not equate with physiological or functional age. Guidelines for preventive geriatrics need to take this into account. One approach is to use life expectancy and functional status to help delineate categories of older people that are more useful than those based on chronological age. Overall health status is a good predictor of life expectancy compared with age alone, and functional capacity among older people has been found to be a predictor of mortality. Four categories can be used to help guide decisions about preventive measures. Although overlap exists and functional status may fluctuate, Gillick proposed the following: Robust (life expectancy of >5 years and functionally independent), Frail (life expectancy of <5 years and significant functional impairment), Moderately Demented (life expectancy 2–10 years and may or may not be functionally impaired), and End of Life (usually a life expectancy of <2 years).1
Preventive geriatrics requires making decisions. Healthcare decisions are complex, involving society, healthcare workers, and patients. Guidelines for preventive geriatrics need to take into account the following practice principles: (i) patients’ expectations and needs, including quality of life, satisfaction, and reassurance; (ii) physicians’ need for diagnostic certainty; (iii) physicians’ comfort with risk‐taking and concerns about malpractice; (iv) the need for cost‐effective medical care; (v) variations in practice patterns, particularly with regard to subspecialty care; and (vi) the practical realities of running a practice.2
Healthcare decisions are not black and white. Thus, four levels of recommendation were developed to allow for decisions to be made on a ‘graded’ rather than an ‘all or nothing’ basis and to allow for better patient involvement in decision‐making. The four levels are also based, when available, on the strength or weakness of EBM that exists or does not exist. The four levels are ‘Do’, ‘Discuss’, ‘Consider’ and ‘* * * *’. ‘Do’ reflects the strongest recommendation. ‘Discuss’ reflects a recommendation that the physician discusses the risk‐benefit of the decision with the patient. ‘Consider’ reflects a recommendation that the physician gives consideration but does not necessarily need to discuss the decision with the patient. ‘* * * *’ reflects that a particular evaluation or management measure is not recommended based on these principles.
Table 9.1 is a shortened version of the original Health Maintenance Clinical Glidepath that details the recommendations for each area of prevention and each category of Robust, Frail, Moderately Demented, and End of Life. It will be noted in the following sections whether recommendations are based on organizational guidelines, EBM, or expert consensus. All areas of the Glidepath underwent a Delphi process.3
Office visits
Although there is no direct evidence available on how often Robust elderly versus Frail or Moderately Demented elderly need office visits because other screening procedures need to be done, the minimum frequency should be once per year. ‘Do as needed’ is recommended for the elderly at the end of life because of potential limitations or inability on the part of the patient to get to the office.
Blood pressure (BP), including orthostatic measurements
Performing BP measurements in all groups is recommended at each visit. Although this pertains to screening for hypertension in all four categories, it also pertains to hypotension (and associated symptoms) in the Frail, Moderately Demented, and End of Life categories. Recommendations for hypertension screening are based on organizational guideline. The US Preventative Services Task Force (USPSTF) recommends annual screening for hypertension in adults aged 40 years or older who are at high risk for hypertension, which includes those with a BP of 130–139/85–89 mmHg and those who are overweight, obese, or African‐American. In contrast, screening is recommended every three to five years for adults aged 18–39 with a BP less than 130/85 mmHg who do not have other risk factors. If BP is elevated on subsequent measurements, the USPSTF recommends ambulatory BP monitoring or home BP monitoring to confirm the diagnosis of hypertension.4 The American Heart Association (AHA) and American College of Cardiology (ACA) recommend treatment for hypertension for BPs greater than 130/80 in all patients with cardiovascular risk factors.5 The goal should be individualized in the elderly, especially those greater than >80–85 years of age, to prevent falls and acute kidney injury.6 The Assessing Care of Vulnerable Elders (ACOVE) Project recommends screening for systolic hypertension begin at a BP >160 mmHg.
Screening for orthostatic hypotension (OH) is based on evidence that OH is prevalent among older patients (13–30%) and that there is an association between OH and adverse outcomes. The Joint National Committee (JNC) 8 recommends screening all patients treated for hypertension for orthostatic hypotension, but the frequency is not specified.6 Although no studies have been carried out to show improved outcomes if this screening is done, the cost and risk of the intervention are low enough that postural blood pressure measurements are recommended.
Weight
Weight loss in older patients is associated with increased mortality, morbidity, and other unfavourable outcomes (e.g. loss of muscle mass, decreased muscle strength, altered immune function, decreased wound healing). The data on benefits and outcomes with nutritional management are controversial and mixed. More recent studies that have shown oral nutritional suppliement (ONS) can result in weight gain of 1–3 kg over one to three months have not shown decreased mortality or improved functional benefits in the general elderly population. In certain subgroups of older adults who were frail, malnourished, or had had recent illnesses, the use of ONS showed improved cognition, weight gain, and functional status, reduced rehab stays, and prevention of wounds.7
Table 9.1 The Health Maintenance Clinical Glidepath.
| Item | Robust elderly Life expectancy >5 years and functionally independent | Frail Life expectancy <5 years or significant functional impairment | Moderately Demented Life expectancy 2–10 years | End of life Life expectancy <2 years and functionally non‐independent |
|---|---|---|---|---|
| Office visits | Do 2 times/year | Do 1–4 times/year | Do 1–4 times/year | Do as needed |
| Blood pressure including orthostatics | Do each visit | Do each visit | Do each visit | Do each visit |
| Weight | Do each visit. If loss of >5 lb/year, perform SNAQ/MNA | Do each visit. If loss of >5 lb/year, perform SNAQ/MNA | Do each visit. If loss of >5 lb/year, perform SNAQ/MNA | * * * * |
| Height | Do each visit | Do yearly | * * * * | * * * * |
| Pain assessment | Do each visit | Do each visit | Do each visit | Do each visit |
| Medication review including OTCs and herbal medicines | Do each visit | Do each visit | Do each visit | Do each visit |
| Lifestyle education (exercise, smoking cessation, alcohol, and injury prevention) |
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