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CHAPTER 9 Preventive geriatrics
Gerald M. Mahon1, Suzanne M. Mahon2, and Joseph H. Flaherty3
1 Saint Louis University School of Medicine, St. Louis, Missouri, USA
2 Saint Louis University School of Medicine, St. Louis, Missouri, USA and Saint Louis University Trudy Busch Valentine School of Nursing, St. Louis, Missouri, USA
3 Division of Geriatrics, University of Texas Southwestern, Dallas, Texas, USA and Geriatrics, Questcare/Envision Physician Services, Dallas, Texas, USA
Introduction
Preventive geriatrics is not an oxymoron. It is, however, a challenging area of medicine for many reasons. (i) How can guidelines for prevention take into account the variability seen among older people? (ii) How can preventive geriatrics balance the dichotomy between the treatment of populations and the treatment of the individual? (iii) How can clinicians handle the unclear areas or ‘grey zones’ of preventive geriatrics? (iv) Does early detection or case‐finding equate with better outcomes?
To deal with these questions, this chapter presents a model of preventive geriatrics called the Health Maintenance Clinical Glidepath, which is primarily for office‐based practices. It addresses screening for geriatric specific areas (e.g. cognition, gait, and balance) and screening for common medical illnesses and diseases (e.g. certain cancers, heart disease).
Background
Prevention in medicine has traditionally been divided into primary, secondary, and tertiary prevention. Primary prevention is the prevention of disease before it actually starts.
The traditional definition of secondary prevention is the detection of disease at an early stage. This can be detection of asymptomatic disease by screening tests or identification of unreported problems by case‐finding. The following caution needs to be added to the definition: detection should only be done if detection is likely to improve outcomes such as mortality, morbidity, function, or quality of life. The priority and importance of outcomes need to be made based on patient preference.
Tertiary screening, using a comprehensive geriatric assessment approach, allows for the identification and intervention of established health conditions such as cognitive impairment, gait and balance disorders, malnutrition, and urinary incontinence. The goal of the intervention would be to prevent or minimize a patient’s functional decline in order to maintain their independent lifestyle, since functional decline and loss of independence are not inevitable consequences of ageing.
The Health Maintenance Clinical Glidepath
The Health Maintenance Clinical Glidepath answers the first two questions above and addresses the limitations of two types of clinical decision‐making tools: practice guidelines and evidence‐based medicine (EBM). Although practice guidelines and EBM have been important in raising the standards of healthcare in the past decade, their use in preventive geriatrics is limited. Many guidelines do not include older age groups or, if they do, are no more specific than ‘over 65 years of age’. EBM emphasizes outcomes of populations, whereas clinical practice emphasizes the outcome of the individual. One of the limitations of EBM is the discrepancy between patients in the EBM studies and clinical practice. For example, many randomized controlled trials of medication interventions for common diseases such as congestive heart failure and osteoporosis exclude patients who are frail, demented, or at the end of life.
The