Providing appropriate preventive care for elderly persons is a growing challenge for family physicians. In the year 2000, persons over age 65 will constitute 12.7 percent of the total U.S. population, and persons over age 85 will make up 1.5 percent of the population.1 Among all age groups, elderly persons have the highest risk for death and disability from a multitude of causes. It is natural for physicians and patients to want to prevent death and disability in the elderly. However, astute clinicians recognize that the true goal of prevention in the elderly should be to maintain optimal function as long as possible, postpone the development of disability, and support the patient and family through the inevitable terminal phases before death.
Physicians have been taught in the past two decades that preventive interventions should be evidence-based and that, in the absence of evidence, leaving the asymptomatic patient alone may be the best option. Yet, few preventive interventions have direct evidence of effectiveness in the elderly. Few studies of the prevention of major causes of death or disability have been conducted in elderly populations. Such studies are expensive and difficult to do because of the high all-cause mortality of the population, which confounds the results and makes long-term follow-up difficult.
In this issue of American Family Physician, Mouton and Espino2 discuss recommendations of the U.S. Preventive Services Task Force3 that apply uniquely to elderly persons. However, in making evidence-based preventive recommendations, groups such as the U.S. Preventive Services Task Force3 and the American Academy of Family Physicians4 face a dilemma when confronting the lack of direct evidence for the effectiveness of prevention in the elderly. These groups must either stick rigidly to principles of evidence and, in the absence of studies that include elderly patients, state that there is insufficient evidence to recommend screening, or they must have faith that extrapolations of data from younger populations are valid for older persons.
The U.S. Preventive Services Task Force has not always been consistent in its policy. For example, the task force states “there is insufficient evidence to recommend for or against routine mammography in women over age 70” based on the lack of studies in elderly women. However, the task force recommends fecal occult blood testing for colon cancer screening in all persons over the age of 50, even though no studies of the effectiveness of screening have been done in persons over the age of 75. In the case of colon cancer, extrapolation of the data was believed to be acceptable; in the case of mammography, it was not.
Klinkman, Zazove and colleagues,5,6 in a careful review of geriatric health maintenance, found only a few preventive measures with directly proved value in asymptomatic elderly persons over age 75. Effective measures include the following: obtaining a history of tobacco use, monitoring blood pressure measurements, evaluating hearing, initiating estrogen replacement for women, and ensuring up-to-date tetanus and influenza immunizations. All other interventions either had not been directly studied in the elderly or had been studied but with inconclusive results.
The elderly population is heterogeneous, and it is accepted that grouping them solely by chronologic age is misleading. The “young” elderly, such as an active couple who are mentally alert and enjoying retirement (perhaps traveling in a recreational vehicle) have preventive needs that more closely resemble those of middle-aged persons. This active couple has little need for routine vision and hearing screening. They are acutely aware of any changes in function and will report them immediately to their family physician, or they may bypass the primary care physician and go directly to a subspecialist such as an ophthalmologist or a hearing center.
Contrast this couple with the “old old,” such as a frail elderly woman who is living alone, perhaps getting increasingly forgetful, and starting to have difficulty with activities of daily living. The frail elderly woman probably could benefit from vision and hearing screening, but has little need for fecal occult blood testing for colon cancer or mammography for early detection of breast cancer. Differences in biologic age and life expectancy, not chronologic age, are what determine the appropriate strategy for specific patients.
Preventive protocols based on chronologic age can lead physicians into the trap of continuing to offer frail patients preventive procedures that are no longer appropriate and may even be harmful. In my practice, the most frequent example of this is the patient who has had fecal occult blood testing annually, year after year. It becomes almost automatic. Then, one day, the test comes back positive in a frail person who probably should not undergo endoscopic work-up. Multiphasic blood chemistry panels can provide a similar trap. If you do not want to act on the results of a test, do not order it in the first place.
National and international organizations making preventive recommendations have an ethical obligation not to recommend procedures unless evidence shows that they are effective, or at least to clearly state that the recommendation is not based on scientific evidence. Clinicians, however, have a different mandate—to provide the best care and advice to their individual patients.
Given the uncertainty surrounding the effectiveness of preventive procedures and the heterogeneity of the elderly population, what is the physician to do? Zazove6 has categorized interventions of unproven effectiveness as either “low effort” or “high effort,” which may help physicians prioritize their efforts in a pragmatic manner. Ultimately, physicians will have to extrapolate data obtained in other populations and examine the biologic plausibility that these data apply to the elderly. They will need to consider the specific individual patient, biologic age and life expectancy as well as individual preferences and desires. The physician, patient and perhaps family members will then decide on a reasonable course of action. There is a name for this activity that is as relevant as it was 100 years ago: It is called the art of medicine.