Cancer is the second most common cause of death in the elderly population. Table 6.1 shows the annual incidence of the ten most common cancers in England and Wales and the proportions of these cases that occur in men and women aged over 70 and over 80 years. The reasons for the increased rate of cancer in old age is unknown, though it may be due to a decrease in immune surveillance or to an increasing frequency of DNA damage resulting in more frequent malignant transformation of normal cells.

Despite cancer being so common, surprisingly little is known about its behaviour in older patients. Previously, older patients have tended to be excluded from clinical trials because of negative ageist bias, misperceptions about the ageing process or, on occasions, the sheer impracticality of including very frail elderly individuals in such research. Despite this, cancer has been closely scrutinised by the biomedical industry for many years and more is probably known about the prevention of cancer than the prevention of many other health problems in old age.

This chapter therefore reviews the importance of each of the major cancers afflicting the elderly population, evaluates the worth of screening programmes, and makes recommendations for practising clinicians based on current evidence. Where appropriate, comment is also made about primary preventive strategies.

In order to safeguard an essentially healthy population from iatrogenic insult, to prevent unnecessary costs both to individuals and to society, and to maintain the scientific integrity of the health professionals concerned, a number of rules or principles have been evolved over the years to define acceptable strategies for the screening of ‘normal’ populations. Rogers et al. have further refined these criteria so they become relevant to the elderly population with chronic illness. Despite this emphasis on screening criteria, the relevant principles are also pertinent to a wide range of other preventive care and health promotional strategies. In those countries where preventive care programmes have been widely practised, national ‘task forces’ have been set up to critique the various strategies and to make reliable recommendations on good practice. Most noticeable of these was firstly the Canadian Task Force on the Periodic Health Examination and subsequently the United States Preventive Services Task Force. These working parties have further developed the above principles to establish new international standards.

The preventive care and health promotional strategies outlined in this book are therefore discussed in the context of these accepted principles. For ease of presentation, each health problem is therefore considered under the following headings.

• Importance

• Feasibility of detection

• Effectiveness of preventive strategies

• Cost of applying detection and prevention strategies

These aspects are now considered in more detail.

In this chapter I consider some of the practical aspects of incorporating preventive care and health promotional strategies for elderly people into existing health and social care delivery systems. An overview will be given of the implications for both the providers and purchasers of health. It is assumed that the majority of purchasers will be governments and also health insurance companies and other third-party payers who commonly meet the costs of provision on behalf of the older population. It is also assumed that the purchasers of health care have (or should have) a close liaison with public health professionals and that the latter will guide purchasers in formulating a strategy and setting quality standards. In the discussion that follows, the boundaries between the provision of certain health care services and health promotional strategies will be deliberately blurred because the distinction between the two is artificial and counterproductive.

Public health

Assist purchasers on appropriate health services

An essential task for public health professionals is to assist health purchasers in buying an appropriate mix of health services that will have maximum impact on the health of an older population. Often the health services available to a local population have arisen because of historical precedent and the interests of the people working within the system. Much money is often spent on high technology aspects of biomedical care that at times have marginal benefit. Some aspects of intensive care and oncology treatments are examples of this.

General deconditioning with age

Importance

In the adult years, activity is at its highest in the twenties and thirties. Thereafter, activity levels decline as energetic leisure time pursuits are abandoned. These levels then remain stable until retirement, when a second major decline in activity occurs. There is evidence that a significant proportion of the changes commonly ascribed to the ageing process are, in fact, the biological consequences of this inactivity and disuse. Foremost amongst these changes is cardiovascular deconditioning as manifest by the maximum oxygen consumption, which declines at about 1 per cent per annum with age, but a range of other changes such as reduced red cell mass, loss of lean body mass and osteoporosis have, at least in part, been implicated as being due to disuse that occurs during ageing.

There is also increasing evidence that inactivity in later years is associated with an increased susceptibility to certain disabling disorders, such as cardiovascular disease, stroke and hip fracture, that play a major role in functional decrement. Furthermore, further deconditioning rapidly accompanies the recumbent bed rest and even non-recumbent rest that results from the frequent bouts of intercurrent illness commonly occurring in the elderly population.

Targeting/detection

It is extremely difficult to distinguish between the normal ageing process and the changes due to inactivity and disease. No reliable technique is available to identify those at particular risk of inactivity. Health promotional measures must therefore be applied to the whole of the elderly population.

This book is concerned with promoting the good health of individuals who have already reached old age. This may be achieved by a number of strategies that have been variously described as preventive health care, health promotion or health maintenance. Unlike the situation for younger people, however, interest and knowledge about the preventable problems of old age and strategies to combat these problems are still in their infancy. Irrespective of the age group under consideration, there is also a good deal of emotional controversy surrounding many preventive care strategies. Several of these issues are discussed in detail in later sections of this book. This chapter broadly sets the scene for health promotion and preventive care and begins by defining what is meant by the terms elderly people and old age.

What is meant by old age?

This book concentrates on people who have already reached old age or who are elderly persons. The concept of what is meant by these terms has changed gradually throughout human history and has altered markedly in the last hundred years. In previous centuries, because of the considerably shorter life expectancy, older members of society would be those who, in present day terms, might not yet have reached middle age. However, from the early part of the twentieth century, the age when someone becomes ‘elderly’ has, for largely political and economic reasons, been considered to start around the age of retiral at 60 to 65 years.

In the previous four chapters I have identified 64 common health problems afflicting elderly people and have discussed the research evidence on the available preventive care and health promotional strategies to counter each. In this chapter I provide a summary of this evidence in tabular form.

Section A (Tables 10.1 to 10.4) contains recommendations for inclusion in a preventive care protocol. These are based on what, at the present time, seem useful, safe, simple and reasonably cost effective to apply. Section B (Tables 10.5 to 10.7) contains those strategies excluded because they are not, at the present time, considered to be so.

The conclusions drawn are personal to the author. At times, these recommendations may differ from those proposed by various professional societies or from those proposed by the US Preventive Services Task Force or Canadian Task Force on the Periodic Health Examination. Readers will need to reach their own conclusions on what is appropriate for inclusion in their daily practice based on this conflicting information, the financial resources available to their health care system and what is considered by society as usual and normal preventive care.

Within the UK, preventive care for elderly people has historically centred around population screening and surveillance by the family doctor and his primary care team. In this chapter, therefore, I look at the primary care services as a resource for this older age group, review in detail the value of such screening, consider more efficient methods of targeting the frail elderly and discuss the implications of recent government legislation mandating an annual health check being offered to those over 75 years.

Primary care as a resource for elderly people

In the community, primary care services usually consist of family practitioners or other ‘generalist’ doctors who serve as first point of contact for elderly patients and who provide comprehensive, ongoing care. Community nurses also figure prominently in community care, either being directly employed by the family doctor's practice or liaising closely with it. Primary care is also represented by a wide range of other health professionals who work as part of a multidisciplinary team, or network, with the practice. In some countries, family doctors have a statutory responsibility to consider their patients' social needs and to make referral through the appropriate social services.

Some countries still have problems in providing geographically and financially accessible care to their older populations or in making this readily available on a 24-hour, 7-day week basis.

When the specific strategies outlined in the previous chapters are applied, they should be tailored to meet the needs and wishes of elderly individuals according to the following broad principles.

Time the intervention precisely

There is a ‘critical intervention time’ or ‘window’ during which various types of support should be provided. A patient's functional status may deteriorate slightly for several years, with the impairment being noticeable only to the family. A crisis may then develop during which the situation deteriorates rapidly. If support is added too late, institutionalisation is often the outcome. If it is provided too early, however, it merely fosters dependency, wastes resources, is costly to society, and is considered by many elderly people to be an intrusion on their privacy.

Intervention of any sort, whether it be the relocation of an elderly person into specialised housing or the provision of a community service, must, therefore, be timed precisely if it is to be effective and to avoid detriment. Many caring professionals, however, will be tempted to prescribe unnecessary supports for the elderly during the early phase of functional decline because of their own anxieties and pressure from anxious family members. There is, for example, evidence from the UK that a significant proportion of social service ‘home help’, ‘meals on wheels’ and home aid allocation is given to those elderly people who are relatively fit and who are not strictly in need of the service.

Imposed burden on family carers

Importance

The impact of the caring role on the health and wellbeing of family and other informal carers is considerable. While the caring bond may be of mutual benefit and enhance relationships there is now well-documented evidence that caring for elderly people can have numerous adverse effects (see Fig. 9.1). Many researchers have produced evidence that such caring can produce increased levels of anxiety, embarrassment, guilt, low morale and depression. Several studies attest to a significant degree of physical ill-health in carers, and diabetes, arthritis, anaemia and the use of psychotropic medication have been shown to be more common than in non-carers. This may be because the caring role is causal or because many carers themselves are elderly. Caregiving undoubtedly involves a degree of financial penalty incurring both direct and indirect (or opportunity) costs. Caring can also jeopardise opportunities for employment, many younger relatives giving up work or restricting their working hours to continue with the role. If they remain at work their performance often suffers significantly.

The impact of caring on carers can have a subsequent negative effect on their families, on the elderly people themselves and on society at large. For example, caregiving often involves spending time away from the carer's own family and family disharmony frequently accompanies the caregiving role.

Hypertension

Importance

Although some studies have shown a lack of association between hypertension and mortality in elderly people and two have even shown an unexpected survival advantage, the considerable bulk of evidence indicates that hypertension is not a benign accompaniment of ageing. It is associated with greater mortality and morbidity from stroke and cardiovascular disease. Cardiovascular risk gradients actually increase with advancing age (see Fig. 7.1). Diastolic blood pressure is a predictor of risk in its own right but systolic pressure is equally, if not more, predictive of risk for cardiovascular morbidity and mortality and for future stroke events.

Prevalence estimates of both diastolic and isolated systolic hypertension in elderly people vary widely, tending to decrease with increasing numbers or occasions on which the blood pressure is measured prior to making the diagnosis. Between ages 60 to 70 years, the prevalence of elevated levels of combined casual systolic and diastolic pressure (upon which risk estimates may be based) range between 17 and 24 per cent. However, the prevalence of sustained levels for systolic and diastolic hypertension (upon which treatment decisions should be based) is about a third of this.

It is important to have explicit, clear goals for health promotion and preventive care that encompass the broad view of health as described in Chapter 2. The needs of carers, and to an extent the needs of society (as a ‘corporate carer’ for this population), must also be considered. Once these goals are identified, specific measurable and realistic targets can then be formulated for each. The following goals are offered as a starting point in this process.

Health promotion and preventive care for elderly people should:

• catalyse, enable and empower elderly people to continue their self development as individuals and as important members of society

• prevent or palliate physical, psychiatric and psychological disorders and the symptomatic consequences thereof

• prevent iatrogenic insult to health, to functional status and to the social support system

• prolong life where this is desired by the elderly person and is compatible with ethical principles of care

• prolong the period of effective activity and independent living in old age

• ensure a support system adequate to preserve people's autonomy, independence, dignity and quality of life at all levels of care

• avoid institutionalisation as far as is practicable in both humanitarian and economic terms

• support and assist elderly people to adapt to loss when this is inevitable

• ensure that when illness is terminal there is as little distress as possible to patient and caregivers

• […]

It is generally believed that, in addition to its obvious health benefits, prevention costs less than cure and that because the potential savings are so great, more attention should be given to prevention simply on the grounds that it saves money. For example, President Jimmy Carter of the USA wrote that prevention ‘can substantially reduce both the suffering on our people and the burden on our expensive system of medical care’. Likewise, in outlining a four point programme to control Medicare costs in the USA, Somers commented how distressing it was to see continued lack of attention on prevention which was ‘potentially the most effective of all cost-control strategies’. The situation is much more complex, however, and careful economic analysis suggests a different picture. In reviewing a variety of health promotional strategies for all age groups, Russell concludes that ‘even when financial cost of the preventive measure looks small, careful evaluation often shows that the full costs are rather large, larger than any savings’.

In this chapter, therefore, I look at the nature of the costs of health promotion, summarise current information on the magnitude of these costs to individuals and to society, describe some of the ways in which costing techniques may be biased against elderly people, emphasise the lack of current funding on health promotion and suggest ways in which potential purchasers might get the best value for their money.

The health of a nation is one of its most valuable resources, and is one foundation for the generation of economic wealth. This idea begs the questions: what exactly is health, and in particular, what does it mean to elderly people? Several concepts have been propounded. One of the most commonly quoted is that of the World Health Organization (WHO) who took a broad perspective and defined health as ‘a state of complete physical, mental and social well-being’. There are, however, several problems with this type of definition. Firstly, it is too perfect and may create an inappropriate escalation of demand. Complete physical, mental and social wellbeing means the avoidance of influenza or better access to public facilities for the disabled. It may also mean an increasingly higher pension and better housing or any rights or civil liberties that make the elderly person more content. Taken to its extreme, it can mean virtually any physical goods to keep that person satisfied. Using WHO's definition of perfect health begins to blur the margins between the search for legitimate and feasible health promotional strategies within a society and its narcissistic pursuit of hedonism. Secondly, WHO defines a perfect health that, as we see in Chapter 14, few people even wish to try to attain. The achievement of perfect health is not without a variety of unacceptable costs to many of the individuals concerned.