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JOHNS HOPKINS L \ I ~ E R > I T 1 School of Hygiene and Public Health 624 N. Broadway Baltimore MD 21205 (410) 955-f)565/ FAX (410) 955-0470 Health Services Research and Developnent Center For Testimony Before the Special Committee on Aging: The United States Senate May 13, 1992 Preventive and Older Peonle The last decade has seen intensified interest in the potential for preventive services as a strategy for increasing the quality of life, decreasing health costs and generally improving the present and future health of the public. There has been a hesitancy in applying this approach to older people for a number of reasons, some of them dubious, some outright ageism and some of them reflecting the need for a better fit between prevention and the problems faced by older Americans. The definition of prevention, as it is commonly understood, is that of "primary prevention", that is, activities by both providers and consumers of health and health related services aimed at preventing a disease from developing or delaying its onset until late in life. Immunizations, cessation or never smoking in people free of heart or lung disease, or proper diets and exercise in healthy individuals to avoid a broad array of diseases, are examples of primary prevention. And these are very important. However, it is not the only preventive approach. It is less usual for people to think of secondary and even tertiary prevention -- actions and behaviors in the presence of disease either in early stages and undiagnosed or known and diagnosed. Secondary and tertiary

preventive strategies are aimed at detecting disease at an early stage, and/or decreasing undesirable effects and secondary occurrences of related disease in already diagnosed conditions. This may include some of the same strategies used as primary prevention. The goal is to minimize acute flair-ups and exacerbations, to achieve the highest level of function so that institutionalization can be avoided and so that independence, so valued by older people, can be maintained. Such a strategy includes education, appropriate health monitoring for care and rehabilitation, and encouragement of appropriate responsibility by both concerned groups: providers and consumers. Secondary and tertiary prevention is, in fact, prevention of disability. There is evidence that preventive initiatives have been met in the past with less than high enthusiasm by the older population. It might be argued that this rests in the highly visible emphasis on primary prevention which is interpreted as inappropriate by a population in which 80% have at least one chronic disease and the vast majority of this 80ye have two or more chronic diseases. When prevention is presented in a meaningful format, older people do and will respond. In a current multi-site demonstration, Congressionally mandated and being carried out under HCFA, both the acceptability of and the effect of preventive services are being tested. In the Johns Hopkins site, the majority of Medicare beneficiaries responded to the offer of Medicare waivers and took the initiative to secure preventive services from their physicians. We are now examining the impact of such services on health behaviors, on use of acute care, both in and outpatient, on crisis occurring in new and in existing conditions, and on deaths and institutionalizations. We need more examined experience with prevention to assess its outcome in quality of life and cost.

And what are some examples of such preventive services and at what specific problems are they aimed? There is of course early diagnoses of prevalent diseases of older people: diabetes, high blood pressure, breast and cervical cancers, prostatic cancers. The objective is to secure appropriate treatment in order to avoid some of the more serious conditions and improve the chance of control. Then there are less life threatening conditions which decrease function and increase risk of institutionalization such as arthritis, hearing and vision, dentition and mouth disorders. There are as well the highly publicized mental health problems of this age group which isolate, cause great pain and are associated with neglect and poor self care. Included as appropriate targets for preventive interventions are nutrition, drug regimen management, exercise. Finally, the most positive action that can be taken to help older people feel responsible for their health is convincing them that there are ways to help stay independent, function and decrease pain even if the underlying condition is not "curable". If we cannot cure arthritis, the most prevalent condition of those 65 and over, we can head off total immobility, increase comfort and extend function. Right now, we know how to do all of these things. The integrated and multiple approach to prevention and older people involves: 1. convincing older people that prevention is a reasonable approach for them; 2. increasing the skills of clinicians of all types to practice preventive strategies with their older patients; 3. teaching appropriate prevention to this population in which existing diseases are prevalent; 4. designing and implementing effective approaches for dissemination among professionals for their use in practice; 5. establishing those strategies that achieve the best results; 6. consider reimbursement mechanisms that encourage the practice of prevention.

The extension of Medicare for several of these areas presents one immediate strategy. Immunizations, counselling for drug regimens, stress, sleep disorders within the context of the outpatient visit (where most older people are likely to bring their concerns and problems), hearing and vision testing, dentition and nutrition examination, are all places to begin. Proper prevention is a great untapped potential to address the heavy cost of care for older people while improving the quality of lives, increasing independent functioning and bringing hope of greater control by those we have helped to live longer, albeit with a plethora of diseases/conditions. Pearl S. German, Sc.D. Professor, The Johns Hopkins University