50 UNIT 1 Principles and Practice
PROPHYLACTIC MEDICATION USE
Prevention of Cardiovascular Disease
Despite evidence that oral anticoagulation
with warfarin is the most effective prevention
of stroke caused by atrial fibrillation, older
adults are less likely to receive this treatment.
When addressing anticoagulation, consider-
ation should be given to quality-of-life issues
and the need for ongoing monitoring of blood
work, as well as underlying disease and life-
style issues.
Clinical trials remain the cornerstone for guiding pro-
viders as to what treatment options are provided
to older individuals regarding prevention of cardiovas-
cular disease. The “ABC” format (antiplatelet agents/
anticoagulation, blood pressure control, cholesterol
management) has been used to best summarize find-
ings and organize recommendations.
Antiplatelet Agents
The latest guidelines for secondary stroke prevention
recommend that aspirin monotherapy, aspirin 25 mg
plus ER dipyridamole 200 mg twice daily, or clopidogrel
monotherapy (75 mg/day) are all acceptable options
for initial therapy for patients with noncardioembolic
(i.e., atherothrombotic, lacunar, or cryptogenic) ische-
mic stroke or transient ischemic attack who have no
contraindications to the use of an antiplatelet agent.38,39
Aspirin inhibits the cyclooxygenase enzyme involved
in the production of thromboxane, a factor that pro-
motes platelet aggregation. Guidelines for the primary
prevention of stroke recommend that aspirin be used
in individuals whose risk is high enough for the ben-
efits to outweigh the risks of this antiplatelet therapy
(i.e., 10-year risk of coronary heart disease of 6% to
10%).40 The use of aspirin, according to these recom-
mendations, is associated with a reduction in the risk
of a first stroke in women but not in men. As a result,
aspirin is not recommended for the prevention of a
first stroke in male patients. However, according to the
recommendations above, aspirin can be used in at-risk
men to reduce the risk of cardiovascular events. In the
absence of a contraindication, the use of aspirin is
also recommended for all patients with asymptomatic
carotid artery stenosis for the primary prevention of
stroke.40,41 Aspirin use is known, however, to increase
the risk of gastrointestinal irritation owing to the anti-
platelet and gastric mucosal effects, and cotherapy with
a proton pump inhibitor is an effective preventive
option. Clopidogrel inhibits platelet activation by block-
ing the binding of adenosine diphosphate to its receptor
on the platelet surface. As shown in several random-
ized trials, clopidogrel should be recommended in place
of aspirin in patients who are intolerant or resistant
to the effects of aspirin.38,39
The use of warfarin or aspirin to prevent stroke in
older adults with a known history of atrial fibrillation
should likewise be addressed. (See Chapter 6 for
an extensive discussion of warfarin management.)
As with other health prevention interventions, the
patient needs to be aware of the risk versus benefit
to treatment and the implications of accepting or
rejecting treatment options. Repeatedly, it has been
shown that oral anticoagulation with warfarin is the
most effective prevention of stroke caused by atrial
fibrillation.42,43 Clinicians, however, are often fearful
of anticoagulating older adults because of the risk of
falls and associated bleeding. Consideration should
certainly be given to the risk/benefit of anticoagula-
tion among older individuals and the individual or
proxy should be included in the decision-making
process. If a decision to treat with warfarin is made,
optimal anticoagulation in the range of 2.0 to 3.0
international ratios (INR) should be the goal. The
risk for intracranial hemorrhage was reported to in-
crease for those 85 years of age or older when the
INR ranged from 3.5 to 3.9. The risk of intracranial
hemorrhage at INRs of less than 2.0, however, was
not different from the risk of hemorrhage at INRs
of 2.0 to 3.0.44
Beta-Blockers
Beta-blocker use has been recommended to prevent
first events of nonfatal myocardial infarction in pa-
tients with high blood pressure since 1989.45,46 Beta-
blocker use has also been noted to be effective as
secondary prevention of a myocardial infarction and
can lead to a 19% to 48% decrease in mortality and
up to a 28% decrease in reinfarction rates.46 Older
adults may need to be started on a lower dose than
recommended in the younger adult population owing
to normal physiologic changes that increase the risk
of low cardiac output and bradycardia. In patients
with type 1 diabetes, nonselective beta-blockers can
impair glucose control, leading to hypoglycemia, and
blood glucose levels should be monitored regularly
in these individuals. In patients with type 2 diabetes,
the incidence of hypoglycemia with beta-blockers is
much lower. However, hyperglycemia is more com-
mon in patients with type 2 diabetes as a result
of beta-blocker inhibition of insulin release. Beta-
blockers should be avoided in patients with type 1
diabetes if possible, primarily in those prone to devel-
oping hypoglycemia. Because glucose regulation is
mediated in part by beta-2 receptors, beta-1 selective
agents may cause less of an alteration in glucose, in-
sulin, and glucagon concentrations in diabetic pa-
tients. The greatest risk when using beta-blockers is
the risk of bradycardia, particularly among older
adults who have a sinus bradycardia and partial AV

block, and are also receiving diltiazem, verapamil, or
digoxin. Bronchoconstriction can occur, especially
when nonselective beta-blockers are administered
to asthmatic patients. Therefore, nonselective beta-
blockers are contraindicated in patients with asthma
or chronic obstructive pulmonary disease. Abrupt
withdrawal may precipitate rebound tachycardia or a
myocardial infarction.
Statins
The Adult Treatment Panel III of the National Choles-
terol Education Program established current recom-
mendations based on a review of five randomized,
controlled clinical trials. Overall, the statins seem to
be most helpful in patients who have underlying car-
diovascular disease.47,48 In the meta-analysis by the
Cholesterol Treatment Trialists Collaboration, statins
prevented 18 major cardiovascular events for every
1000 patients without preexisting coronary heart dis-
ease treated. In contrast, 30 major coronary events
were prevented for every 1000 patients with existing
coronary heart disease treated more than 5 years.
This reduction was similar in patients older than
65 years of age.49 It should be recognized, however,
that although there were some older adults in these
trials, very few of the participants were older than 70
years of age. In high-risk persons, treatment should
be aggressive, and the recommended LDL cholesterol
(LDL-C) goal should be less than 100 mg/dl and ide-
ally could drop to an LDL-C goal of less than 70 mg/dl.
Moreover, when a high-risk patient has high triglyc-
erides or low HDL cholesterol (HDL-C), consideration
can be given to combining a fibrate or nicotinic acid
with an LDL-lowering drug. For moderately high-risk
persons (two or more risk factors and 10-year risk of
10% to 20%), the recommended LDL-C goal should
at least be less than 130 mg/dl. In addition to drug
treatment, all individuals at high or moderately high
risk for coronary heart disease who have lifestyle-
related risk factors (e.g., obesity, physical inactivity,
elevated triglycerides, low HDL-C, or metabolic syn-
drome) should be encouraged to engage in appropri-
ate lifestyle modifications.
Prevention of Musculoskeletal
Disorders
It is never too late to initiate healthy habits
that augment musculoskeletal health. This is
best done by incorporating exercise into daily
activities and getting optimal calcium and
vitamin D intake.
Although prevention of musculoskeletal disorders
ideally should begin in childhood and young adult-
hood, it is never too late to initiate healthy habits
4 Wellness and Prevention 51
that will augment musculoskeletal health as one
ages. This is particularly true with regard to osteopo-
rosis and degenerative joint disease. Osteoporosis by
definition is a bone density that is 2.5 or more stan-
dard deviations below the young-adult peak bone
density. Osteopenia, defined as 1 to 2.5 standard
deviations below the young-adult peak bone density,
is a weakening of the bones that, if left untreated, will
likely progress to osteoporosis. The USPSTF recom-
mends that routine screening for osteoporosis begin
at age 65 for all women.2 It is not clear, however,
how often individuals should go through screenings
and/or when such screening should be terminated.
Exercise is central to prevention of osteoporosis
and is one of the most effective nonpharmacologic
treatments for osteoarthritis.50,51 (See Chapter 44.)
Muscular conditioning can be achieved through long-
term walking, isokinetic quadriceps exercise, high- and
low-intensity bicycling, aquatic exercise classes, and
tai chi.52-57 In addition to exercise, dietary and pharma-
ceutical interventions are effective in maintaining and
improving bone density.58 (See Chapter 43.)
Calcium and Vitamin D
The nutritional needs for bone health can be met by a
diet high in fruits and vegetables, adequate in protein
but moderate in animal protein, and that includes
dairy or calcium-fortified foods. When calcium from
diet is inadequate, supplements spread out through
the day, for a total intake of 1200 to 1500 mg, are
recommended. No more than 500 mg should be con-
sumed at a meal to optimize absorption. The upper
limit for calcium supplementation is 2500 mg per day.
Calcium is difficult to absorb, and foods such as spin-
ach, green beans, peanuts, and summer squash inhibit
calcium absorption. In addition, high levels of protein,
sodium, or caffeine increase excretion of calcium and
should be avoided. Calcium citrate is better absorbed
than is calcium carbonate and does not need to be
taken with food.
In individuals older than 70 years, vitamin D intake
of at least 600 IU per day (up to 1000 IU per day) and
an upper limit of 2000 IU per day is recommended to
enhance absorption of calcium, strengthen bones, and
decrease risk of fracture.59,60 Dosages of 100,000 IU
every 4 months have been reported to decrease the
risk of first fracture among older males and females
living in the community.
Bisphosphonates
Bisphosphonates are recommended for the preven-
tion and management of osteopenia. Decisions re-
garding their use should be based on the individual’s
comorbidities, lifestyle, cognition, and personal pref-
erences. Adherence to the treatment protocol for safe