Disease prevention is treatment intended to prevent a disease from occurring or worsening. Disease prevention measures benefit independent older people with minimal or no chronic disease and older people with several noncurable but treatable diseases.
Primary and Secondary Prevention
Primary prevention aims to stop disease before it starts, often by reducing or eliminating risk factors. Primary prevention may include immunoprophylaxis (vaccinations), chemoprophylaxis (see table Chemoprevention and Immunization for Older Patients ), and lifestyle changes (see table Lifestyle Measures That Help Prevent Common Chronic Diseases).
Secondary prevention aims to detect and treat disease or its complications at an early stage, before symptoms or functional losses occur, thereby minimizing morbidity and mortality.
Chemoprevention and Immunization for Older Patients
Disease to Be Prevented | Measure | Frequency | Comments* |
|---|---|---|---|
Atherosclerotic cardiovascular disease (coronary artery disease, stroke) | Daily | ||
Boosters as they are available | For everyone over 6 months old: Recommendation by the CDC‡ For people ages 6 years and older if unvaccinated or previously received only monovalent vaccine doses: Recommended to receive 1 bivalent mRNA vaccine dose (for those with a monovalent dose, at least 8 weeks after) Adults ≥ 65: May receive 1 additional bivalent mRNA vaccine dose at least 4 months after the first dose of a bivalent mRNA vaccine. People who are immunocompromised: Case by case basis after discussion of risk and benefit | ||
Influenza | Yearly | For everyone: Recommendation by the CDC† | |
Pneumococcal infection | Once or twice depending on specific vaccine | For adults > 65 who have never received a pneumococcal vaccination: PCV15 followed by PPSV23 at least 1 year later or PCV20 alone, recommended by the CDC Centers for Disease Control and Prevention: Pneumococcal Vaccination). | |
Tetanus | Every 10 years | For adults > 19 who never received Tdap§: 1 dose of Tdap unless they have specific contraindications to the pertussis vaccine (dose is given at any time, regardless of the timing of the last dose of the Td vaccine) recommended by the CDC For all people who have received Tdap: A Td or Tdap booster every 10 years recommended by the CDC | |
Zoster | 2-dose series once at age 50 | For people ≥ For immunocompromised patients: Possibly a shorter interval between the 2 doses of RZV | |
* Recommendations in the table rely mainly on the USPSTF and sometimes on the CDC and other organizations. USPSTF recommendations are based on strength of evidence and net benefit (benefit minus harm):
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‡ For a summary of changes to the 2023 adult immunization schedule, including changes to COVID-19 vaccine information, see the Advisory Committee on Immunization Practices Recommended Adult Immunization Schedule, United States, 2023: Changes to the 2023 Adult Immunization Schedule. | |||
§ Tdap—Diphtheria (D) vaccines contain toxoids prepared from Corynebacterium diphtheriae. Tetanus (T) vaccines contain toxoids prepared from Clostridium tetani. Acellular (a) pertussis (P) vaccines contain semipurified or purified components of Bordetella pertussis. | |||
CDC = Centers for Disease Control and Prevention; Td = tetanus diphtheria; USPSTF = U.S. Preventive Services Task Force. | |||
Lifestyle Measures That Help Prevent Common Chronic Diseases*
Measure | Examples of Diseases |
|---|---|
Smoking cessation | Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer, chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, hypertension, osteoporosis |
Achievement of and maintainenance of a desirable body weight | Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer, diabetes mellitus type 2, hypertension, osteoarthritis |
Reduction of dietary saturated fat and avoidance of trans fats | Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer, diabetes mellitus type 2, hypertension |
Increased intake of fruits, vegetables, and fiber | Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer (possibly), hypertension |
Increased aerobic exercise | Atherosclerotic cardiovascular disease (coronary artery disease, stroke), cancer |
Reduction of dietary sodium | Atherosclerotic cardiovascular disease (coronary artery disease, stroke), hypertension |
Reduced intake of salt- or smoke-cured food | Cancer |
Minimized radiation and sun exposure | Cancer |
Muscle strengthening and stretching | |
Atherosclerotic cardiovascular disease (coronary artery disease, stroke), dyslipidemia (hyperlipidemia), osteoarthritis | |
Osteoporosis | |
Regular weight-bearing exercise | Osteoporosis |
Osteoporosis | |
* Recommendations in the table rely mainly on the USPSTF and sometimes on the CDC and other organizations. | |
Screening
Screening can be a primary or secondary preventive measure. Screening can be used to detect risk factors, which may be altered to prevent disease, or to detect disease in asymptomatic people, who can then be treated early.
Multiple organizations publish screening guidelines, which sometimes differ. Whatever a guideline recommends, individual patient characteristics and preferences must also be considered. Guidelines for cancer screening and screening for certain other disorders (eg, abdominal aortic aneurysm, elder abuse, depression) are available.
Selected Screening Recommendations for Older Patients
Disease to Be Detected | Test | Frequency | Comments* |
|---|---|---|---|
Abdominal ultrasonography | Once between age 65–75 | For men who have ever smoked: B recommendation by the USPSTF For men who have never smoked: C recommendation by the USPSTF For women who have ever smoked: I recommendation by the USPSTF For women who have never smoked: D recommendation by the USPSTF | |
Inquire about mistreatment (eg "Are there any problems with family or household members that you would like to tell me about?") | At least once | For all older patients: I recommendation by the USPSTF | |
Alcoholism screening questionnaire (eg, AUDIT, AUDIT-C) | Yearly | For all adults, including those ≥ 65: B recommendation by the USPSTF For all patients with a positive screening test: B recommendation by USPSTF for brief behavioral counseling interventions For patients who meet the criteria for alcohol use disorder: Abstinence recommended | |
ASCVD (atherosclerotic cardiovascular disease [1]) | Framingham criteria (up to age 75) Reynolds Risk Score (up to age 80) Multi-ethnic study of atherosclerosis (MESA) score (up to age 85) | Every 5 years People with multiple global risk factors‡ more frequently | Possibly measurement of serum lipid levels, high-sensitivity C-reactive protein, and/or ABI, recommended by the ACC/AHA (2) Older women: screened in the same way as older men |
Cognitive impairment (eg, dementia, delirium) | Cognitive impairment screening instrument (eg, Mini-Cog) | Yearly | For community-living adults > 65: I recommendation by the USPSTF |
Depression (major depressive disorder) | Depression screening questionnaire (eg, PHQ-2) | Yearly | For all adults, including those ≥ 65: B recommendation by the USPSTF† |
Fasting plasma glucose level | Yearly | For adults 35–70 with overweight or obesity: B recommendation by the USPSTF For adults > 35 with overweight, obesity, or other risk factors§: At least every 3 years recommended by the ADA (3) | |
Inquiry about falls during the previous year and about difficulty with walking or balance Get-Up-and-Go test, STEADI, or another fall risk assessment tool | Yearly | For all adults > 65: Use of a fall risk assessment tool recommended by the AGS and BGS (4) For community-dwelling patients ≥ 65 who have an increased risk of falls: B recommendation by the USPSTF for exercise interventions | |
Intraocular pressure measurement | Yearly | For all adults < 40: I recommendation by the USPSTF | |
Bedside hearing test | Yearly | For all adults ≥ 50: I recommendation by the USPSTF | |
HIV testing of serum, blood, or oral fluid | At least once | For all adults 15–65 and for patients > 65 with HIV risk factors: A recommendation by the USPSTF | |
Blood pressure measurement | Every 3–5 years for people 18–39 with normal blood pressure and no risk factors Annually for people > 40 and those with high-normal blood pressure and/or risk factors (eg, overweight or obesity, sedentary lifestyle, strong family history, African-American) | For all people ≥ 18: A recommendation by USPSTF (treatment based on the initial office blood pressure measurement and additional measurements outside of the office) | |
Obesity-related morbidity and mortality | Height and weight measurement BMI (kg/m2) calculation¶ | At least yearly as needed | For all adults with a BMI> 30: Referral for multicomponent behavioral interventions: B recommendation by the USPSTF |
Dual-energy x-ray absorptiometry | At most every 2 years | For all women ≥ 65 : B recommendation by USPSTF For women < 65 with increased risk as determined by formal screening tools: B recommendation by the USPSTF For men ≥ 65: I recommendation by the USPSTF | |
Behavioral counseling | At least once | For all sexually active adolescents and for adults who have an increased risk of STIs: B recommendation by the USPSTF | |
Thyroid dysfunction (hypothyroidism or hyperthyroidism) | Thyroid-stimulating hormone level | NA | For all nonpregnant adults: I recommendation by the USPSTF |
Inquiry about tobacco use | At least once | For all adults: A recommendation by the USPSTF For all patients who report tobacco use: Cessation counseling and appropriate medications | |
Snellen visual acuity test | Yearly as needed | For all adults ≥ 65: I recommendation by USPSTF | |
Blood 25-hydroxyvitamin D level | N/A | I recommendation by USPSTF | |
* Recommendations in the table rely mainly on the USPSTF and sometimes on the CDC and other organizations. Recommendations vary slightly among different professional societies and groups. USPSTF recommendations are based on strength of evidence and net benefit (benefit minus harm):
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† USPSTF recommends screening only in practices with systems to ensure accurate diagnosis, effective treatment, and follow-up. | |||
‡ Global risk factors for ASCVD include hypertension, tobacco use, high blood glucose levels, physical inactivity, and overweight and obesity). | |||
¶ BMI ≥ 25 = overweight; BMI ≥ 30 = obesity. | |||
AAOS = American Academy of Orthopedic Surgeons; ABI = ankle-brachial index; ACC = American College of Cardiology; ADA = American Diabetes Association; AGS = American Geriatrics Society; AUDIT = Alcohol Use Disorder Identification Test; AUDIT-C = abbreviated AUDIT Consumption Test; BGS = British Geriatrics Society; BMI = body mass index; HDL-C = high-density lipoprotein cholesterol; IFG = impaired fasting glycemia; IGT = impaired glucose tolerance; MESA = Multi-Ethnic Study of Atherosclerosis; NA = not applicable; PHQ-2 = Patient Health Questionnaire-2; USPSTF = U.S. Preventive Services Task Force | |||
Cancer Screening* Recommendations for Older Patients
Cancer to Be Detected | Test | Frequency | Comments† |
|---|---|---|---|
Mammography | Every 2 years | For women 50–74: B recommendation by the USPSTF For women 40–49: Individualized screening decision based on assessment of potential benefits and harms: C recommendation by the USPSTF For women ≥ 75: I recommendation by the USPSTF Continuing screening if in good health and life expectancy is >10 years recommended by the ACS | |
Papanicolaou (Pap) test (evidence for newer methods is insufficient) | One of the following:
| For women > 65: D recommendation against screening by the USPSTF if results of adequate recent screening have been normal and women are not at high risk For women who have had a total hysterectomy and no history of high-grade precancerous lesions or cancer: D recommendation against having Pap tests by the USPSTF For women > 65: Stopping screening suggested by ACOG if women have no history of cervical changes plus one of the following:
| |
Screening test (FOBT/FIT, flexible sigmoidoscopy, colonoscopy) | For adults 50–75: A recommendation by USPSTF For adults 45–49: B recommendation by USPSTF For adults 76–85: C recommendation by USPSTF (citing a very small net benefit of screening in those who have been previously screened) for selective routine screening (should be individualized, taking into account patient’s overall health and screening history) For people> 85: Stopping screening (USPSTF guidelines state that most organizations recommend that screening stop in people > 85 years) | ||
gFOBT FIT FIT-MT-sDNA | gFOBT and FIT: Yearly FIT-MT-sDNA: Every 1–3 years | ||
Flexible sigmoidoscopy | Every 5 years | When sigmoidoscopy is used with FIT, every 10 years plus FIT every year, recommendation by the USPSTF | |
Colonoscopy | Every 10 years | Recommendation by the USPSTF | |
CT colonography | Every 5 years | Recommendation by the USPSTF | |
Low-dose CT | Every year | For patients 50–80 who have a ≥ 20 pack-year smoking history and currently smoke or have quit within the past 15 years: B recommendation by the USPSTF | |
PSA measurement DRE | Individualized | For men 55 to 69: PSA screening based on individualized evaluation of harms versus benefits (C recommendation by the USPSTF) For men ≥ 70 years: D recommendation against PSA screening by the USPSTF | |
* Cancer screening should be carefully considered and individual risks versus benefits should be considered, particularly in patients with an estimated life expectancy ≤ 10 years. Recommendations vary slightly among different professional societies and groups. | |||
† Recommendations in the table rely mainly on the USPSTF and sometimes on the CDC and other organizations. USPSTF recommendations are based on strength of evidence and net benefit (benefit minus harm):
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ACS = American Cancer Society; ACOG = American College of Obstetricians and Gynecologists; DRE = digital rectal examination; FIT = fecal immunochemical test; FOBT = fecal occult blood test; gFOBT = guaiac FOBT; PSA = prostate-specific antigen; MT-sDNA = multitarget stool DNA; USPSTF = U.S. Preventive Services Task Force. | |||
Screening references
1. Jellinger PA, Handelsman Y, Rosenblit PD, et al: American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease. Endocrine Practice 23 (4):479–497, 2017. doi:10.4158/EP171764.APPGL
2. Arnett DK, Blumenthal RS, Albert MA, et al: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation140 (11):e596–e646, 2019. doi: 10.1161/CIR.000000000000067
3. American Diabetes Association: Introduction: Standards of medical care in diabetes—2020. Diabetes Care 43 (Supplement 1): S1–S2, 2020. https://doi.org/10.2337/dc20-Sint
4. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society: Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 59:148–157, 2011.
Tertiary Prevention
In tertiary prevention, an existing symptomatic, usually chronic disease is appropriately managed to prevent further functional loss. Disease management is enhanced by using disease-specific practice guidelines and protocols. Several disease management programs have been developed:
Disease-specific care management: A specially trained nurse, working with a primary care physician or geriatrician, coordinates protocol-driven care, arranges support services, and teaches patients.
Chronic care clinics: Patients with the same chronic disease are taught in groups and are visited by a health care professional; this approach can help patients with diabetes achieve better glucose control.
Specialists: Patients with a chronic disease that is difficult to stabilize can be referred to a specialist. This approach works best when the specialist and primary care physician work collaboratively.
Patients with the following chronic disorders, which are common among older adults, can potentially benefit from tertiary prevention.
Arthritis
Arthritis (primarily osteoarthritis; much less commonly, rheumatoid arthritis) affects about half of people ≥ 65. It leads to impaired mobility and increases risk of osteoporosis, aerobic and muscular deconditioning, falls, and pressure ulcers.
Osteoporosis
Tests to measure bone density can detect osteoporosis
Diabetes
Hyperglycemia, especially when the glycosylated hemoglobin (HbA1C) concentration is > 7.9% for at least 7 years, increases the risk of retinopathy, neuropathy, nephropathy, and coronary artery disease. Glycemic treatment goals should be adjusted based on patient preferences, duration of diabetes, comorbid conditions, vascular complications, risks related to hypoglycemia, concomitant medications, and life expectancy. For most adults ,an HbA1C goal of < 7% without significant hypoglycemia is appropriate. However, appropriate HbA1C goals can change based on additional factors:
< 7.5% for otherwise healthy diabetic older patients with a life expectancy of > 10 years
< 8.0% for patients with comorbidities and a life expectancy of < 10 years
< 9.0% for frail patients with a limited life expectancy
Control of hypertension and dyslipidemia in diabetic patients is particularly important.
Patient education and foot examinations at each visit can help prevent foot ulcers.
Vascular disorders
Older patients with a history of coronary artery disease, cerebrovascular disease, or peripheral vascular disease are at high risk of disabling events. Risk can be reduced by aggressive management of vascular risk factors (eg, hypertension, smoking, diabetes, obesity, atrial fibrillation, dyslipidemia).
Heart failure
Morbidity due to heart failure is significant among older adults, and the mortality rate is higher than that of many cancers. Appropriate, aggressive treatment, especially of systolic dysfunction, reduces functional decline, hospitalization, and mortality rate.
Chronic obstructive pulmonary disease (COPD)
Smoking cessation, appropriate use of inhalers and other medications, and patient education regarding energy-conserving behavioral techniques can decrease the number and severity of exacerbations of COPD leading to hospitalization.
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
U.S. Preventive Services Task Force (USPSTF) Published Recommendations: The U.S. Preventive Services Task Force publishes recommendations for screening and preventive strategies for specific conditions, based on a systematic review of the evidence.
