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ESTABLISHING COMMUNITY-BASED SCREENING PROGRAMS

PEARLS

❖ Prevention strategies can improve the quality of life and conserve health resources.

❖ “Successful aging” is a combination of good lifestyle and behavioral habits, including exercise, diet, and socioeconomic well-being.

❖ Resiliency of the human being is incredible.

❖ There is a need to change the health care approach from curative to preventive interventions. It is important to convince third-party payers through research efforts of the efficacy of preventive approaches.

❖ Primary, secondary, and tertiary prevention are the 3 levels of health intervention.

❖ Eighty-six percent of those 65 years and older have at least one chronic disease.

❖ “We must protect what we can’t replace.”

The prevention of disease or mitigation of disability can improve a person’s quality of life at any age. Anyone can benefit from gains in function, fewer periods of acute illness, more days free of disability, and less need for long-term care.¹ Prevention strategies can also conserve health resources. In recent decades, the number and proportion of the US population greater than or equal to 65 years of age have increased remarkably. Between 1950 and 1980, this age group doubled from 12.5 million to 25.5 million.² In 2014, 46 million people 65 years and older lived in the United States, accounting for 15% of the population.³ Persons greater than or equal to 85 years of age experienced the largest increase, from 577,000 in 1950 to more than 2.2 million in 1980. This oldest-old population (ie, those 85 years and older) grew from just over 100,000 in 1900 to 6 million in 2014.³ The population greater than or equal to 65 years old currently constitutes 15% of the total population. By the year 2030, this proportion is expected to reach 21.1%.³ As the number of older persons in the United States increases, the role of health promotion needs further exploration as a means of improving activity levels and productivity during the later years and extending functional life spans. To meet these challenges, health professionals need to better understand the health needs of older adults and the available preventive interventions.^1,2,4

The average annual health care costs for Medicare beneficiaries varied by demographic characteristics. In 2012, low-income individuals incurred higher health care costs; those with less than $10,000 in income averaged $24,596 in health care costs, whereas those with more than $30,000 in income averaged only $14,687.³ Since the older age group is the fastest growing segment of the population, these health care cost estimates signal the need to examine strategies that might lower expenditures, such as health promotion and disease prevention, for those over age 65. In the next 25 years, the number of people over the age of 60 will double, and those over 85 years are projected to increase more than any other age group.^2,3,5

Nearly $1 of every $3 spent on health care each year can be attributed to behavioral factors, including crime, drug abuse, and the use of alcohol and tobacco; therefore, behavior accounts for $247 billion of the $866 billion Americans spend on health care.² The health care crisis cannot be successfully resolved unless damaging patterns of behavior are altered. Twenty-nine billion dollars in annual health care costs are attributable to cigarette smoking and other forms of tobacco use, and alcohol abuse may add another $92 billion a year. Other behavioral cost factors include failure to use technology like seat belts and smoke detectors, failure to have routine medical checkups that could expose cancer and other treatable conditions, and participating in dangerous recreational activities.3,5,6

There are many factors that contribute to the concept of “successful aging,”⁷ the most important of which is optimal health. The human being’s resiliency is incredible. It allows many older individuals to function adequately with considerable degrees of disability because of their inconceivably large amount of reserve. A person’s ability to function independently is closely associated with optimum health status because it impacts the ability of the older adult to successfully reside in the community at the highest possible level of independence rather than being institutionalized. Other factors that directly impact an individual’s ability to maintain independence in the community are adequate financing and the individual’s support system (eg, significant others such as family, kin, friends, or church).⁸ In a report published by the US Department of Health and Human Services, the following conclusion was reached⁹:

The allocation of resources focuses on long-term care in an institutional setting like nursing homes rather than on preventative care, a costly alternative. There is a gap in the system between the income support provided to “well” older adults and the intense health care provided to “sick” older adults. There is nothing in between. Physical and occupational therapists have a unique opportunity to demonstrate innovation and leadership in the development of community screening programs that combine health care, personal care, and social maintenance; maximize effective preventive approaches; use the special knowledge of physical rehabilitation potentials to reduce unnecessary institutionalization; and ensure proper use of limited resources. This chapter focuses on screening programs that are community based and enhance the older adult’s ability to maintain the highest level of physical functioning and independence.

Physical problems affecting the older adult are often undetected until they cause a debilitating loss in the person’s capability to independently maintain activities of daily living (ADLs) and functional ambulation. The complications of many chronic diseases can be minimized or prevented by early detection through community-based screening programs, regular medical care, environmental adaptations to facilitate function, and fitness programs that promote independence and the overall well-being of older adults. Few older adults have annual physical checkups, and, rarely, if ever, are functional limitations directly addressed. In light of this, preventive screening programs have the triple benefit of identifying high-risk individuals, detecting medical and physical problems, and preventing them from progressing into a loss of functional independence.

PREVENTION/HEALTH PROMOTION

Interventions such as exercise, diet, stress reduction, and smoking cessation have been shown to positively affect the musculoskeletal, cardiovascular, cardiopulmonary, sensory, and neuromuscular systems. These preventive modalities can lead to corrective and ameliorative changes that have the potential of delaying the onset of pathologies as well as preventing the disabling effects of existing chronic disease(s).^10–12 Even in the oldest-old population, those 85 years and older, research reveals that improvements can be made in every system of the body through exercise.¹² Proper attention to diet significantly modifies the onset of certain disease processes,¹³ and the implementation of dietary control in combination with exercise has the potential of reversing, if not avoiding, some pathological manifestations, such as diabetes^14,15 and coronary artery disease.¹⁶ Stress reduction and exercise also have positive effects on hypertension.¹⁷ It is never too late to stop smoking. For example, a study by Rogers and associates¹⁸ showed a significant improvement in cerebral blood flow in older participants who stopped smoking, and this improvement happened in a matter of 3 to 5 days. In a relatively short period of time, the abstinence from cigarettes also significantly improves cardiovascular and cardiopulmonary circulation and perfusion.¹⁹ In terms of the quality of life for older adults, preventive interventions can have a substantial impact on health care needs and days free of disability.

Secondary aging relates to systemic or organ-specific changes associated with either acute or chronic disease. Secondary prevention is the implementation of therapeutic interventions at the earliest possible time within the acute phase of an illness. For instance, with pneumonia, the early intervention with chest physical therapy and the early resumption of ambulation and exercise avoids the debilitating effects of bed rest and increases the individual’s ability to ward off the infection.20 Secondary prevention in chronic illness deals with the earliest possible intervention to reverse or maintain existing impairments and prevent further deficits from impeding maximal functional capabilities of the older adult. Screening programs are the hallmark of secondary prevention at the community level.

Tertiary aging refers to functional impairments that have already progressed to the level of disability (see Chapter 9) and impede ADLs. Tertiary prevention attempts to minimize the ill effects of diseases once they have occurred and to rehabilitate the older adult’s residual capacities. Functional activities and therapeutic interventions, such as proprioceptive neuromuscular facilitation and Bobath techniques, in addition to strength and endurance training, are all important elements in restoring function and preventing a further decline in chronic illnesses.

Webster²¹ states, “It is increasingly clear that what was previously accepted as normal primary aging actually relates much more to unappreciated secondary or tertiary influences.” Preventive measures that address the most prevalent diseases, such as heart disease, cancer, and cerebrovascular accidents, are particularly applicable in the older population. There is a correlation between healthful interventions like diet and exercise and the development of disease, and there is compelling evidence that suggests that the control of risks, such as smoking, an unhealthy diet, high blood pressure, physical inactivity, and exposure to toxic substances in the environment, could significantly diminish the prevalence of the 3 leading causes of death in the United States.¹⁰

HEALTH PROBLEMS IN OLDER ADULTS/SYMPTOM PREVALENCE

Studies estimate that of the US population who are 65 years and older, 87% have at least one chronic disease that limits their functional activities and decreases the number of “disability-free” days progressively with advancing age.²² Disability generally increased or was unchanged in the United States between 1996 and 2010.²² Increased trends were more apparent for near-elderly than elderly persons. Sociodemographic shifts (ie, an increased number of people over the age of 65) tended to reduce disability, but their favorable effects were largely offset by increased self-reported chronic disease prevalence. Changes in smoking and heavy drinking prevalence had relatively minor effects on disability trends. Increased obesity rates generated sizable effects on lower body functioning changes. Disabling effects of self-reported chronic diseases often declined, and educational attainment became a stronger influence in preventing disability.²² Chronic diseases that affect older adults are sometimes misidentified as normal age changes and can go untreated for years.

Heart disease, cancer, and cerebrovascular disease cause almost 70% of deaths in the United States.¹⁰ According to the National Center for Health Statistics, the older population is afflicted (in decreasing order of frequency) by arthritis (48%), heart disease (40%), hypertension (39%), cataracts (36%), diabetes (28%), cancer (26%), osteoporosis/hip fracture (16%), and stroke (9%). Comorbidities are common, and the frequency of these disorders increases with advancing age.²³

The major causes of frailty and disability in older adults relate to the broad functional problems of immobility and instability. Intellectual impairment is also a major component of functional decline. Confounding factors with older adults include depression and transient dementias, isolation, urinary and bowel incontinence, sexual dysfunction, immune deficiency and infections, malnutrition, sleep disorders, impairment of sensory abilities, and iatrogenesis. Many of the health problems of older adults are especially well suited for preventive efforts. For instance, impaired mobility, injuries, sensory loss, adverse drug reactions, deconditioning due to a lack of exercise, depression, malnutrition, alcohol abuse, hypertension and cardiovascular disease, cancers, osteoporosis, urinary incontinence, and abuse and neglect are all preventable or can be postponed as a result of screening programs that identify these problems and follow-up intervention to address each individual’s risk factors.

Planning preventive care packages and counseling approaches for older people requires special considerations. Older people suffer from one or more chronic diseases or syndromes, and total risk increases as a function of the number of individual risk factors.24

Screening tests and laboratory standards have not been developed or adapted specifically for older adults.²⁵ “Aging, even without disease, changes physiology, which can alter lab test results.”²⁶ Most of the normal laboratory values are based on 20- to 40-year-old participants. This makes it difficult to determine what is abnormal in terms of a test result in older adults. Aside from laboratory values, normal physiological changes of aging and the use of medications to treat chronic diseases may mask the symptoms of other physical problems.

Some diseases and conditions, such as coronary heart disease, may manifest themselves differently in older patients than in younger.²⁷ For example, an elevated serum cholesterol level becomes less predictive of heart-related morbidity in an older individual. In fact, a low serum cholesterol level is a predictor of mortality in people of advanced age²⁸ because they are associated with an increased risk of cancer and hemorrhagic stroke.

Some chronic conditions common in old age have competing risk factors. For example, obesity is a major risk factor for heart disease, diabetes, and other chronic diseases, but modest obesity is protective for osteoporosis.²⁹ Conversely, low body weight is a significant risk factor for hip fracture.³⁰

In older individuals, functional disabilities associated with chronic diseases become as important as preventing the onset of disease.³¹ Of the population aged 65 years who live independently, 27% have some degree of functional impairment, 18% are unable to perform major activities, and 10% are less impaired. Of those who are dependent on others for daily care, 9% are in nursing homes, and 19% are homebound.²²

What to Screen For

Many diseases can be prevented or forestalled by identifying and avoiding high-risk behaviors, whereas others can be treated in the early stages, thereby reducing the risk of disability or death. Yearly physical assessments are the preferred method for identifying problems; however, the majority of people 65 years of age and older do not seek medical attention on an annual basis. As a result of initiatives implemented by the Surgeon General in the early 1980s,²⁹ many agencies now offer preventive health programs, including screening for high-risk behaviors and the presence of disease. The costs associated with the treatment of chronic disease are clearly not desirable in today’s malnourished economy. Health screening and early detection of disease processes can reduce costs substantially.

Screening programs for older adults need to address behavior patterns, such as smoking, level of activity, dietary habits, living environment, health care needs such as dental and foot care, and immunization history. These programs aim to determine what the problems are and how to address them from an educational perspective. Ideally, screening programs should have a follow-up mechanism or referral sources for evaluating and treating physical or medical problems identified during the screening. Screening programs for older adults can be holistic and screen all systems of the body, or they can be system or disease specific (eg, blood pressure screening, diabetes screening, cholesterol screening, or dental screening).

Primary prevention screening programs include immunizations, accident prevention, exercise programs, posture and flexibility assessment, nutritional modifications, and smoking and alcohol cessation. Secondary prevention screening focuses on early detection and treatment and is particularly applicable in disorders such as hypertension, vision and hearing impairments, musculoskeletal problems, neuromuscular involvement, depression, and iatrogenic adverse drug affects. Tertiary preventive screening focuses on functional assessment and maximizing physical potential and environmental efficiency to prevent the progression of functional decline.

In the early 1990s, the US Preventive Services Task Force^32,33 identified screening interventions that successfully alter the outcomes of various diseases, and emphasized the importance of educating the older population in high-risk behavior modification. For instance, the Task Force advised that older individuals be provided with educational material regarding the benefits of physical activity in disease prevention and that guidance in establishing appropriate exercise levels and selected modes of exercise be provided on an individual basis to each person screened. Other components of the Task Force’s recommendations include smoking cessation programs; dietary modification to prevent diseases associated with dietary excesses or imbalances (eg, osteoporosis, heart disease, some cancers, cerebrovascular accidents, or dental diseases); alcohol cessation programs when abuse is identified; home modification screening to reduce the potential for accidental injuries; vaccination programs for pneumococcal, influenza, and tetanus immunization; and screening for preventive “chemoprophylaxis” programs, such as low-dose aspirin therapy (325 mg every other day) for those at risk for cardiovascular diseases and estrogen replacement therapy for women who are at an increased risk of developing osteoporosis.

Before a comprehensive community-based screening program is initiated, it is valuable to prescreen the community served to identify groups within the older population that would benefit from specific health screening procedures. Health questionnaires or interviews are helpful tools in identifying subgroups within the older population that may require special attention (eg, diabetes mellitus, cardiovascular or pulmonary problems, a decrease in functional ADLs, or foot problems). There are some particularly valuable prescreening tools available. For instance, the Self-Evaluation of Life Function questionnaire developed by Linn and Linn34 includes questions about health behaviors, existing diseases, symptoms, level of basic and instrumental ADLs, medication use, cognitive status, and socioeconomic well-being.

Another useful tool for prescreening community-dwelling older adults is the Health Hazard Appraisal (HHA), which is used in many preventive health care programs in both the United States and Canada³⁵ to determine high-risk populations for screening in community-based settings. Safer³⁵ demonstrated that through the use of the HHA prescreening tool, Milwaukee residents reduced their health risk by 32% as a result of the health screening, follow-up counseling, and interventions that were used to address the health care needs determined by the prescreening. The HHA prescreening is based on the assumption that “an individual’s response to health threats depends on how he or she feels physically rather than on a rational calculation of health benefits and risks.” The HHA is a valuable educational tool. By questioning older individuals and generating a “health hazard score,” it informs people about how their health habits and lifestyles affect their probability of dying within 10 years from potentially preventable causes. The HHA also helps to target the population who are most likely to benefit from health screening and follow-up counseling and intervention programs.

An evidence-based medicine study is cited below.

Secondary Prevention Screening

Screening and assessments necessary for health promotion in older adults should include the evaluation of the presence of chronic diseases; symptoms that may suggest the presence of disease; health habits including nutrition, exercise and activity levels, smoking, medication use, and substance abuse; the evaluation of musculoskeletal, neuromuscular, and sensory deficits; safety; and mental status.

Cardiovascular Disease

Routine monitoring of blood pressure is an important component in controlling and reducing high blood pressure. Individuals with diagnosed high blood pressure need to be counseled regarding appropriate exercise levels, weight reduction, dietary sodium reduction, and alcohol consumption. Periodic screening with the finding of persistent high blood pressure (eg, greater than 140/90 mm Hg) may direct the health care professional to refer the individual for possible drug therapy to control excessively high blood pressure. Routine monitoring of the electrocardiogram is recommended in individuals who are symptomatic (eg, had a previously positive electrocardiogram, angina, or dyspnea on exertion), but it is not recommended for those older adults who are asymptomatic. Although somewhat controversial, total serum cholesterol measurements are often used to determine the presence of elevated blood cholesterol levels that have also been shown to place an individual at a higher risk for the development of cardiovascular diseases.

Cardiovascular screening should also include weight monitoring, and in those individuals who are 20% overweight by the height/weight standards, appropriate dietary and exercise counseling should be implemented as a preventive measure. Additionally, information on transient ischemic attacks, the presence of diabetes mellitus, cardiac arrhythmias, claudication, and any musculoskeletal limitations that place the individual at a high risk of developing problems associated with inactivity should be recorded and monitored. Peripheral vascular status and skin condition are important to evaluate, especially in someone with diabetes or someone with known peripheral vascular disease.

Cancer

There is little agreement as to the efficacy of screening for cancer in older adults, and conflicting data exist regarding the accuracy and efficiency of the screening strategies in all ages (eg, breast examinations, mammography, and Papanicolaou [Pap] testing). Because certain cancers are more easily treated if diagnosed early, the consensus is that regular screening for cancer is recommended until more substantial evidence is presented that negates the value of the screening strategies in question. In the summary of current guidelines for the cancer-related checkup recommendations,37 the recommendations for cancer screening are as follows:

❖ Annual Pap smears and pelvic examinations for all women who are sexually active or are 18 years of age or older; after 3 consecutive normal annual examinations, Pap tests may be performed less frequently or at the discretion of the physician

❖ Endometrial tissue samples at menopause for women who are at high risk

❖ Baseline mammogram between 35 and 39 years of age; repeat every 2 years from ages 40 to 49 and annually thereafter

❖ Breast physical examination every 3 years for women between 20 and 40 years of age and yearly thereafter

❖ Breast self-examination monthly for all women 20 years and older

❖ Stool guaiac slide test every year for men and women over 50

❖ A sigmoidoscopic examination every 3 to 5 years for men and women over age 50

❖ Yearly digital/rectal examination for men and women over age 40 to screen for prostate and rectal cancer

❖ Cancer examination and health counseling every 3 years after age 20 and yearly after age 40

The second most common neoplasm in the United States is colorectal cancer, and it also has the second highest mortality rate.³⁷ Sigmoidoscopy and fecal occult blood testing are important in the early detection of this disease, especially in a known high-risk population (eg, family or personal history of cancer, colonic polyps, or inflammatory bowel disease). High-risk patients include those with ulcerative colitis involving the entire colon with a duration of 7 or more years, a past history of an adenoma of the colon, or a past history of colon cancer or female genital cancer.³⁸ Early detection is particularly important in colorectal cancer as the survival rate in asymptomatic patients is 90% compared to 43% in those with more advanced disease.³⁸ Once symptoms of colorectal cancer occur, the disease is usually in an advanced and nonlocalized stage, which decreases the likelihood of successful surgical removal. There are home screening tests for occult blood that are reliable and available through a pharmacist; however, the tests require several stool smears over a 3-day period with dietary restrictions and are difficult to accurately accomplish when older adults have physical or cognitive deficits. Cost-effectiveness studies clearly indicate that the early detection of colorectal cancer significantly reduces the overall medical costs and improves survival.³⁹

Breast cancer is the second leading cause of cancer deaths in women, and of those deaths, 50% occur in women over the age of 65,⁴⁰ and 75% of all breast cancers occur in women over the age of 50.⁴¹ There is some controversy regarding the accuracy of both self-breast examinations and mammography; however, it is recommended that breast examination be taught to all women, especially to those over the age of 50, and that a breast self-examination be done monthly. After the age of 40, the American Cancer Society recommends that women have a breast examination by a physician and a mammogram annually.³⁷

Cervical cancer is accurately detected by a Pap test; however, many older women do not have Pap smears on a regular basis. For the most part, women diagnosed with cervical cancer after the age of 65 are usually in the advanced stages of the disease, and 40% of all deaths from cervical cancer occur in women over the age of 65. Yearly screening using the Pap smear for 3 consecutive years is recommended by the American Cancer Society.³⁷ If the test is negative for 3 years, it is recommended that Pap tests be done at the discretion of the physician or at least once every 5 years thereafter.

Digital rectal examination is the best way to screen for prostate cancer in men. The American Cancer Society recommends that men receive a yearly screening for prostate cancer after the age of 40 and every 3 to 5 years after the age of 50 as the greatest incidence of this form of cancer occurs in the age range of 40 to 50 years.

A total skin examination is an important part of the routine physical examination. Inspection of the mouth is also recommended for those who are known smokers and for those who use excessive amounts of alcohol. Seventy-five percent of deaths from oral cancers occur in individuals 55 years and older.⁴² Screening for oral cancer can be done routinely during periodic dental care; however, many older individuals do not go to the dentist on a regular basis, and it is recommended that oral screening be done by the physician or other health care personnel at community-based screening clinics and health fairs since it is a noninvasive assessment.

Diabetes Mellitus

Over 8.9 million people in the United States over the age of 65 have diabetes mellitus.⁴³ Diabetes has been found to contribute to cardiovascular diseases, end-stage renal failure, amputations, blindness, and peripheral neuropathies.⁴³ The American Diabetes Association recommends that periodic serum glucose measurements be taken in the older population as the incidence of diabetes mellitus increases exponentially with increasing age. In known persons with diabetes, the recommendations include periodic testing for asymptomatic bacteriuria, hematuria, and proteinuria by urinalysis screening.⁴³

Osteoporosis

Older adults, particularly white women over the age of 60, have the highest risk for developing osteoporosis. Subtle changes in posture related to the breakdown of vertebral body height directly affect the individual’s flexibility and strength. The person may report that he or she is “shrinking” or that he or she has pain in the cervical, thoracic, or lumbar region(s) of the back. Because height changes are frequently the first clinical indication of osteoporosis, regular screening should include height measurement.44 Older adults who are screened show, on average, a 2-inch loss in height and demonstrate osteoporotic changes on x-ray. Measuring height is a reliable, inexpensive, and noninvasive screening tool for osteoporosis.

Other valuable screening information for the evaluation for osteoporosis includes nutritional information and dietary habits (eg, calcium intake, excessive caffeine or soda consumption, or excessive protein intake), level of activity or inactivity, family history of osteoporosis, and alcohol and tobacco consumption. All of these factors have been found to have a contributory effect toward the development of osteoporosis. Low estrogen levels in women have also been found to influence the integrity of bone.⁴⁵ It is particularly important in postmenopausal women that height measurements be taken periodically to screen for osteoporotic changes. Because osteoporosis contributes to more than 1.5 million fractures in people over the age of 65 annually,⁴⁵ screening becomes a vital component in the identification of risk factors and the prevention of accidental injury.

Health Habits

Nutrition, exercise levels, smoking, substance abuse, and medication use need to be considered when screening older adults. Optimal health is the key factor in maintaining an independent and productive life. Health promotion and disease prevention activities have the potential of interrupting or slowing the progression of aging and disease before pathological changes become irreversible. The expected outcome of health promotion must reach beyond longevity toward an acceptable quality of life without debilitating physical or mental disabilities.^23,46 Preventive measures seek to detect the precursors that allow for early intervention and risk factors for disease that can be modified⁴⁷ because modification of personal health habits could have a potential impact on disease outcomes. For instance, smoking cessation improves physical stamina and lessens susceptibility to infections, while it reduces the risk of lung cancer and heart disease.¹⁰

To meet the needs of the older population, health care practitioners involved in screening strategies should educate individuals on ways to promote good health by adopting better lifestyle habits and a safer local environment, assist people to identify their own genetic/familial predispositions and risk factors for specific diseases, and promote public awareness of the myths as well as the realities pertaining to good health.²⁹

One of the most significant advances was the convergence of opinion on what constitutes a “proper diet.” Two documents, the 1988 Surgeon General’s Report on Nutrition and Health⁴⁸ and the 1989 National Research Council’s Report on Diet and Health,⁴⁹ summarize the consensus of the scientific community and make dietary and health recommendations for the general public⁵⁰ including reducing dietary fats and cholesterol; limiting salt intakes; limiting the use of alcohol; maintaining adequate but not excessive protein intakes; eating more fruits, vegetables, and complex carbohydrates; balancing caloric intake with expenditure to maintain a healthy weight; and avoiding the use of dietary supplements in excess of the National Research Council’s recommended dietary allowances. Both documents caution against unsafe dietary practices, health fads, and outright health fraud, much of which is directed at older persons.⁴⁸ These recommendations are still pertinent today. Screening for nutritional problems is best accomplished by a registered dietitian; however, if this is not feasible, the collection of information on socioeconomic status, food supply, eating patterns, and self-perceived nutritional and dietary status is valuable in establishing the need for further counseling and education.

The effects of inactivity mimic the effects of aging.⁵¹ Almost 50% of the functional decline attributed to aging may, in fact, be related to inactivity.⁵² Increasing energy expenditure through exercise appears to influence mortality and morbidity through a number of complex physiological mechanisms (see Chapter 13). Lifetime physical inactivity interacts with secondary aging (ie, aging caused by diseases and environmental factors) in 3 patterns of response. First, lifetime physical inactivity confers no apparent effects on a given set of physiological functions. Second, lifetime physical inactivity accelerates secondary aging (eg, speeding the reduction in bone mineral density, maximal oxygen consumption, and skeletal muscle strength and power) but does not alter the primary aging of these systems. Third, a lifetime of physical activity to the ages of ~60 to 70 totally prevents decrements in some age-associated risk factors for major chronic diseases, such as endothelial dysfunction and insulin resistance. The present review provides ample and compelling evidence that physical inactivity has a large impact in shortening the average life expectancy. In summary, physical inactivity plays a major role in the secondary aging of many essential physiological functions, and this aging can be prevented through a lifetime of physical activity.⁵³

Despite these benefits, there has been some reluctance in recommending fitness programs for older adults because exercising too intensely may injure muscles or joints, provoke heart attacks and irregular heart rhythms, increase blood pressure, and increase fall-related fractures.⁵³ Regular exercise training can increase protein turnover (37% higher muscle catabolism) in older adults. As a result, older individuals prescribed an exercise program should be advised to increase their protein intake.⁵⁴ Some older adults are unable to maintain high-intensity training programs because of weight reductions association with the loss of lean muscle mass.⁵⁵ Therefore, special attention to the dietary needs of the exercising older adult need to be considered when prescribing a fitness program. It is important to determine the intensity, duration, and frequency of physical training to delay declines in functional capacity. These variables vary from one older individual to the next.

Combined with a calorie-appropriate diet, regular physical activity maintains a reasonable body weight, delays loss of lean muscle mass, and promotes good physical performance. A high activity level can predict survival for both institutionalized and people living in the community aged 60 to 80 years.56,57 High-intensity training appears to decrease fat cell hypertension, increase insulin resistance, and slow the rate of the decline of maximal oxygen uptake in older persons.^58–60

Exercise programs designed for older adults can reduce bone loss and strengthen skeletal muscle in both men and women of very advanced age,^58–61 thus decreasing the risk of falls and fractures.^62,63 For example, a group of sedentary men and women aged 86 to 96 years, including those with a past history of falling, increased the strength in the knee extensors by as much as 167% to 180% after an 8-week course in weight lifting exercise.

It is never too late to quit smoking. At any age, cigarette smoking imposes higher risks of coronary heart disease, lung and mouth cancers, stroke, and osteoporosis.⁶⁴ Smoking cessation results in a decline of body nicotine within 6 months, a reduced risk of sudden heart attack in 1 to 2 years, and a lowered risk of cancer in about 15 years. Smoking combined with low-calorie intakes can also compromise vitamin C status, which is essential in wound healing, infection, and maintenance of the connective tissue health. Smokers take 2 to 3 times longer to heal wounds, require longer to recover from acute illnesses such as pneumonia, and are twice as likely to die prematurely of coronary artery disease.⁶⁴

The use of medications is another risk factor to look for when screening an older population. The Centers for Medicare and Medicaid Services indicate that 48.2% of all prescription drugs are doled out to people 60 years and older in the United States. The average number of prescriptions per older American is 15.7, and there are over 9 million adverse drug reactions in people over the age of 65 each year.⁶⁵ Normal aging results in changes in the way older adults absorb, metabolize, distribute, and excrete medications. The half-life of drugs is longer in older adults, and the cumulative effects of drugs last longer. Because older adults are often existing on polypharmacy, they are more likely to overdose and experience adverse effects when medication combinations are inappropriate. Falls and fractures can be related to drug effects; for instance, beta blockers often induce an orthostatic hypotensive response on standing. Certain drugs actually induce neurologic symptoms, such as tardive dyskinesia and parkinsonism, and many drugs create mental impairment. These drugs are discussed more thoroughly in Chapter 7. Additionally, noncompliance has been found to be a problem in close to 50% of older adults.⁶⁵ Woolf and coworkers³³ found that the factors related to older persons not taking their medications were financial difficulties, language barriers, sensory deficits, accidental overdoses, and cognitive impairments.

Pharmacists often evaluate and monitor medication problems that may occur, but older adults do not always go to the same pharmacy. Over 17% of all expenditures for medications by older adults are for over-the-counter medications, which makes monitoring that much more difficult.⁶⁶ Screening and education for medication use often take the form of health education programs combined with a review of current medications by a pharmacist or nurse in a community screening program.

The older population are among those who abuse alcohol.^67,68 However, late-onset alcohol-related problems occur in less than 1% of older adults because most were abusers before reaching the age of 65.⁶⁷ In addition, as an individual ages, the alcohol tolerance diminishes; less alcohol is required to produce intoxication in older adults, so dependency may develop at a level of drinking that would not cause addiction in a younger individual. Screening tools are accurate for identifying alcohol abuse 95% of the time.⁶⁸ Questions are designed to elicit subtle defensiveness, whereas other questions directly ask about drinking habits and patterns.⁶⁸ Although individual screening by health care professionals is recommended, mass screening is not because of the low incidence of late-onset alcoholism and the fact that the screening has not been shown to lead to a decrease in morbidity or mortality.²⁸

Drug abuse is not an issue in the older population. However, it can be expected that as those individuals who use substances such as cocaine, heroin, marijuana, and so forth age, drug abuse may become a significant problem.

Sensory Deficits

Visual acuity testing in asymptomatic older adults should be done routinely. Although many older persons maintain nearly normal vision, their eyesight is subject to various changes and disabilities as discussed in Chapters 3 and 5. Yearly eye examinations are recommended to detect the presence or progression of presbyopia, as well as the presence of disease. Three disorders—cataracts, glaucoma, and senile macular degeneration—are commonly found through screening.²⁸

Anyone with impaired hearing should receive an otoscopic examination and audiometric testing. Between 30% and 60% of people over age 65 and up to 90% of nursing home residents in that age group are estimated to suffer from some degree of hearing loss.⁶⁹ Screening for hearing loss can range from a thorough history and interview of family members to testing by a clinical audiologist. A tuning fork is a wonderful screening tool. According to Alpert,⁷⁰ if the health care provider can hear the fork’s hum when the client can no longer hear it and visual inspection of the ear shows no gross pathology (eg, cerumen or serous otitis), then there is a hearing deficit. With a suspected hearing deficit, a more definitive audiometric screening by a trained individual can be easily used in a community setting.

Older individuals should be specifically screened for depression and the potential for suicide. This screening needs to include a family history of depression/suicide, the presence of a chronic illness, recent loss (real or perceived), problems with sleep disorders, the presence of multiple somatic complaints, recent divorce or separation, unemployment, alcohol abuse, living alone, and the presence of prolonged bereavement. Depression is more prevalent in the older population than any other age group. White men, in particular, are at the highest risk for suicide.70

Dementia

The Mental Status Questionnaire, Fact-Hand Test, and Dementia Rating Scale are frequently used along with screening for other mental, neurologic, and physical deficits to determine if patients are suffering from dementia. However, in the early stages, it is difficult to distinguish true dementia from depression, the adverse effects of medication, and other mental and physical illnesses. Screening can determine only whether or not a problem exists, not what the underlying cause is. Magaziner and associates⁷¹ were able to show that a shortened version of the Mini-Mental State Examination could be used as a reliable predictor of scores on the longer version of the test. The shortened version makes screening easier and more cost-effective.

Urinary Incontinence

Urinary incontinence affects a significant number of older persons. In fact, urinary incontinence contributes to nursing home admission in nearly half of older adults admitted to long-term care facilities. Women have a weakening of the muscles of the pelvic floor and abdomen following pregnancy, which can be treated with Kegel exercises. In addition, birth injuries, hormonal changes, infections, tumors, or side effects of medications may cause urinary incontinence. Men develop urinary incontinence most often because of bladder or prostate disease. Causes of urinary incontinence need to be determined to prevent the need for institutionalization.

Safety

Older individuals account for almost 30% of all accidental deaths and about 15% of all hospitalized accident victims. Hou and colleagues substantiated previous research that established that mortality rate increased following hip fracture.⁷² Decreased mobility, reduced independence, and a higher incidence of illness are common after a hip fracture. Impaired hearing and eyesight, slower physical reactions, poor balance and coordination, circulatory changes, orthostatic hypotension, and decreased physical stamina are among the reasons for the high accident rate in older adults. For these reasons, it is important to assess the older adult’s risk for falls as well as the presence of fall hazards in the home. The US Consumer Product Safety Commission has developed a “Home Safety Checklist for Older Consumers” to help spot possible safety problems in the home. These were distributed through Area Agencies on Aging to senior centers, public health departments, and other community groups. Copies may be obtained from the US Consumer Safety Commission in Washington, DC.

Several evidence-based medicine strategies are cited below.

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