Health Articles

Despite recent conclusive evidence, many professionals and laypersons still consider loss of cognitive function a normal part of aging. However, any significant decline in memory or other mental function reported by a patient or family member and confirmed by a simple mental status test calls for thorough evaluation because the decline almost certainly results from a disease process, which may be reversible (see Chs. 9, 89, and 90). Similarly, any evidence of depression reported by the patient or family or observed during a routine assessment should be investigated and treated appropriately. Although depression is common in older persons, it is not a normal part of aging, and early attention can be beneficial. Depression is frequently associated with physical and social problems that make diagnosis difficult and complicate management. Among depressed elderly persons, the incidence of suicide has increased. The suicide rate increased rapidly between 1980 and 1985 and continues to increase among those > 85 yr; in 1991, the rate for those > 85 yr was twice the national average. Older people who are depressed should be treated with appropriate antidepressants and psychotherapy (see also Ch. 95). Mental and emotional status can affect sleep patterns. Sleep problems are sometimes associated with treatable health conditions and modifiable behavioral and environmental characteristics. Evidence of psychosocial stress—in family relationships, living environments, or marital and sexual relationships—should also be explored with older persons and family members. Significant stresses can interact with and may even affect immune competence and interact with chronic medical conditions. An older person’s social and support network of family and friends and involvement in outside activities also help maintain overall health and enjoyment of life. One preventive strategy is to ensure the effectiveness of support networks through counseling and the use of social resources.

Because of fluoridated water and frequent regular dental checkups, most older people today still have their own teeth. The physician should stress the importance of continuing good oral health practices, including regular dental prophylactic examinations, early correction of problems, and personal dental care (including use of fluorinated toothpastes) at least twice daily. Keeping the mouth and teeth in good condition is essential for proper nutrition, good appearance, and general enjoyment of life.

Before administering a particular vaccine, the physician should note when the patient last received it. A tetanus booster is recommended every 10 yr. The current year’s influenza vaccine should be given to older persons who have underlying conditions that may reduce immunity or who are prone to pulmonary infections. In fact, many experts recommend yearly influenza immunization for all persons > 65 yr of age.
A once-in-a-lifetime pneumococcal vaccine is generally recommended for older persons. Because more local reactions occur with a second vaccination than with the first, re vaccination may not be advisable except with overriding indications. More data and further guidance about pneumococcal vaccine use should be forthcoming.

An essential preventive strategy in older persons is routine screening for problems that are likely to develop. Upon early detection, many such problems may be reversed or corrected. Usually part of a general medical examination, the screening procedures are discussed in detail elsewhere in the manual.
Older persons should undergo tests of hearing, vision, blood pressure, and hemoglobin and cholesterol levels, as well as urinalysis. The frequency of such evaluations depends in part on symptoms and findings. For a person with no evidence of abnormalities, these evaluations should be performed every 1 to 3 yr.
The skin, mouth, breasts (male or female), prostate, colorectum, and cervix and uterus should be examined regularly for evidence of early cancer. Colorectal screening should include tests for occult blood. Opinions differ on how often the cervix and uterus should be examined in women over age 65 who have had one normal examination, have no symptoms such as bleeding, and are not receiving estrogen therapy. Some specialists recommend yearly examinations, others recommend one examination every 5 yr.
Persons of all ages should be advised to avoid extensive sun exposure and to use sunscreen to prevent skin cancer. For dry skin, regular use of lotions is suggested (see also Ch. 101).
Because hypothyroidism can develop unexpectedly in older persons, clinical examinations should include a specific search for even subtle signs and appropriate laboratory follow-up. In patients who are known to be hypothyroid and are taking replacement hormone, thyroxine (T4) and thyroid-stimulating hormone (TSH) levels should be checked periodically to deal with possible overtreatment and osteoporosis.
Attention should be given to a person’s individual profile. If a person has a family history of diabetes or a tendency toward obesity, a glucose tolerance test or a 2-h postprandial glucose test should be considered. A person with a family history of symptomatic osteoporosis, a thin build, or a loss of stature should have radiologic and laboratory examinations for osteoporosis (see also Ch. 73). More frequent pelvic and cytologic examinations are indicated if estrogens are being used. Perimenopausal women should be counseled about the benefits and risks of estrogen replacement therapy for preventing osteoporosis, as well as management of menopausal symptoms (see also Ch. 83).
Use of prescription and over-the-counter medications should be reviewed regularly. Such reviews should focus on potential interactions and side effects, and patient compliance. A small daily dose of aspirin is now recommended as prophylaxis for vascular thrombosis, as long as no contraindications exist.
Nosocomial infections can have a major deleterious impact on older persons and require good infection control practices in an institutional setting. With the increased incidence of drug-resistant tuberculosis, prevention and monitoring are especially important in older persons whose immune systems are usually less effective. Older persons in chronic care institutions are particularly vulnerable.

The general condition and vigor of the older person should be assessed. Specifically, the physician should assess height and weight, the ability to walk normally, the ability to carry out ordinary daily activities, joint flexibility, and any history or evidence of urinary incontinence. The physician should note any significant changes over time.

Accidents, particularly falls, increase markedly with age. Because falls often cause hip fractures and fear of more falls, they are a major cause of a loss of functional independence. Maintaining good physical condition helps prevent such accidents .
The home should have certain safety features, such as handrails on stairways both indoors and outdoors, handrails and nonskid surfaces in showers and bathtubs, good lighting, nonskid rugs, and smoke and fire alarms. The safety of the neighborhood should be assessed, and alternative living arrangements should be considered, if necessary.
Modifying dangerous driving practices, such as avoiding driving at night with impaired night vision, should be strongly encouraged. The need for caution in hazardous situations such as walking or driving in wet or icy conditions should also be emphasized. If a significant decline in mental or physical condition might make driving risky, a decision to stop driving should be considered by the affected person and family members in consultation with the physician. Data indicate that older persons involved in car crashes suffer greater physical damage than younger persons. These injured elderly persons need to be closely evaluated and may require monitoring for a period of time.

Studies have documented that a lifestyle including regular exercise, good nutrition, moderate (if any) alcohol intake, abstinence from tobacco, involvement in meaningful activities, supportive and satisfying personal relationships, and adequate amounts of sleep (generally 7 to 8 h each night) is associated with a longer, healthier later life.
Exercise: Weight-bearing and aerobic exercise, such as walking or bicycling, 20 to 30 min at least three times a week is associated with improved cardiac capacity, maintenance of muscle strength, and reduction in age-related progressive loss of bone mass. Regular exercise also helps reduce the risk of falls, including those resulting in hip fractures, which often lead to further physical deterioration. Persons in their 60s and 70s who take part in organized fitness programs not only increase their maximum aerobic capacities almost as much as younger persons in these programs but also improve their glucose tolerance and blood lipid levels. Daily stretching exercises are also important for maintaining joint flexibility (see also Ch. 31).
Although organized fitness programs do not appeal to everyone, virtually everyone can make vigorous walking part of an exercise regimen. Maintaining the ability to walk comfortably requires properly fitted, supportive shoes; clean feet; and routine care of nails and skin, including attention to calluses. A podiatrist should be consulted for foot problems that affect comfort or function (see also Ch. 77).
Nutrition: Good nutrition for older persons has not been clearly defined because adequate dietary, metabolic, and longitudinal data are not available. Based on studies of younger adults, however, older persons should have adequate but not excessive amounts of protein (0.6 to 1.0 gm/kg/day, relatively low fat (< 30% of calories) and cholesterol intakes, and the National Research Council’s recommended daily allowances of vitamins and minerals in food or as supplements. The importance of including about 1.0 to 1.5 gm of calcium in the daily diet should be stressed, although most older women need to take calcium supplements (see Ch. 73). However, the value of taking more than the recommended daily allowances of food supplements (ie, the megadoses marketed to the general public) has not been proved, and in some cases these doses may be toxic. For example, excessive doses of vitamin A or vitamin D can be toxic. For general use, vitamin D supplements of 400 to 800 IU/day are suggested.
Adequate fiber intake is the simplest means of minimizing constipation and gaining benefits such as reducing the risk of colon cancer and diverticulosis. Such fiber intake can be achieved through a regular nutritious diet that includes grains, fruits, and vegetables. Complex sugars, such as starchy foods, rather than simple sugars are also recommended, although the value of this substitution, like that of fiber intake, has not been proved conclusively. Salt intake should be modest, ie, little or no salt should be added to foods unless more is medically indicated. Data are not available on the impact of adding salt to the food of elderly persons with no history of hypertension or heart failure.
Most important, dietary intake (including alcohol intake) should be tailored to the individual. A person’s diet must take into account hereditary tendencies toward hyperlipidemia, a history of alcoholism, evidence of diabetes, a need to achieve weight reduction, activity level, and personal preferences.

Far more people than ever before are living into their 70s and beyond in relatively good health, leading vigorous, independent lives. Recent studies indicate that most body organs function nearly as well in later life as in younger years in those who maintain healthy lifestyles and have no chronic diseases. Of course, chronic diseases and disabilities tend to accumulate with age in many persons, threatening their independence. However, to a large extent, disease and disability in later life are linked to unhealthy behaviors in the earlier years and thus are preventable.
Preventive strategies for older persons have two general objectives: to maintain good health and function through behavioral choices and lifestyles beginning in the early or middle years and continuing through the later years, and to minimize the loss of health and function when chronic disabilities do occur.