Educational Notes

Preventive Geriatric Medicine: Reality or fiction?

1 2
Aya Biderman MD and David Galinsky MD

1 2
Department of Family Medicine, Clalit Health Services and Department of Geriatrics, Soroka University Medical Center and

Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel

Key words: prevention, geriatrics, elderly, quality of life, functional dependence

IMAJ 2001;3:615±617

tegies. Many of these require social effects in the elderly, is sometimes

See page 618
support, a change in public attitudes, sketchy or contradictory. These be-

and manipulation of the environment, in havioral patterns include smoking,

The primary aim of care for the elderly is addition to activities that target the diet modification, exercise, weight
``to help old people remain as indepen- individuals directly. This is the holistic control, participation in social activ-
dent as possible for as long as possible, approach to prevention that is embodied ity, and stress reduction.
and to offer them as much control over in the new ``health promotion'' ideology. . Problems necessitating attention from
their lives as possible'' [1]. To achieve For most elderly individuals, the objec- professional health care providers.
this goal, preventive activities must tive is not prevention of a specific disease Physicians see most elderly persons
relate to the pathological processes and (it is often too late for that), but rather regularly and have the opportunities
the normal frailties of old age, as well as prevention of the progression of disease to identify conditions that could
to the social and physical environment to disability, handicap, or death. Quality cause disability. More active assess-
that enhances their effect. of life in the later years is becoming ever ment and intervention on the part of
Classical approaches to prevention more important for individuals, their physicians could potentially prevent
must be modified for patients between families, and society. Thus the question dysfunction (a form of secondary
the ages of 70 and 80. Opportunities for that must be addressed is: what strategy prevention). Such conditions include
primary prevention are scarce, and the should be employed to maintain auton- vision and hearing impairment, den-
distinctions between secondary preven- omy as long as possible in the presence tal problems, foot pathology, depres-
tion (early diagnosis to stop the progress of disease? [2]. sion, alcohol abuse, and urinary
of disease) and tertiary prevention (ade-
This paper examines selected issues incontinence.
quate treatment of established disease to
for which various preventive strategies . Iatrogenic problems. These are im-
diminish disability) are obscure. Delay
have been advocated, and distinguishes pairments, disabilities and handicaps
of death, limitation of disability, and
the notion of high risk groups among the that stem from healthcare itself.
maintenance of well being are among the
elderly in the community. These preven- Paramount among these are adverse
desired results of early intervention. The
tive strategies can be categorized into drug reactions or drug side effects.
WHO Scientific Group [1], in a search

for a universal endpoint for epidemiolo-

five general groups:
. Environmental hazards. These include

gical studies, proposed the maintenance

. Problems that can be addressed using poor lighting, frayed carpets, lack of
traditional prevention approaches. hand holds, and accidents. Abuse and
of autonomy as the basic requirement of
These are definable diseases or con- neglect of elderly persons is also
the elderly. It follows that preventing the
ditions that can be managed success- included in this category [3,4].
loss of autonomy should be a major
fully to prevent further damage, such
objective of intervention programs for The clinical presentation of disease in
as hypertension and glaucoma.
this age group. More specific objectives the elderly is unique. Lack of awareness

have been described in the literature, . Behavioral patterns that could lead to of these special characteristics can cause

ranging from the prevention of influenza beneficial or adverse effects on health irreversible damage, so knowledge of

to delay in admission to nursing homes. status. These health behaviors are risk these processes and their prevention

The vast majority of these objectives, factors rather than diseases or im- should be germane to geriatric practice.

however, can only be achieved by pairments. Evidence as to their im- An understanding of the clinical mani-

implementing multiple intervention stra- portance, or the reversibility of their festations of disease in the elderly is

IMAJ . Vol 3 . August 2001 Preventive Geriatric Medicine 615

Educational Notes

based on the interacting concepts of diabetes, Parkinson's disease and os- These models are based on the principles

biological change, multiple pathology, teoarthritis easily lead to falls and of a multidisciplinary team approach

and social factors [5±7]. fractures. Drugs commonly used that (doctors, nurses, physiotherapists, occu-

The biological changes of aging affect can add to the risk of falling include pational therapists, social workers, psy-

every cell, organ and body system and diuretics or laxatives, beta-blockers, chologists, podiatrists, dentists,

their ability to function. Multiple pathol- anti-depressants and sedatives. Other dietitians, and others), continuous care

ogies in the elderly are characterized by causes of falls are eye pathology (catar- including acute care and rehabilitation,

the presence of several diseases in one acts, glaucoma), and common social and community services and long-term care.

person at the same time. Studies have environmental problems such as exces- The coordination of well-trained profes-

shown that people above the age of 65 sive or inadequate furniture, frayed sionals in these different service frame-

have three to six diseases, on the average carpets and inadequate lighting. works, both medical and social, should

[2]. In addition to the effect of biological In proper geriatric practice, the as- be implemented on a broad scale. In

and pathological conditions, social fac- sessment of functional loss and the aim Israel, generally, geriatric physicians

tors, such as loneliness, bereavement, of maintaining health ± not just the work in hospitals and do not take an

retirement, and poverty, play a major treatment of disease ± are emphasized. active part in community medicine,

role in determining the health status of Identifying people in the community neither in direct care nor as consultants.

the elderly. The clinical manifestations who are at high risk of losing their Recommended medical activities for

that result are often completely different ability to perform activities of daily which direct intervention and follow-up

from the symptomatology of similar living (loss of independence and auton- are warranted in the elderly include [14±

diseases in younger patients. These omy) should be a top priority. In this 17]:

multiple interacting processes can lead context the high risk elderly that should . Assessment of nutrition, physical

to the loss of ability to perform activities be targeted are [10]: activity and drug use (including

of daily living independently. . Those who live alone: they are prone over-the-counter medications)

Not all diseases or disabilities of the to loneliness, apathy and self-neglect. . Avoidance and discontinuation of

elderly are identified by physicians. One . Those who were recently bereaved: any unnecessary drugs

study showed that older adults attribute they are prone to depression, a first . Assessment of ability to perform

their functional decrements to ``old age'' step in the process of functional activities of daily living

[8] and therefore do not report them to deterioration. . Active check for sight and hearing

the physician at all. Conditions that are . Those with significant locomotor accuracy, appropriate teeth and den-

generally recognized are related mainly difficulties: they are in continuous tures

to the cardiovascular, respiratory and danger of falling, being injured and . Measurement of height, weight and

central nervous systems. In contrast, suffering subsequent additional phy- body mass index

there is a group of disabilities of which sical deterioration. . Annual measurement of blood pres-

doctors are less aware, especially those . Those with evidence of mental im- sure (in non-hypertensive patients)

associated with disease of the joints, feet pairment: early mental impairment is . Active search for signs of depression,

and urinary tract, and with mental illness not easily diagnosed and can only be mental deterioration, physical and

(especially dementia). Yet, these largely identified by appropriate screening. emotional abuse and neglect

unrecognized disabilities are of great . Those who were recently discharged . Search for a history of falls, and

significance for the affected individual. from the hospital. advise specifically about fall preven-

Locomotor disabilities are painful and Other high risk groups could be tion and exercise, driving, alcohol and

progressive and tend to restrict mobility. included in this list, such as the elderly cigarettes

Hence, they may readily lead to reduced living below the poverty level, those . Advise about heating in the winter

social activity, difficulty in shopping, above the age of 80, and the homebound . Search for urinary incontinence

and the danger of social isolation and and bedridden. The identification and . Mammography and colonoscopy are

loneliness with eventual apathy, depres- treatment of these groups requires dif- indicated for high risk persons, with

sion and the risk of malnutrition. ferent strategies, particularly screening annual check-up of occult blood in

Falls among the elderly are a good and case-finding [10,11]. stool until age 80

example of these interacting processes With a holistic approach to the care . Vaccines: influenza vaccine yearly,

[9]: biological changes due to aging that of the elderly, preventive activities can- diphtheria-tetanus vaccine every 10

affect the autonomic system include not be distinguished from the traditional years, and pneumovax every 6 years.

postural hypotension, disordered regula- practice of medicine. Thus, preventive Other conditions for which periodic

tion of body temperature, dysfunction of and curative care are intertwined in this assessment may be warranted [17] but

gastrointestinal motility, and dysfunc- age group. To achieve this goal effi- still need further research include: ane-

tion of bladder contraction. Other com- ciently, different models of geriatric mia, glaucoma, hyperglycemia, prostatic

mon medical conditions such as services have been developed [12,13]. and gynecological neoplasms, renal im-

616 A. Biderman and D. Galinsky IMAJ . Vol 3 . August 2001

 Educational Notes

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A

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Overpaid, overfed, oversexed and over here

Tommy Trinder, English comedian (1909±89), on American troops in Britain during World War II

Capsule
Myocardin expression in the heart
The availability of large databases of expressed sequence tags through its physical association with another, more widely

and tissue-specific cDNA libraries has greatly facilitated the expressed, transcription factor called serum response factor

identification of novel factors regulating the development and (SRF). Studies in developing mice and Xenopus embryos

function of individual tissues and organs. The power of this revealed that myocardin is expressed exclusively in the

approach is illustrated by Wang et al. who used a bioinfor- myocardium after birth and is required for myocardial cell

matics-based screen to find a previously elusive transcription differentiation. It remains to be established whether myocar-

factor that selectively turns on gene expression in heart din participates in signaling pathways that are disrupted in

muscle. The new protein, designated myocardin, potently human heart disease.

activated transcription of heart and smooth muscle genes Cell 2001;105:851

IMAJ . Vol 3 . August 2001 Preventive Geriatric Medicine 617