Chronic Disease and Aging: Prevention in the Elderly Person—Can We Get it Right?
Dr. Clarfield suggested the need for greater nuance to two key terms: prevention and elderly. Preventive measures recommended are not always appropriate for frail elderly adults, who are a heterogeneous population—some 80-year-old patients have years of vigour ahead, whereas others may require institutional care.
While preventive care is increasingly advocated, he noted that doctors are temperamentally ill-suited to doing substantial amounts of preventive care. They are well-trained to note the signs of health impairment that precede health decrements, and therapeutic efforts are more effective at these earlier stages.
At later stages of life, the benefits that accrue to screening are more modest. Screening, further, may fail to detect problems due to biases, e.g., lead-time biases. The oldest patients have lower physiologic reserves, more comorbidities, and more polypharmacy. Good data about the oldest-old are scarce. Additionally, preventive care can be time-consuming and may lead inexorably toward aggressive interventions that may not coincide with the wishes or best interests of the patient. Some of the screening recommendations are not appropriate for the eldest frail patients. Therefore, Dr. Clarfield ascribed greatest importance to confronting the symptoms that patients report.
As for the value of screening, he advised that data on mortality and life expectancy yield important information. The healthiest quartile have 10 years left to live and may see some benefit from screening, but those with poor health markers, often in long-term care, have often less than 3 years.
Dr. Clarfield further recommended considering the sensitivity and specificity of tests. In a context of finite resources, it is important to avoid the testing spiral. Further, it is essential to note risks as well as benefits to screening: for example, there is a risk of perforating the colon on colonoscopy. Patients should be involved interlocutors and physicians must remain cognizant of their values—patients may not want aggressive testing. This is particularly so when it comes to mammograms, where benefits can be modest.
He then recommended pursuing prevention measures within comorbidity. An example he outlined concerned falls prevention. He advocated identifying a vulnerable patient subgroup, e.g., those on Coumadin, at which to direct specific preventive measures.
Involving other health professionals to maximize resources, and improved health behaviours, may yield better benefits than screening. He identified the four primary areas of risk-factor modification: smoking cessation, moderate alcohol consumption, adequate intake of fruits and vegetables, and exercise.
At advanced stages of life he advised reconsidering or discontinuing pap smears, PSA testing, and coronary calcification measurements. In turn physicians should reconsider or commence moderating polypharmacy, assessing falls risk, and checking vision and hearing. Dr. Clarfield concluded that prevention can be effective if it is well-targeted. Clinicians should review available evidence and add their own clinical judgment. Preventive measures can benefit the elderly, but the risk-benefit ratio changes unpredictably with advancing age and frailty.