educate client how to promote his health
4. Reinforce promoting & protecting behaviors
5. If examination done at home, it permit
evaluation of environment

Immunizations
Vaccination
Influenza (over
65y)
Tetanus &
diphtheria
Pneumococcal
vaccination

Period
Annually (mid
October to mid
November)
Every 10 years
Once at age 65y,
revaccination for
high risk fatal
pneumonia/6 y

Fall Prevention
Fall prevention interventions include a thorough

assessment of the environment in which the older adult

lives.
Area rugs and furniture that may be fall hazards should
be removed and appropriate lighting and supports
should be added to areas in which older adults ambulate.
Many homes and facilities have placed a patients
mattress on the floor to prevent injuries from falling out
of bed.
The use of wall-to-wall carpeting also pads a patients
fall, resulting in less injury on impact.
The use of an alarm for the bed or wheelchair to alert
caregivers of an older adults mobility may assist older
adults who have had falls in the past

Role of the nurse in health promotion

Assessment to his physical health, Psychosocial

Well- being, lifestyle pattern, hobbies, high risk

behaviors, knowledge, believes& attitudes that
affect health & wellbeing.
Assess health needs
Assess social , environmental & cultural influences
on health behaviors
Lifestyle modifications is a comprehensive
approach for effective change in heath promotion
behaviors

Role of the nurse in health promotion

Nurse role should directed toward helping elderly to cope

with his function level delay disabilities & impairments.

Nurse identify environmental hazards & make necessary
modifications
Identify social needs & encourage participation & social
support groups.
Nurse should inform elderly & caregivers about aging process,
common disorders & disabilities , different services available
Encourage elderly to take better care to them, avoid high risk
behaviors,& hazards affecting their health.
Regular and continuous evaluation is important aspect of
nurses role

SECONDARY
PREVENTION

Secondary Prevention
Based on early detection of disease screening or case-

finding, followed by treatment

Strategies for detecting disease at an early stage involve
annual physical examinations; laboratory blood tests for
tumor markers, cholesterol, and other highly treatable
illnesses; and diagnostic imaging for the presence of
internal disease.
Screening process of evaluating a group of people
for asymptomatic disease or risk factor for developing
disease, usually occur in community setting and applied
to a population
Case finding process of searching for asymptomatic
disease and risk factor among pepople in clinical setting

The Process of Screening

Types of health screening

Health screening
Blood Pressure
Height & wt

Dental check up
Fecal occult blood&
sigmoidoscopy
Vision including
glaucoma test

Period
Each Dr. visit or 3-6
months
Periodically as part of
comprehensive physical
examination
Once / year( annually)
(annually)
Every 2 years

Types of health screening

Health screening
Hearing
Cholesterol level

Period
Evaluate
periodically
Every 5 years

Cancer screening

Annually

Mammography for
women under 70 y
Digital rectal
examination

years 1-2
Annually

General Screening Recommendations

*check with your doctor for specific recommendations
Pap test every 1-3 years up to age 65
Lipid Screen every 5 years, starting mid-thirties (male)

or mid-forties (female) up to age 70

Mammogram every 1-2 years, age 40-74, then optional

Fecal Occult Blood every year, age 50-80+
Lower GI Endoscopy depending on individual factors,

every 5-10 years, starting at age 50

PSA optionally, every year up to age 70 (men)

Bone density mid-sixties (women)

Evidence for OT within mental health, well

being and older people
Graff et al 2007 Effects of Community OT on Quality of Life,

Mood and Health Status of Dementia Patients and Their

Caregivers: A Randomised Control Trial. Journal of
Gerontology. Vol.62A, No 9 1002-1009.
Sample - 135 community dwelling older people with mild to
moderate dementia and their informal caregivers
Intervention - 2 groups ; OT intervention group
( environmental modification, cognitive behavioural strategies,
problem solving) and no OT intervention for 10 weeks.
Outcome measures - Dementia Quality of Life Instrument,
the Cornell Scale for Depression, Centre for Epidemiologic
Studies Depression Scale, General Health Questionnaire 12 and
Mastery Scale used with patients and their carers.
Results - Overall Dementia Quality of Life was significantly
better in the intervention group compared to the control group
and significant 12 weeks post intervention.

Evidence for OT in health promotion training

for older people with visual difficulties
Eklund et al (2008) A randomized control trial of a health promotion

programme and its effect on ADL dependence and self-reported

health problems for the elderly visually impaired. Scandinavian
Journal of Occupational Therapy. Vol.15, pp68-74.
Sample - 229 older people (65 years +) who have macular
degeneration
Intervention -Activity based health promotion programme
compared to an individual programme- both led by OT`s
Outcome measures Functional tasks e.g. stairs, bath, dressing
etc., SF-36 and self-rating scales for health issues such as coronary,
vascular, musculoskeletal, psychological and fatigue issues.
Results - The health promotion maintained their ADL
independence level despite lowered visual acuity whilst individual
intervention group increased dependence in ADL. Both groups
lowered general health levels but the health promotion groups
reported fewer health problems- maintained at 28 months post
intervention

Evidence for OT regarding well being and

life engagement for older people
Horowitz and Chang (2004) Promoting well-being and engagement

in life through occupational therapy lifestyle redesign. Topics in

Geriatric Rehabilitation. Vol.20, No.1, pp46-58.

Sample - 28 older people with a range of chronic conditions

(depression, COPD, diabetes and spinal stenosis)

Intervention - 16 week experimental group for lifestyle

redesign( focused on daily routines, physical and mental activity,

nutrition, medication, home and community safety and assistive
technology) controlled with usual adult day programme.

Outcome measures -Mini-Mental Status Exam, Functional Status

Questionnaire, SF-36(V2), Centre for Epidemiological Studies

Depression Scale, Life Satisfaction Index-Z Scale, and the Master
Scale.
Results -a favourable outcome for the experimental groups in
relation to Role Functioning, Bodily Pain, General Health Survey SF36,Social Activity on the Functional Status Questionnaire and Centre
for Epidemiological Studies Depression Scale.

Thank You