Preventive Gerontology: Strategies for Optimizing Health Across the Life Span: Introduction
In developed societies, the success of disease prevention strategies over the last century, coupled with more effective treatments for many diseases, has resulted in a decline in mortality due to acute disease. However, this has been associated with a rise in chronic illness and attendant morbidity in the form of chronic disability in old age. The sheer magnitude of the elderly population of the near future will place critical demands on existing health care delivery systems. Continued independent functioning of the elderly population has therefore emerged as a major challenge to public health. The ability to perform activities of daily living is essential for ensuring independent living. Thus, preventive gerontology—the study of individual and population health strategies across the life span aimed at maximizing both the quality and quantity of human longevity—must now aim not just to retard chronic disease but also to prevent functional decline.
Aging is a lifelong process in which early- and mid-life events and behaviors can have an important influence on the health and functioning of individuals as they age. Development of chronic disease, functional decline, and loss of independence are not inevitable consequences of aging. Health and function in late life can be seen to a great degree as under one’s own personal control. Disability is associated with chronic conditions that are potentially preventable, and changes in behavior and lifestyle will reduce risk factors that lead to many chronic conditions. This is true throughout life, and has been shown to apply even for persons of advanced age.
What should the primary care provider advise his/her young adult and middle-aged patients about how to maintain optimal health and function into their later years? Health promotion efforts at the level of the individual should ideally be established early in life and maintained throughout life. Chronic disease, an avoidable outcome intermediate in the pathway to functional decline or death (Figure 9-1), is unlikely to have a single cause but rather, to be the result of the interactions of multiple factors. Efforts to prevent such disease require a comprehensive approach that focuses primarily on behavioral modification.
Individuals who pursue a healthy lifestyle have a lower risk of developing a chronic disease. A healthy lifestyle can be conceptualized as one that involves avoidance of health-damaging behaviors along with the adoption of a proactive approach to one’s health. This chapter will first examine those behaviors that should be avoided and then focus on those that should be adopted if one is to maximize the time spent in a state of independent functioning.
Behaviors with Adverse Health Consequences
Achieving and maintaining health and function in advanced years can be aided by a commitment to a lifestyle that involves avoidance of smoking and other behaviors that adversely affect health. The Nurses Health Study found that middle-aged women who did not smoke, drank alcohol in moderate amounts, were not overweight, consumed a healthy diet, and exercised at least one-half hour daily had an 83% reduction in their risk of coronary events as compared with all the other women in the study. Each factor independently and significantly predicted risk, even after adjustment for age, family history, presence or absence of diagnosed hypertension, or diagnosed high cholesterol, and menopausal status. The online publication of Healthy People 2010, at http://www.healthypeople.gov/, contains links to reliable information about behavioral risk factors that lead to chronic disease and disability for individuals at every age (click on Be a Healthy Person link, and then click the Online Health Checkups link). Information on these topics can be found organized by age, race, ethnicity, and gender, and for parents, caregivers, and health professionals by clicking on the Be a Healthy Person link and then on Health Information by Age, Gender, Race… link.
The Task Force on Community Preventive Services, an independent, nonfederal, multidisciplinary group charged with reviewing and assessing the quality of available evidence on the effectiveness and cost-effectiveness of essential community preventive health services, publishes reviews in an online document entitled, The Guide to Community Preventive Services. Topics coordinate with Healthy People 2010 objectives and address actual causes of death as described by McGinnis et al. in their 1993 JAMA article as well as prevalent risk behaviors. As topic reviews are completed, they are made available at http://www.thecommunityguide.org (click on a topic of interest under the heading, Topics).
Tobacco use is the largest single preventable cause of illness and premature deaths in the United States. Illnesses related to tobacco use (coronary artery disease (CAD), cancers of the lung, larynx, oral cavity, esophagus, pancreas, and urinary bladder, stroke, chronic obstructive pulmonary disease) account for one in every five deaths in the United States. Evidence from the National Health and Nutrition Examination Survey (NHANES) indicates that tobacco use predicts shorter survival time for middle-aged (45–54 years of age) and older (65–74 years of age) men. Although studies of prevalent cases have suggested that tobacco use either has no effect or is protective against Alzheimer’s dementia, prospective data investigating incident cases found that, quite to the contrary, tobacco use is associated with an increased risk of dementia, including Alzheimer’s dementia. Tobacco use can also multiply the risk associated with other carcinogenic agents: for example, heavy alcohol consumption, associated with esophageal cancer, carries an even greater risk when combined with cigarette smoking. Furthermore, the relative risk of developing lung cancer is at least additive among individuals who smoke and also have history of exposure to certain occupational agents such as arsenic, asbestos, chromium, nickel, and vinyl chloride.
It is increasingly evident that exposure to environmental tobacco smoke may also be a risk factor for lung cancer in lifelong nonsmokers. The adverse health effects of environmental tobacco smoke are far-reaching. In one case study, the attributable risk of death for second-hand smoke was similar to that of melanoma and motor vehicle collisions. A new report summarizing current evidence about second-hand smoke, entitled, The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General 2006, is available at http://www.ahrq.gov/path/tobacco.htm.
Tobacco dependence should be viewed as a chronic condition requiring ongoing assessment and repeated intervention. However, effective treatments are available that can lead to long-term, and in some cases, permanent abstinence. Studies have shown that individuals at any age can benefit from quitting the tobacco habit. Benefits include reduction in the risk of CAD, malignancy, stroke, and even hearing loss, along with improved pulmonary function, arterial circulation, and pulmonary perfusion.
Studies have found that only about 35% of adults are routinely asked about their tobacco habits or counseled to quit if they use tobacco. If providers do advise patients not to use tobacco, as many as 25% will quit or reduce the amount they use. Thus, providers should ask all patients at each clinic visit about tobacco use and advise all tobacco users about the importance of quitting, emphasizing factors that have been found to contribute most to successful attempts to quit: health concerns (symptoms); a desire to set an example for children; the expense of the habit; odor of breath, home, and clothing; and loss of taste for food. Providers should then assess a patient’s willingness to attempt to quit. Patients who are unwilling to attempt to quit should be provided with a brief intervention designed to increase their motivation to quit. Patients who are willing to quit should be provided with treatments that have been identified as effective. First-line pharmacotherapies that have been shown to increase long-term smoking abstinence rates include bupropion and nicotine (gum, inhaler, nasal spray, or patch). Second-line therapies include clonidine and nortriptyline, the latter, a tricyclic antidepressant with anticholinergic activity, should be avoided unless there is a compelling contraindication to the other therapies. Additional information about these therapies, as well as descriptions of brief clinical interventions for patients willing and unwilling to make a quit attempt, can be found in the June 2000 guideline, “Treating tobacco use and dependence,” available at http://www.ahrq.gov/clinic (click on Clinical Practice Guidelines link, then Treating Tobacco Use and Dependence box).
The harmful health effects of substance abuse are well documented. Studies have shown that individuals at any age can benefit from quitting these habits, and effective, brief interventions are available. Providers may consider participating in continuing education programs to hone screening and counseling skills.
Epidemiological studies support a survival benefit associated with moderate (up to two 8-ounce drinks per day) alcohol consumption, primarily through reduction of cardiovascular risk, including elevation of high-density lipoprotein (HDL) cholesterol. Additionally, both epidemiological and experimental studies suggest a protective effect against the development of cardiovascular disease with moderate consumption of red wine. The exact mechanism of the protective effect remains to be established, although it has been attributed to the properties of tannins or phenolic compounds, and to alcohol content, and moderate alcohol intake has been shown to be associated with less coronary atherosclerosis in a high-risk population. Weaker associations with moderate alcohol consumption include a protective effect against bone loss in older women, Alzheimer’s disease, intermittent lower extremity claudication, ischemic stroke, and prevention of hearing loss.
However, consumption of alcohol beyond a moderate level can induce adverse effects on every organ system, including increased risk of hypertension; breast, colon, esophageal, liver, and head and neck cancer; cirrhosis; gastrointestinal bleeding; pancreatitis; cardiomyopathy; seizures; cerebellar degeneration; peripheral neuropathy; cognitive dysfunction; insomnia; depression; and suicide. Counseling about problem drinking following a few screening questions is a high-impact, cost-effective service (see “Priorities Among Effective Clinical Preventive Services: Results of a Systematic Review and Analysis” at http://www.prevent.org, under the “Tools and Resources” link). Screening can be accomplished by taking a careful history of alcohol use or by using a standardized screening questionnaire. All adults should be counseled on the health risks associated with excess alcohol consumption as well as the risk of injury (i.e., motor vehicle crashes or other equipment-related injury) after drinking alcohol. Nondependent heavy drinkers as well as those with alcoholism (a chronic illness involving a state of dependency) should be counseled about the benefits of decreasing alcohol intake. Brief counseling by primary care providers can result in a significant reduction in alcohol use. Dependent drinkers should be referred to formal alcohol treatment programs and considered for a trial of naltrexone, an opioid antagonist that reduces the pleasurable effects of alcohol and may reduce relapse to heavy drinking.
The prevalence of injection drug use among older adults is unknown. Injection drug users typically initiate injection drug use during late adolescence (under age 21); however, a sizable subgroup begins injecting during early and late adulthood. Persons with a history of recreational drug use on only one or a few occasions are unlikely to self-identify; thus, clinicians should probe for such a pattern of usage.
Noninjection drug use (crack smokers, methamphetamine, intranasal heroin or cocaine, etc.) contributes to development of gastroduodenal ulcers, chest pain and myocardial infarction, and increased risk of death. As might be expected, higher levels of drug involvement also were associated with increased age-adjusted mortality. The United States Preventive Services Task Force (USPSTF) is currently updating its 1996 recommendations about screening for substance abuse.
Prescription drug misuse is poorly described in the medical literature but is a more prevalent problem than illicit drug use among older adults. Misuse of prescription medications may be related to insomnia, chronic pain, depression, and anxiety. The potential misuse of benzodiazepines is well recognized and has led to prescribing recommendations that suggest only short-term use and use only for intended indications. Amphetamine-like stimulants have abuse potential, but addiction to these drugs is seldom documented. Other medications that are often misused are sedative hypnotics, opioid analgesics, and barbiturates. Chronic use of such agents may lead to physical dependency and the development of withdrawal symptoms with attempts to discontinue use. Treatment may require detoxification followed by rehabilitation (see also Chapter 24).
A number of case–control studies indicate that, in addition to maximizing one’s years of education and minimizing exposure to neurotoxins, avoidance of significant head trauma (which resulted in loss of consciousness or seeking of medical attention) may lower the risk of eventual development of Alzheimer’s disease. It therefore stands to reason that with implementation of cranioprotective measures during early life, such as wearing helmets during high-risk activities, and avoidance of high-risk behaviors that may put one at risk for head trauma, the risk of eventual cognitive decline may be reduced.
Increased risk of melanoma and nonmelanoma skin cancers as well as cataracts is associated with exposure to ultraviolet B (UV-B, or 280–320 nm) rays. More than five sunburns have been found to double the risk of melanoma, irrespective of the timing in life. Avoiding peak exposures, wearing protective clothing, avoiding artificial tanning devices (tanning lamps and beds) that emit UV radiation, and using sunscreen with a sun protection factor (SPF) of at least 30, indicating protection against UV-B, along with a star rating for Ultraviolet A (UV-A, or 320–400-nm rays) protection of 3 to 4 may reduce the risk of melanoma and other skin cancers. Wearing sunglasses that afford UV-B protection along with hats with brims can reduce the risk of cataracts by lowering eye exposure to UV-B light. Thus, patients should be advised to change behaviors that may increase the risk of skin cancer and cataracts. USPSTF, in its Guide to Clinical Preventive Services (available at http://www.ahrq.gov/clinic/prevenix.htm), concluded in 2001 that there is insufficient evidence to recommend for or against a periodic skin examination by clinicians; an update of this topic is in progress.
Age-related macular degeneration (ARMD) is the leading cause of blindness in developed countries. The cause of ARMD is unknown; treatment is usually only partially effective, and thus prevention is an active area of investigation. Cigarette smoking appears to be a risk factor for the development and progression of ARMD; other risk factors appear to include hypertension, high cholesterol, high total fat intake, and obesity. The role of sunlight exposure is unclear. A high fish intake (more than four servings per week) may reduce the risk of ARMD. Observational studies examining the association between concentrations of antioxidant vitamins and ARMD development have yielded conflicting results. Published data from randomized controlled trials have thus far shown no clear benefit for vitamin E or beta carotene on the prevention of incident ARMD.
Noise-induced hearing loss ranks second only to presbycusis as a leading cause of sensorineural hearing loss, a well-described disability that is unarguably preventable. Such an insult can occur at any age and can affect one’s life for years thereafter. Importantly, progression of cell death at the level of the cochlear cilia can be halted with avoidance of the offending recreational or occupational noise and using hearing protection, such as earplugs. Patients who have been exposed to excessive noise should be screened for hearing loss. When hearing loss is suspected, a thorough history, physical examination, and audiometry should be performed. If these examinations disclose evidence of hearing loss, referral for full audiologic evaluation is recommended.
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