e in a community dwelling elderly persons, influenza vaccination reduced hospitalization rates by 48-57% for pneumonia and influenza.11 Persons who were 65 years of age and older reported that during epidemic periods influenza vaccination prevented 31-45% of hospitalizations and 43-49% of deaths due to all respiratory conditions. Evidence is showing that during the influenza outbreaks, influenza vaccine is reducing illness, hospitalization and deaths in the elderly living in institutions and senior centers. Vaccination of nursing homes residents may prevent institutional outbreaks. The cost benefit and cost effectiveness support the recommendations for vaccination of all persons aged 65 and over. Immunization was cost effective and resulted in cost savings compared with no vaccination strategy. It is clear that strategies aimed at the patient or healthcare provider are needed to increase implementation of vaccination policy to ensure that any recommended vaccine program is clinically and economically effective. Vaccine is most cost effective when included as part of routine health care encounter. The Medicare Influenza Vaccination Demonstration, performed 1988-1992, found influenza immunization to be effective and offer cost savings to the Medicare program. Therefore, as of May 1, 1993, influenza immunization joined pneumonia immunization as a fully reimbursed Medicare service.
“When should the vaccine be given?” - Mid October to mid November is the recommended period for vaccination. Evidence suggests that aggressive promotions of vaccination directly to patients by physicians and health care institutions increase vaccination rates. The American Geriatrics Society strongly recommends that comprehensive programs to provide wide spread influenza vaccination will contribute significantly to maintaining the health of older Americans.8
Reducing Falls: The annual incidence of falls among the elderly is approximately 30 percent in persons over the age of 65 years.13 Children fall all the time but they bounce, however, falls are more serious for the elderly. The risk of falls is greater in older persons, with the annual incidence up to 50 percent in those over age 75. Approximately 30 to 50 percent of falls result in minor soft tissue injuries that do not require medical attention. An estimated 1 percent of falls result in hip fractures; 3 to 5 percent result in other types of fractures, and an additional 5 percent produce serious soft tissue injuries. Because of the significant incidence of falls in the elderly, physicians should have an organized approach to fall assessment and prevention. Detecting the history of falls is essential. Falls could happen from environmental factors such as slippery floors, loose rugs, uneven thresholds, or from age related factors such as; vision, medications, weak lower extremeties, and problems with walking and balance. Studies have shown that frequency of falling is higher in hospitals and nursing homes compared with those living in the community. It is estimated that one in five in older hospitalized patients will fall during a hospital stay. In nursing homes, up to 50 percent of residents fall each year.
Of all the fall related fractures, hip fractures cause the greatest number of deaths and lead to the most severe health problems and reduced quality of life (Hall 2000). Most patients with hip fractures are hospitalized for about one week. Medicare costs for hip fractures were estimated to be over $3 billion in 2000. Through self-help, seniors can reduce the environmental risk factors by:
Health professionals could prescribe interventions such as: Bone strengthening medications, foot wear interventions in the shoes which could help balance and stability, and assistive devices such as walkers and canes. In addition, educational training programs for staff in hospitals and nursing homes help to reduce incidences in those institutions. In the long term, interventions to reduce falls will cut the cost of specialists and hospitalization in the elderly. There are many programs for reducing falls in the elderly which make a difference in health outcome. For example, the Toledo program “Guard Rails”, another example is “Tai-chi” it was reported that older people who participate in programs like this are less likely to fall.
Secondary prevention - Screening
Secondary prevention is to identify and treat symptoms existing in persons with risk factors or pre-clinical disease such as screening. Screening could be done for blood pressure, colon cancer, mammograms, pap test, prostate exam, vision screening, hearing impairment, and hypertension. Many screening tests are considered effective preventive intervention. For example: screening for colorectal cancer is recommended for all persons aged 50 and older. The frequency of screening varies with the test chosen. Pap smears for instance could be discontinued for women after the age of 65 if the patient has received regular screening prior to that time and all tests came normal. For Prostate Cancer, PSA measurement for men is recommended by the American Cancer Society to begin at age 50 (age 40 for African American men). Screening for Hypertension is recommended for all adults at least every two years. Women aged 65 and older should be screened routinely for osteoporosis. Screening should begin at age 60 for women at increased risk for osteoporotic fractures. Vision screening is recommended for all elderly people. Although evidence is insufficient to recommend routine screening in elderly persons, clinicians should consider cholesterol screening on a case by case basis for persons age 65-75 years old with additional risk factors.
Will the patient survive long enough to benefit from screening? Many recommendations for screening in the elderly state that screening should be continued if the patient is in “good health” or has a reasonable life expectancy.11 The answer often is derived from time-to-benefit from screening and the patient’s estimated remaining years of life. Also, age associated body changes may cause screening tests to perform differently in older patients. Mammography, for instance, performs better in older women, whereas the Pap smear test is more reliable in younger people. Mammography screening helps older women in detecting tumors and the fact that tumors grow slower in older women this means that through screening breast masses could be detected and removed.
Screening for hearing impairment: Hearing loss can be identified in 33% of persons aged 65 and older and in up to half of persons 85 years and older. Older persons are particularly prone to suffering the associated social and emotional disabilities that come from loss of hearing. Since screening is a preventive measure it should be suggested that all older persons aged 65 and older should have a hearing impairment screening.
Several disease and patient specific factors need to be considered when assessing the candidacy of an older person for screening. The physician must assess the impact of aging on the screening test performance. The patient’s remaining years of life and candidacy for further testing should be assessed. Systematic assessments should lead to maximizing the benefit of screening elderly people while minimizing the harm and the unnecessary cost involved. Public health recommendations need to weigh the benefit of screening elderly people against the cost and potential harm from screening. For elderly patients who have a short life expectancy, clinical care focus should be on a treatment that is likely to be of more immediate benefit than on screening. Older people with multiple medical problems or dementia may find screening burdensome. The decision for screening for older people should be based on the individual’s medical condition, life expectancy, and personal preference and willingness. Thus, patients should be allowed to be excluded from screening test if it is unlikely to be of benefit to them and on the other hand should have access to it if they wish. Guidelines and insurers should not employ strict age-based criteria for deciding who should be screened or whose screening tests should be paid for.
Tertiary Prevention - Rehabilitation
In tertiary prevention, an existing, usually chronic condition is appropriately managed to prevent frailty and further functional loss. Geriatric rehabilitation services are designed to enhance and restore functional ability and enable many older people to live with less restrictions, thereby resulting in net savings in health care costs. Geriatric rehabilitation is done after any kind of major surgery i.e. heart, lung, hip, knee, stroke etc. Rehabilitation should not be restricted to short term hospital rehab units or free standing rehabilitation hospitals. Services should be available in all settings in which older persons receive health care such as medical units in general hospitals, nursing homes, and home care programs. An interdisciplinary approach is very effective in the delivery of geriatric rehabilitative services. It may involve physical, speech, occupational and recreational therapists, doctors, nurses, social workers, and other health professionals.7
Primary care providers should be trained to assess the need for these services. They need to know when to seek the consultation of rehabilitation professionals and monitor the progress towards achieving the goals of these services. Although these services are often beneficial, focus has to be geared towards the merits and costs of some approaches. Intensive therapy after a stroke or brain injury may result in more rapid progress in the patient and earlier discharge from the hospital. Rehabilitation after a knee surgery may accelerate the functional recovery. Rehabilitation can also be tailored toward specific problems such as heart disease, hip fracture, and leg amputation. Speech disorders may also require rehabilitation. Because patients respond differently, rehabilitation programs must be individualized.
Rehabilitation is central to the practice of medicine in the elderly. The evidence of its efficacy led commissioners and health providers to invest in rehabilitation. Its scope is wide and includes acute and chronic perspectives. It is an intervention between impairment and disability or between disability and handicap - with the ultimate aim of reducing handicap. It can also be more focused, for example, at specific therapy to reduce the impairment associated with a painful shoulder. Poly pharmacy is now as important as rehabilitation in geriatric practice and that is reviewing the medications of the elderly people.4
Evaluation of the rehabilitation process is necessary to provide evidence for its effectiveness. Intervention should include treatment, care and advice on coping strategies for patients and carers. The most favorable outcomes of the intervention would be the reduced use of hospitals and nursing homes and reduced annual medical care costs. A good example of this was the demonstration that falls could be prevented in the elderly people by targeting rehabilitation on those identified as being at high risk of falling.
Funding for rehabilitation services of various durations and intensities should be provided to the elderly because it is an important component of geriatric care. However, data and evaluations are needed to determine which older individuals with functional disability will derive the greatest benefit from these services. For example, it has been established that women continue to live longer than men and although they appear to have more biological protection from stroke until the oldest age group, those who develop strokes may be more severely impaired and are less likely to be referred for rehabilitation. A point to consider also is the willingness of the older disabled patients to go for rehabilitation services. Medical professionals can not force patients to participate in these activities because the patients’ wishes must be respected. Healthcare workers should be sensitive to the willingness of the older patients as well as the compliance with the prescribed therapy. Healthcare workers should be advocates for patients and include them in the decision making process. In some people factors which contribute to willingness to undergo therapy could be; independence, stamina, lack of pain, no presence of regressive behavior, and the belief that older people should participate in some physical activity. The deterrent factors could be; lower sense of independence, presence of pain, depression, dementia, and the expectation of help from others. In a comparative study done between Japan and the U.S.A, the differences were found to be in the family background and culture. Japan had a higher bed-ridden elderly than the U.S because the Japanese people depend on others and expect help from them all the time much more than the American people. They expect to live with their children or grandchildren and be taken care of. Healthcare workers in Japan have to educate the elderly patients and repeatedly encourage them to utilize their functional capacity as much as possible in their daily activities. However, it is worthwhile mentioning that excessive willingness for rehabilitation for older people could be dangerous and should be examined as well.
1. Department of Health and Human Services, USA (2002). A profile of older Americans: 2002. Retrieved April 10, 2003 from: http://www.aoa.gov/aoa/stats/profile/default.htm
2. Media Relations & Marketing (2002). Elderly need to emphasize good diet and exercise. Retrived 4/1/03 from www.mediarelations.ksu.edu
3. Tom Hickey, Marjorie A. Speers, Thomas R. Prohaska, Public health and aging. Johns Hopkins University Press, 1997.
4. Stanley F. Wainapel, Avital Fast, Alternative medicine and rehabilitation. New York: Demos, c2003
5. Mary Law, Evidence-based rehabilitation: a guide to practice. Thorofare, NJ: Slack, c2002
6. Marie S. Seabrook, Elderly Americans: issues and programs. Nova Science Publisher, 2002.
7. The Merck Manual of Geriatrics. Chapter 5. Prevention of disease and Disability. Retrieved 4/4/03 from www.merck.com/pubs/mm_geriatrics
8. Disease Management & Health Outcomes (2002). Economic Evaluations of Influenza Vaccination in the Elderly: Impact on Public Health Policy. Retrieved 4/10/03
9.The National Institute of Health. Exercise: A Guide from the National Institute on Aging, (99-4258), 3-5, 16-19.
10.The American Geriatrics Society (1996). AGS Position Statement Prevention and Treatment of Influenza in the Elderly. Retreived 4/9/03 from: www.americangeriatrics.org/products/positionspapers
11. Adult Health Screening. Preventive Health Care. Retrieved 4/10/03 from www.sh.Isuhsc.edu/fammed/OutpatientManual/PreventHealthCare.htm
12. National Center for Chronic Disease Prevention and Health Promotion. Healthy Aging. Retrieved 4/4/03 from www.cdc.gov/nccdphp/bb-aging/
13. National Center for Injury Prevention and Control. Falls and Hip Fractures Among Older Adults. Retrieved 4/4/03 from www.cdc.gov/ncipc/factsheets/falls
14. Center for Disease Control and Prevention. Deaths: Leading causes for 2000. National Vital Statistics Reports 2002; 50(16).