Individualizing Prevention for Older Adults

Abstract

Prevention can help older adults avoid illness by identifying and addressing conditions before they cause symptoms, but prevention can also harm older adults if conditions that are unlikely to cause symptoms in the individual's lifetime are identified and treated. To identify older adults who preventive interventions are most likely to benefit (and most likely to harm), we propose a framework that compares an individual's life expectancy (LE) with the time to benefit (TTB) for an intervention. If LE is less than the TTB, the individual is unlikely to benefit but is exposed to the risks of the intervention, and the intervention should generally NOT be recommended. If LE is longer than the TTB, the individual could benefit, and the intervention should generally be recommended. If LE is similar to the TTB, the individual's values and preferences should be the major determinant of the decision. To facilitate the use of this framework in routine clinical care, we explored ways to estimate LE, identified the TTB for common preventive interventions, and developed strategies for communicating with individuals. We have synthesized these strategies and demonstrate how they can be used to individualize prevention for a hypothetical beneficiary in the setting of a Medicare annual wellness visit. Finally, we place prevention in the context of curative and symptom-oriented care and outline how prevention should be focused on healthier older adults, whereas symptom-oriented care should predominate in sicker older adults.

Decision Making for Older Adults With Multiple Chronic Conditions: Executive Summary for the American Geriatrics Society Guiding Principles on the Care of Older Adults With Multimorbidity

“…Consider patients' health trajectory: While there are few predictive tools to address prognosis for outcomes such as function or quality of life, consider likely changes over 1 to 2 years. Lack of return to prehospital function predicts poor health trajectory Estimate lag time (time horizon) to benefit: Time to benefit for treatments (lag time) may be longer than the individual's projected life span, and varies for different interventions Consider time frames of 1 to 2, 2 to 5, 6 to 10, and 10 or more years …”

“…Estimate lag time (time horizon) to benefit: Time to benefit for treatments (lag time) may be longer than the individual's projected life span, and varies for different interventions Consider time frames of 1 to 2, 2 to 5, 6 to 10, and 10 or more years …”

Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review

“…A detailed discussion of this topic is beyond the scope of this review, although we will highlight some methods that have been proposed. It has been suggested that life tables (which account for persons who may be more or less healthy than average, based on the presence of multiple co‐morbidities and/or functional impairment, for example) can be used for insight into life expectancy . One study in our review categorized persons as having limited life expectancy based on the NECPAL CCOMS‐ICO tool .…”

“…One study in our review categorized persons as having limited life expectancy based on the NECPAL CCOMS‐ICO tool . Mortality indices and online calculators have also been suggested as ways to estimate life expectancy in the context of medication decisions . Finally, the “surprise question” (Would you be surprised if this patient died in the next 12 months?)…”

“…It has been suggested that life tables (which account for persons who may be more or less healthy than average, based on the presence of multiple co-morbidities and/or functional impairment, for example) can be used for insight into life expectancy. 18,45 One study in our review categorized persons as having limited life expectancy based on the NECPAL CCOMS-ICO tool. 19 Mortality indices and online calculators have also been suggested as ways to estimate life expectancy in the context of medication decisions.…”