The population of the United States, like that of other industrialized nations, is aging. This rapid growth is evident with the aging of the “baby boomers” born between 1946 and 1964 who will begin turning 65 in 2011. The aging population is also heterogeneous with individuals expressing the poorest health often identified as ‘frail” or “at risk” elders.

In the rapidly changing fields of health care financing and delivery, services that promote or improve functional abilities, prevent or delay disease progression, and improve the overall health status of this aging population are needed. Little information and evidence are available about what constitutes the best practices in health promotion, prevention, and counseling for older adults. This chapter defines successful and healthy aging, provides recommendations for prevention and health promotion, and describes how to assess for at-risk elders.

In a highly heterogeneous population, some individuals are ravaged early by a multitude of chronic conditions and disabilities, whereas others appear to have excellent health and a high level of functioning. Aging is a process, and the term healthy aging does not imply an absence of limitations, but rather an adaptation to the changes associated with the aging process that is acceptable to the individual. Successful or healthy aging appears to include three factors: (1) low probability of disease and disability, (2) higher cognitive and physical functioning, and (3) an active engagement with life. (Table 39-1). Health care providers can promote healthy aging by assisting the older adult in developing competence in directing and managing future roles, thereby maintaining autonomy and a sense of self-worth.

Most older adults are healthy and independent, and contribute to the society in which they live. The epidemiology of aging evaluates not only the demographic changes associated with aging but also those diseases and conditions causing excess morbidity, mortality, disability, and decline in independent function. Many epidemiologic studies on aging focus on prevention in an attempt to establish a scientific basis for minimizing the illnesses associated with aging and their related burden. Health status in the elderly is a function of the chronic diseases associated with aging as well as the “geriatric syndromes” most commonly associated with this population (Table 39-2).

The overall health status and well-being of older adults is highly complex and results from many interacting processes, including risk factor exposure (tobacco, alcohol, drugs, diet, sedentary lifestyle), biological age-related changes, and the development and consequences of functional impairments. Many of the conditions previously thought of as “normal aging” are now known to be modifiable or even preventable if disease prevention and health promotion strategies are taken seriously not only by health care providers but also by the patients for whom they care.

Prevention in geriatrics attempts to delay morbidity and disability and is a primary goal of any medical practice caring for older individuals. The primary strategy for prevention lies in the alteration of lifestyle and environmental factors that contribute to the development of chronic disease.

Health promotion is a broad term that encompasses the objective of improving or enhancing the individual’s current health status. The purpose of health promotion, especially as applied to the elderly, is the prevention of avoidable decline, frailty, and dependence, thereby promoting healthy aging.

Frailty is emerging as a new geriatric syndrome. It is multifaceted and can be considered the midway point between independence and near-death as the older adult becomes more vulnerable and is at greatest risk for adverse health outcomes. Frailty has been associated with numerous conditions, many of which may be preventable if recognized early (Table 39-3). Important evidence of frailty includes slow walking speed, low physical activity, weight loss, and cognitive impairment. Preventive services for older adults need to be addressed within the framework of disability (frailty) prevention or, put another way, of function preservation.

For health promotion to be effective with older adults, it must be individualized in terms of patient age, functional status, patient preference, and culture. Culture is important in understanding the older adult’s health belief system. Without this understanding, a health care provider may be unable to negotiate a treatment strategy (including prevention practices) that is acceptable to the patient and the provider. The benefits of secondary prevention, including cancer screening, are uncertain for older adults. There is a paucity of evidence due to the lack of randomized clinical trials in patients older than 75 years, and most prevention and health promotion recommendations are extrapolated from younger subjects. The US Preventive Services Task Force (USPSTF) has set the standard for providing recommendations for clinical practice on preventive interventions, including screening tests, counseling interventions, immunizations, and chemoprophylactic regimens. These standards are established by a review of the scientific evidence for the clinical effectiveness of each preventive service. In considering screening strategies, major causes of death (Table 39-4), remaining life expectancy of the older adult should be considered along with the benefits and burdens not only on the preventive screening but the potential further evaluation and management. This is, especially important for individuals who have had repeated negative screenings in the past, who are frail, demented, or who have a limited quantity and quality of life remaining.

Many of the leading causes of death in this population are amenable to both primary and secondary preventive strategies, especially if targeted early in life. The major targets of prevention should therefore be focused at the major causes of death—including coronary heart disease, cancer, and stroke—with the goals of reducing premature mortality caused by acute and chronic illness, maintaining function, enhancing quality of life, and extending active life expectancy. A priority in screening should be given to preventive services that are both easy to deliver and associated with beneficial outcomes. Table 39-5 summarizes the primary health promotion preventive practices for older adults that received A or B ratings by the US Preventive services Task Force. Up-to-date details on preventive services can be found online at http://www.ahrq.gov.

Physical Activity in Older Adults

Exercise and physical activity as a form of primary prevention have many benefits even for sedentary older adults. A recent meta-analysis of physical activity and well-being in advanced age concluded that physical activity had its strongest effect on self-efficacy (self-confidence), and improvements in cardiovascular status, strength, and functional capacity also improved well-being. Lifestyle physical activities that are more unstructured as compared with a formal exercise plan are being shown to increase levels of physical activity in sedentary populations.

Promoting an Active Lifestyle

To make an expected change in physical activity the older adult needs to understand the importance and benefit of increasing physical activity. Obtaining and documenting a detailed history and physical examination should be one of the first steps to embarking on an increased physical activity plan (Table 39-6). The American College of Sports Medicine recommends stress testing for any older adult who intends to begin a vigorous exercise program such as strenuous cycling or running (Table 39-7). Conditions that are absolute and relative contraindications to exercise stress testing or embarking on an exercise program should be evaluated (Table 39-8). Finally, an exercise prescription should be written on a prescription pad to strengthen the endorsement for increased physical activity. The prescription should include frequency, intensity, type, and time of exercise.