Health Promotion and Preventive Care
“Man does not cease to play because he grows old. Man grows old because he ceases to play” George Bernard Shaw
The British Geriatrics Society has had a long standing interest in promoting preventive strategies for older people. The Health Promotion Special Interest Group was instituted in 1994 and was then merged with the Care Home Special Interest Group to form the Primary and Continuing Special Interest Group in 2001.
Ageing Myths and Facts
Public misconceptions and myths about aging continue and there is a widespread belief that frailty is a natural consequence of age.
In the 1970s/early 1980s Fries suggested that marked increases in life expectancy and compressions of mortality would be followed by a “compression of morbidity “ ie—a rectangularisation of the morbidity curve. His view was that non communicable diseases could be postponed through changes in lifestyle, the age of first disability or major infirmity could be delayed to very near the end of life which he set at an average maximum length of 85 years.
His approach was that chronic diseases and physical decline “originate in early life, develop insidiously “ and can be prevented. This has been widely accepted as the basis of today’s approach to degenerative diseases, ageing and health with its focus on the life course, health promotion and “active ageing”. (Health and Ageing: a discussion paper - World Health Organisation 2001)
Changes in social structure and health
Age is associated with a 1-2 % decline in functional ability per year and sedentary behaviour accelerates the loss of performance. Forty per cent of people aged over 50 and 60-85 % of those in ethnic minority groups in the United Kingdom are sedentary .Between the ages of 45 and 74 the number of people, performing enough activity to benefit health, declines from 1 in 3 to 1 in 7.
Social isolation and loneliness are likely to become an increasingly widespread problem among older people in Britain as a result of people living longer, changing family structures, and greater mobility in the working population. By the year 2025, 20% of the population in industrial countries will be aged 65 and over and more than 60% of women over 75 will be living alone.
The responsibilities of the British Geriatrics Society
It has always been the goal of the British Geriatrics Society to add life to years as well as years to life. The members of this society work to ensure that older people maintain their independence, good health and engagement in life for as long as possible.
Through their work and collaboration with other professionals and GPs they aim to prevent disease, disability and injury by a process of primary, secondary and tertiary prevention. This approach allows older people to maintain control over their lives and shorten the length of time that they experience terminal disability.
The Society ‘s members ensure that the public is made more aware that getting older does not mean inevitable decline and deterioration and that people of any age can improve their health if they adopt a healthy life style . Disability can be delayed by as much as 10 years through moderate physical activity, good nutrition and stopping smoking.
National service framework for Older People (standard 8)
The Society therefore welcomed the National Service Framework for older people: Standard Eight “The promotion of health and active life in older age” The aim of this standard is to extend the healthy life expectancy of older people. So far activity in this area has often been fragmented and inadequately coordinated leading to a risk of duplication, gaps and poor use of resources.
The April 2003 milestone whereby Health Improvement Plans and other relevant plans should have included a programme to promote healthy ageing and to prevent disease in older people will be beneficial. It is recognised that they should reflect complimentary programmes to prevent cancer and CHD and to promote health as well as the continuation of flu immunisation.
The April 2004 target to demonstrate year on year improvements in measures of health and well being in older people through flu immunisation, smoking cessation as well of course as blood pressure control will continue to ensure that older people benefit from health promotion interventions and barriers such as ageism are removed.
Advances in Health promotion
Healthy lifestyles are as influential as genetic factors in helping older people avoid the deterioration traditionally associated with aging. People who are physically active, eat a healthy diet, do not use tobacco, and practice other healthy behaviours reduce their risk for chronic diseases and have half the rate of disability of those who do not. Walking, running and swimming should be part of a healthy ageing lifestyle.
Regular physical activity has been shown to contribute to both improvements in physical and psychological function including reduction of depressive symptoms. It contributes to a healthier independent life style by significantly improving the functional capacity and quality of life for older people. The benefits to older people’s quality of life include:
- Fun / enjoyment
- Social benefits
- Mental health benefits
- Physical enhancement
- Enjoying the grandchildren
- Getting into the bath
- Cutting toe nails
- Caring skills (thanks to Dawn Skelton 2001)
Benefits have also been demonstrated in the older frail patient through gains in muscle strength resulting in improvements in functional aspects of daily living
Future plans and governmental responsibility
Planners should be made aware that over half the aged population are women and that the numbers of older people from the black and ethnic minority groups are rising. Health, housing, transport, leisure, voluntary organisations, and social care need to collaborate to ensure that older people enjoy their longevity as healthy active years preventing loneliness, social isolation and immobility. Healthy ageing should be promoted amongst all groups including those with Disability, Dementia as well as older carers, older people living alone and older homeless people (Quality and choice for older people’s housing –A strategic framework 2000)
Diet and life style influences have a considerable influence on morbidity during the life course. Dietary patterns and other modifiable life style factors are associated with mortality from all causes, coronary heart disease (CHD), cardiovascular diseases (CVD) and cancer. The recent publication of the Hale Project showed that amongst individuals aged 70-90, adherence to a Mediterranean diet and healthy lifestyle is associated with a more than 59% lower rate of all-causes and cause specific mortality. (JAMA ,September 22/29- Vol 292,No12.1433-1439)
A strong relationship has been shown to exist between a modestly elevated homocysteine concentration and the occurrence of diseases in older age including Alzheimer’s Disease and cardiovascular and cerebro-vascular disease. There is some evidence that homocysteine lowering agents such as folic acid and to a lesser extent B12 supplements may have a beneficial and controlling effect on the development of these pathologies. Governments need to think carefully about mandatory food fortification. (Genetic and nutritional factors contributing to hyperhomocysteinemia in young adults. Leo A.J .Kluitjmans et al.Blood 1 April 2003 Vol 101 ,No. 7 ,pp.2483-2488).
Pre-disposition to disease in old age may be caused by relationships between genotypes and modifiable risk factors. In younger people the APOE epsilon4 allele and cigarette smoking act synergistically increasing an individual’s likelihood of having a cerebral ischaemic event. This approach could be extended to older people in order to target those at risk and thus modify their risk factors. (Synergistic effect of apolipoprotein E polymorphisms and cigarette smoking on risk of ischemic stroke in young adults .Pezzini A. et al. Stroke .2004 Feb; 35(2):438-42.Epub 2004 Jan 15.)
Opportunistic screening and the management of chronic disease
Older people attend their GPs at least 7 times a year. This provides the GP with an opportunity to identify and treat asymptomatic disease such as Hypertension, Atrial Fibrillation and Osteoporosis.
Medicines review/ management by the general practitioner has been shown to be very beneficial in all age groups but particularly in older people who are more likely to receive multiple medications. Older People have a greater likelihood of having medication –related complications .These increase with the number of medications consumed, both prescribed and over the counter.
Screening for cancer could also take place. Cancers of the breast, prostate and colon are increasingly remediable to surgery or chemotherapy and are best identified early on in their natural history.
Early identification of older people with Dementia is important because they can be referred for appropriate treatment, support and follow up to ensure that both the sufferer and their families can receive ongoing care and review.
Similarly early diagnosis and treatment of depression can similarly improve quality of life in older people.
Older people with chronic diseases such as Arthritis , Diabetes and Parkinson’s disease should be identified to ensure appropriate review ,follow up and review as well as adequate co-operation between Primary and secondary care .
General practitioners should have access to screening tools to identify changes in cognition and mental health.
The National Service framework standards in both Falls and Stroke allow the General
Practitioners /primary care sector to collaborate with secondary care providers in the primary and secondary prevention of these problems.
Urinary incontinence is treatable and preventable and early diagnosis is beneficial.
Measures such as checking visual acuity, testing for glaucoma, hearing ability and functional ability should be part of the statutory requirements of Primary care when dealing with older people.
Primary care should have access to appropriate assessment tools to identify the above sensory and functional deterioration.
Secondary care sector
The British Geriatrics Society recommends that practicing geriatricians will, when reviewing patients in the inpatient or outpatient setting, also recognise the opportunity for primary, secondary and tertiary prevention allowing the older person to maintain control over their lives and their independence.
The society endorses :
- Proposals which provide a focus at European and National levels for the development of policies, strategies and the direction of research
- Multidisciplinary working with focused policies based on effectiveness
- The centrality of the older person
- Development of research strategies.
- Collaboration with the Royal College of General Practitioners , the faculty of Public Health and Age Concern to deliver effective primary , secondary prevention.
- Collaboration between health, leisure, housing, transport and social services.
- 'Active for Later Life' National Conference: Post Conference Review Dawn Skelton 2001
- Flexibilty and functional ability McMurdo 1993;Skelton 1996.
- Depression McMurdo 1993
- Developing evidence based health promotion for older people: A systematic review and survey of health promotion interventions targeting social isolation and loneliness among older people