Preventive Health

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Roger YM Wong, BMSc, MD, FRCPC,
Division of Geriatric Medicine, Department of Medicine,
University of British Columbia, Vancouver, BC

For many adults age 65 years or above, their point of entry into the health care system often begins with an office visit to their family practitioners. In some instances, proper assessment of these elderly patients may become quite a daunting task for the primary care physician in a busy office. Two common barriers to conducting a comprehensive geriatric assessment (CGA) in the office setting include the lack of a systematic approach to screen for common geriatric problems, and more importantly, the paucity of time. The challenge therefore becomes how one can assess a frail older patient with multiple medical and functional problems quickly and effectively. This article will highlight some simple ways to incorporate important concepts of geriatric assessment into one's busy outpatient practice.

CGA and health promotion

The United Nations has declared 1999 as the Year of the Older Person. CGA is one of the ways to promote healthy living in the older adult. Simply defined, CGA refers to the multi-faceted approach of diagnosing and managing complex physical, psychological and functional problems.

Eleanor Brownridge, RD, FDC

The nutrition priorities of the elderly (over age 75) go against the grain of mainstream nutrition messages believes Dr. Katherine Gray-Donald, Associate Professor at the School of Dietetics and Human Nutrition, McGill University in Montreal. "These people shouldn't be worrying about fat and cholesterol. Rather than tons of vegetables and fruit and skim milk, they need omelettes, milk shakes and cream soups."

"We've been able to show that for the homebound elderly declining body weight is a predictor of mortality," says Dr. Gray-Donald. "People who lose weight die sooner."

Moreover, a recent 5-year mortality study of 4300 nonsmoking men and women, aged 65 to 100 years, indicated that being overweight later in life does not pose a significant health risk.¹ Rather the risks associated with significant weight loss should be the primary concern.

Traditionally physicians have asked patients: "Have you unintentionally lost ten pounds or more in the past year?" But even intentional weight loss in an elderly person suggests nutrition problems. Because of low energy needs, it is very difficult for an elderly person to lose weight by dieting and still maintain adequate nutritional status.

By the time a 10-pound weight loss has occurred it may be too late to reverse muscle deterioration. Dr.

Rhonda L. Witte, BSc

Skin--we clean it, shave it, cream it and tan it, all with a common goal--to preserve our youthful image. Not only does it help our general appearance, but it also feeds our self-image, making us "feel" younger. In a society where younger parallels attractiveness, we find ourselves constantly in search of new remedies to prevent our skin from aging . On the other hand, aging is a sign of wisdom and the more signs we have, the better we look. Can't we just age without looking older? And is what we consider to be aging of the skin really due to the aging process itself?

Cutaneous aging is a result of both intrinsic and extrinsic events. Intrinsic aging, also referred to as chronological aging, occurs independently of environmental influences. The changes seen with intrinsic aging occur in sun-protected areas. It is this characteristic that sets it apart from extrinsic aging which occurs as a result of environmental effects on the skin, the most important of which is exposure to sunlight.^1,2 The term "photoaging" refers to the age-related cutaneous changes resulting from exposure to sunlight and accounts for the majority of changes generally associated with appearance.

Michele Kohli, BSc, MSc

The persistence of influenza in the North American population has not been completely explained by epidemiologists.¹ During the last influenza season (1997-98), there were 5,148 laboratory confirmed cases of influenza in Canada (see Table 1).²The elderly population, those aged 65 years and above, are particularly susceptible to this disease. Over 95% of the deaths caused by influenza occur in this age group, in part, because of the higher prevalence of congestive heart failure and lung disease.¹ Last year, the occurrence of influenza peaked between January and March.² When the prevalence of influenza is high in a population, patients presenting with a febrile respiratory illness along with symptoms such as myalgia, headache, sore throat and cough are often diagnosed as having influenza.¹ However, the gold standard for diagnosis is laboratory detection of the virus in nasopharyngeal swabs.¹ The genes of the influenza virus mutate frequently, causing the antigenic molecules of the virus to change, resulting in the emergence of new viral sub-types. This process is known as antigenic drift. When human and swine or avian strains of influenza A recombine, the resulting new subtypes can cause pandemics.

Barry Goldlist, MD, FRCPC, FACP

Ever since the landmark article by Fries in the 1980 New England Journal of Medicine, entitled 'Aging, natural death, and the compression of morbidity,' investigators, elderly people, and probably many younger people, have wondered whether the progressive frailty and dependency traditionally associated with aging are, in fact, inevitable. Preventive medicine, which originally meant preventing death early in life, is now being applied to preventing disability in the elderly. There is persuasive evidence presented by the MacArthur Foundation Study of Aging in America that the lifestyle choices we make are important factors in how we age. This information is clearly and effectively presented by Rowe and Kahn in the 1998 publication, 'Successful Aging.' They make a persuasive argument that while most of the chronic degenerative diseases of aging have a significant genetic basis, manipulating environmental factors can still be incredibly important.

Rowe and Kahn present their most persuasive argument in touting nutrition and physical exercise in preventing age-related frailty. My reading of the literature over the past few years is that although any exercise is better than no exercise, very vigorous exercise is better than moderate exercise. While early detection of specific diseases is important as well (e.g. cancer screening, diabetes detection, hypertension detection and treatment), I for one am firmly convinced that exercise and diet will provide the 'biggest bang for the buck.' Although lifelong commitment to preventive health care is the optimum, it seems like there is benefit in vigorous exercise and proper nutrition regardless of the age at which it is started.

The maintenance of normal cognitive function with aging is a much more difficult issue. We do know that higher levels of education are associated with less cognitive decline in old age, but it is unsure if there is any causal link. Certainly maintenance of good physical health will help maintain good mental health as well. There is really no evidence at the present time that 'mental gymnastics' such as crossword puzzles, or specific diets (e.g. rich in antioxidants), will help in maintaining cognitive function.

In the textbook 'Principles of Geriatric Medicine and Gerontology,' Professor Hazzard writes a chapter on preventive gerontology that emphasizes the lifelong health practices that promote successful aging. It seems that it is never too early to plan for a healthy old age. Fortunately, it is also never too late to start.

Michelle Durkin, BSc

The skin is the largest organ of the body and the most visible. Ironically its importance in health promotion can be easily overlooked, especially in elderly patients. Because the skin is the first line of defense against infection, disease, and injury, proper skin care is always important. As the skin ages, however, the importance of its care increases, because structural changes occur which are responsible for compromised skin functioning (see Table 1) and a transformation in appearance (see related article on the aging skin: Wrinkles, Age-spots and Spider Veins Primary Aesthetic Concerns).

Sharron Ladd, BSc

The Baycrest Centre for Geriatric Care hosted the Dr. Ira Pollock Clinic Day entitled "Issues in Geriatric Medicine," on November 27th. The morning session was comprised of short lectures followed by afternoon workshops. The event, chaired by Dr. Michael Gordon, proved to be both a humorous and sobering experience.

"It used to be common practice to recommend patients stop taking anticoagulants if they are going to the dentist," began Dr. John A. Blakely, director of the Anticoagulation Clinic at Sunnybrook Hospital in Toronto, in his lecture on anticoagulation. A recent study concluded that there were no serious bleeding problems in patients remaining on anticoagulants while receiving dental care (Arch Int Med 1998;158(15):1596-608). Patients should remain on anticoagulants if going for dental work.

Blakely concluded his talk advising that atrial fibrillation (AF) must be treated with warfarin, not aspirin. He admitted that anticoagulants are difficult to prescribe. There are a lot of tests involved, numerous telephone calls, collecting of patient information and discussions with family, for only $9 a month. Conversely, aspirin is easy to prescribe. Despite difficulties, warfarin is the drug of choice for AF!

In a section on fall prevention and assessment, Dr.

Kim Wilson, BSc, MSc

Regular exercise is associated with cardiovascular, respiratory, neuromuscular and metabolic benefits. It is also an important factor in improving the immune system and preventing diseases, such as osteoporosis and coronary artery disease, while reducing disability. Physical activity also gives an energy boost, lowers cholesterol, enhances mood, and increases general feelings of well being.^1,2,3

Research has shown that regular exercise decreases the mortality rate in middle-aged men and probably in middle-aged women, but whether this occurs in the elderly has not been studied extensively.⁴ Very little research has been done to determine how much exercise an elderly person needs to do to obtain health benefits.

The intensity of exercise required to promote cardiovascular health among older persons has remained controversial.⁵ Some studies suggest strenuous activity reduces coronary disease risk while other studies found that less intense activity reduces the risk of coronary disease.^4,5 Not surprisingly, physicians are confused about how to prescribe an exercise regimen to their older patients.

Research in the area of exercise and health has traditionally focused on younger individuals.

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Routine Use of Comprehensive Geriatric Assessment Needed in Outpatient Practice

Forget About Fat Reduction for the Elderly

Wrinkles, Age-spots and Spider Veins Primary Aesthetic Concerns

Less Than 40% of Elderly are Getting Flu Shots

Benefit in Vigorous Exercise and Proper Nutrition Regardless of Age

As Plain as the Skin on Your Feet: The ABC’s of Skin Care

Careful Listening Can Prevent Needless Deaths

Benefits of Exercise in the Elderly: Doing Something is Better than Nothing