Primary and Secondary Prevention Strategies in the Older Adult

Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page 28. On completion of this article the reader should be able to: 1. Discuss prevention measures for the elderly 2. Identify prevention activities for the elderly Primary and Secondary Prevention Strategies in the Older Adult By Laurence Z. Rubenstein/Ruth Nahas Because of the number of effective preventive activities available, the caregiver should take a systematic approach to ensure that these activities are being used to full advantage. Abstract: Most causes of death and disability in older people are partially to fully preventable. To If I'd known I was going to live so long, I would have taken better care of rnyselft --George Burns, on approaching his looth birthday achieve maximum benefits from.i hy do some 85-year-old adults remain active, vigorous, and prevention strategies, use an orga-,,:: productive whereas many other older adults are wasted. nized system tailored to individual... and frail or die long before that age? The list of successful ~: nonagenarians is well-known and dramatic: Pablo Picasso, health risks and circumstances. Grandma Moses, Vladimir Horowitz, Arthur Rubinstein, (Geriatr Nurs 1998;19:11-8.) and Pablo Casals. Although the full explanation is elusive, the three most im- Geriatric Nursing Volume 19, Number 1 11

TABLE 1. MAJOR CAUSES OF DEATH IN ELDERLY PEOPLE AND PREVENTABILITY Rank Cause %* Prima~t Seconda~t 1 Cardiovascular 47 ++ + 2 Cancer 20 ++ ++ 3 Stroke 11 + + 4 Lung disease 6 ++ + 5 Accidents/falls 2 + + 6 Diabetes 2 0 + 7 Kidney disease 1 + + 8 Liver disease 1 ++ 0 * Percentage of all deaths occurring in people age 65 years and older Examples Control risk factors: smoking, hypertension, hypercholesterolemia. Exercise regularly. Take aspirin, estrogens. Control risk factors: tobacco, radiation, sunlight. Screen for cancer of breast, colon, skin, prostate, uterus, mouth. Control risk factors: hypertension, tobacco. Take aspirin, anticoagulants in atrial fibrillation. Secondary prevention: screen for carotid artery plaques, emboli. Avoid risk factors: tobacco, allergens. Immunization: influenza, pneumococcal infection. Reduce risk factors: weakness, imbalance, polypharmacy, environmental hazards. Careful exercise. Screening may allow earlier intervention. 1- Effectiveness of primary and secondary preventive measures: ++, Very effective; +, effective; +, equivocal; O, not effective Control hypertension and diabetes. Treat infections. Avoid toxic substances (e.g., alcohol). Immunization. portant factors seem to be (1) genetics, (2) good luck, and (3) good health habits and preventive measures. Although the first two factors are relatively immutable, the third is certainly also extremely important and is to a great extent up to the individual. This article provides a concise but systematic approach to the third factor--the one about which we, as health care professionals, can do something for our patients and ourselves. INCREASING LIFE EXPECTANCY This century has[seen a dramatic increase in life expectancy. In the United States since 1900, average life expectancy from birth for men and women combined has increased almost 25 years--from about 58 years to about 82 years. Although much of this increase reflects reduced rates of infant death and other deaths in early life (largely because of improved public health measures), life expectancy among older people also has increased substantially. In 1900, the average 65-year-old woman could expect to live about 12 more years, whereas now that same woman can expect to live about 20 more years--and a higher proportion of people are living to age 65 to have the chance of this further increased survival. 1 This increased life expectancy among senior citizens comes from a combination of improvements in medical care and in general health habits and preventive measures, such as improved diet, hypertension control, and reduced smoking. These last factors have become especially important in the past two decades, and several recent, well-designed prevention studies have proven the dramatic efficacy of many preventive interventions, which in turn have been reflected in further reductions among most major causes of death. We are living in an exciting time in the field of preventive medicine! CONCEPTS AND PRINCIPLES OF HEALTH PROMOTION AND DISEASE PREVENTION Any systematic discussion of important preventive activities must stem from an analysis of the predominant causes of death and disability. 2-4 These causes are listed in Tables 1 and 2, together with an assessment of effective preventive techniques. Even a cursory examination of the leading causes of death among older people (i.e., heart disease, cancer, stroke, lung diseases and infections, accidents and falls, and liver and kidney diseases) indicates many diseases are amenable to preventive measures. Similarly, a look at the major chronic conditions causing disability and morbidity in old age (i.e., arthritis, dental problems, heart disease, lung ailments, and depression) reveals a parallel assemblage of disorders amenable to preventive approaches. In the tables, preventive measures are indicated as primary and secondary. A primary preventive measure aims to prevent the onset of a disease. Examples are avoiding cigarette smoking to prevent heart disease and lung cancer, treating hypertension to prevent stroke and heart disease, receiving immunization to prevent influenza and Pneumonia, and keeping physically active to prevent deconditioning and depressive symptoms. A secondary preventive measure aims to identify an established disease in a presymptomatic stage to cure it early or prevent its progression. Examples include screening for several cancers(e.g., breast, colon, and prostate) because early detection may improve survival, screening for depression, and treating asymptomatic heart risk factors (e.g., hypercholesterolemia and hypertension) in patients with known heart disease to prevent disease progression. After identifying the major causes of morbidity and 12 Geriatric Nursing Volume 19, Number 1

Rank TABLE 2. MAJOR CHRONIC CONDITIONS IN Cause %* Primaryt Secondaryt Arthritis 45-55 + + Dental problems 40-60 + + 3 Hypertension 35-45 ++ _+ 4 Heart disease 30-40 ++ + 5 Visual problems 30-40 +_ + 6 Osteoporosis 25-60 ++ _+ 7 Hearing problems 20-35 + + 8 Depression 10-20 _+ + 9 Vascular disease 10-20 + +_ 10 Functional 10-15 + + dependency * Percentage of persons age 65 years and older with the condition (prevalence) 1-Effectiveness of primary and secondary preventive measures: ++, very effective; +, effective; +_, equivocal OLD PERSONS: PREVENTABILITY Examples Avoid joint stress. Early treatment of rheumatoid arthritis. Oral hygiene. Dental prophylaxis. Screening and early intervention. Avoid salt and stress. Exercise. Regular screening. Control risk factors: smoking, hypertension, hypercholesterotemia. Regular exercise. Take aspirin, estrogens. Avoid excessive ultraviolet light. Screening and refraction. High calcium intake. Estrogen replacement. Exercise. Avoid excess noise. Screening and amplification. Screening and treatment. Control risk factors: smoking, hypertension, hypercholesterolemia. Regular exercise. Take aspirin, estrogens. Exercise and other activity. Screening, assessment; and specific treatment and therapies. death and the existence of potential preventive interventions for each, the process of establishing a rational system for prevention proceeds by analyzing the efficacy of these possible interventions, ideally shown in clinical trials under controlled research conditions. Once efficacy of preventive interventions is established in a research setting, then true effectiveness in "real-life" settings must be established. This confirmation needs to done outside the controlled, and often unrealistic, research situation (which typically includes well-organized, regular reminder systems, financial incentives for compliance, and preselected, highly compliant subjects). If true effectiveness can be established, the costs for implementing the strategies must be considered. When all these factors are considered together, a fully rational policy can be established. For example, many important causes of morbidity and death are not amenable to preventive activities (e.g., many cancers, genetic conditions, accidents). Likewise some preventive activities are effective but only in preventing conditions that are relatively uncommon or relatively unimportant in terms of morbidity or death (e.g., tetanus vaccination or thyroid screening). Also, many effective preventive interventions are quite costly (e.g., mammography or colonoscopy) or are not acceptable to a large proportion of otherwise healthy people (e.g., routine sigmoidoscopy and prostate biopsy); both factors can make implementation impractical. Many years ago, the World Health Organization put forth a set of criteria that should be met before a screening test is adopted for general use. 2 These criteria are still valid today, and the general principles are applicable to most preventive medicine interventions, not simply to secondary prevention early detection programs. These criteria ques- tions include the following: Is the target condition an important clinical problem in terms of causing a high burden of disease or disability? Do we understand the natural history of the disease, and does an asymptomatic period exist in which treatment can prevent progression? Are the screening tests sufficiently accurate (i.e., sensitive and specific), and are the follow-up strategies effective? Are the tests and follow-up strategies acceptable enough to patients to ensure compliance and adherence? Are the costs of screening, diagnosis, and treatment balanced by the benefits? THE MAJOR TARGETS OF PREVENTION In identifying the current major targets of prevention, it is logical to begin with the number one cause of death--heart disease. This condition has a number of important preventive interventions that have been shown to be efficacious. Effective primary preventive approaches include avoidance of smoking, blood pressure screening and control, low-dose aspirin prophylaxis, and estrogen replacement therapy; cholesterol screening and control and regular exercise also may be effective, although their effectiveness is not as definitively established in controlled clinical trials for primary prevention. For secondary prevention (preventing progression in people with established heart disease), cholesterol normalization clearly has been shown to be effective, as have smoking cessation, blood pressure control, and aspirin. (The terminology sometimes can be confusing although it is basically logical. For example, blood pressure screening can be viewed in three ways: as primary prevention of heart disease, sec- Geriatric Nursing Volume 19, Number I 13

ondary prevention of hypertension in symptom-free people, or secondary prevention of progression in people with heart disease.) The number two cause of death, neoplasms (i.e., cancer and related conditions), is a very mixed group of diseases, but many preventive activities have been shown to be effective in large epidemiologic studies and in prospective controlled clinical trials for several cancers. The most common cancers in elderly people are breast, colon, and lung cancer in women and prostate, lung, and colon cancer in men. Effective primary preventive activities include avoiding cigarettes and other tobacco products (to prevent lung, oral, gastrointestinal, and several other cancers) and avoiding excessive sun exposure (to prevent skin cancer). In addition, eating a prudent, high-fiber, low-fat diet and taking low-dose aspirin may prove to be effective in preventing colon cancer although the data on these measures are not yet conclusive. Effective secondary preventive activities include screening for breast cancer with regular breast examinations (self-examination at least monthly, examination by a physician at least annually) and mammograms (at least every 2 to 3 years), screening for colon cancer (fecal occult blood testing and follow-up), as well as screening for prostate and skin cancer, although the data are not yet conclusive for the latter two programs. Certainly, any potential cancer symptom needs to be monitored promptly (e.g., nonhealing skin lesions, unexpected bleeding, change in bowel habits, and unexplained weight loss). Such early intervention might be considered secondary prevention although technically it overlaps with tertiary prevention because symptoms have appeared. The next leading cause of death, stroke, is an important and responsive target for preventive activities. These activities include blood pressure screening and control, anticoagulation for patients with atrial fibrillation, and low-dose aspirin prophylaxis, as well as screening for carotid artery plaques and providing anticoagulation or surgery for appropriate lesions. Many lung diseases and infections can be prevented by avoiding cigarette smoking and environmental pollutants and receiving vaccination against influenza and pneumococcal disease. Prevention of falls and other accidents requires a multifactorial approach that includes periodic identification of risk factors (such as muscle weakness, gait instability, inactivity, environmental hazards, and multiple medications) and appropriate interventions (such as exercise, assistive devices, environmental modifications, and medication adjustments). 5 Potential preventive measures for diabetes are currently under study and unproven, but many physicians believe that early detection may be helpful to allow early intervention. Some kidney diseases, particularly those resulting from hypertension, diabetes, or infections, potentially can be prevented by controlling the underlying condition. Some severe liver diseases, such as alcoholic cirrhosis and chronic hepatitis, can be prevented by avoiding exposure to the toxic agent (e.g., alcohol) and receiving immunization against hepatitis. Several less common causes of death also have effective preventive measures. For example, malnutrition is probably worthwhile to screen for with periodic weight checks or dietary interview. 6 Some relatively uncommon infections have established prevention routines that should be incorporated into any prevention system, such as immunization against tetanus and surveillance for tuberculosis with a PPD skin test and follow-up protocol. Prevention of automobile fatalities probably can be minimized through counseling with regard to the use of seat belts and per!odic screening for the development of impairments that would adversely effect driving competency (e.g., visual deterioration, mental incapacity, and alcoholism) together with follow-up counseling and, if necessary, making reports to the state motor vehicles department. Prevention of chronic conditions and causes of nonfatal morbidity and disability in older adults can be likewise effective. Effectiveness of preventive strategies for these conditions is summarized in Table 2. The most important of these strategies include avoiding the same heart risk factors discussed previously, periodically screening for vision and hearing problems coupled with appropriate referrals, engaging in regular exercise to maintain strength and balance, maintaining a prudent diet (with adequate calcium, fiber, and protein while minimizing salt and saturated fat), periodically screening for depression and memory problems, and periodically screening for functional dependency and social isolation coupled with appropriate advice and referrals. ORGANIZING PREVENTIVE ACTIVITIES Because of the large number of available and effective preventive activities that should be used routinely by older people, it is important to take a systematic approach to ensure that these activities are being used to full advantage. Ideally, they should be incorporated into the routine of the primary care setting to facilitate adherence and follow-up. Although these activities can be advocated and organized at the health care provider level, and although many techniques need to be performed by the provider (e.g., mammography), the individual must assume a major role in the actual compliance with the preventive program and its overall effectiveness. This growing involvement of the individual in preventive activities goes hand in hand with the current climate of rising health care costs and diminishing resources. Advertising, health articles in popular magazines, and community education programs all contribute to the growing consumer demand for self-determination in health care. Self-care activities directed toward health protection and promotion will be initiated only when individuals per- 14 Geriatric Nursing Volume 19, Number I

ceive that they will produce desirable outcomes and if they possess the necessary skills and abilities to carry out the activities] Many people examine health care information through the lens of personal experience, rejecting any evidence that contradicts their long-held beliefs and values or is foreign to their cultural framework. For this reason, it is important that the individual be a "partner" with health care providers in setting management goals and that health care education be adapted to cultural beliefs. Nurses increasingly are being challenged to provide the health care education necessary for older patients to comply with preventive activities. Effective health care education must begin with an assessment of the individual's perceived health status, health care knowledge, perceived benefits and barriers of health-promoting behavior, and personal life goals. Behavioral changes usually occur gradually over time and are facilitated by creation of a supportive learning environment, focus on achieving short-term objectives, and use of positive reinforcement. 8 It is not sufficient for the nurse simply to translate healthpromoting information into the patient's intellectual and cultural framework. Self-care activities also are influenced by long-established coping patterns, and elderly patients, in particular, may need verbal persuasion, group support, and challenge to perceive their ability to manage their own health care activities. 9 Management goals are more likely to be achieved when interventions are incorporated into the patient's existing lifestyle. For example, major diet restrictions or enrollment in a fitness class might be ignored, whereas food choices based on nutrition information on package labels or taking a short walk every day might be viewed as achievable. Positive reinforcement by the nurse for small gains increases the patient's motivation and can lead to the adoption of more complex interventions. In addition to the roles of assessor, educator, and motivator, the nurse frequently serves as a reminder. Annual immunization dates, follow-up laboratory appointments, and timely renewal of medications are all too easy to forget. A friendly phone call from the nurse not only reinforces the patient's perception of caring and support but also enhances compliance. A multitude of well-intentioned an~t generally wellconstructed guidelines concerning which preventive activities to use and how often have been compiled by expert task forces and consensus panels over the years, and they are evolving constantly. Many activities appear in virtually all the guidelines because of conclusive evidence of effectiveness and importance (e.g., smoking cessation, blood pressure screening). Others appear in only some guidelines because of less convincing evidence and because the panels set up differing criteria for what levels of evidence would be required to accept a procedure that was not fully proven (e.g., screening for prostate and colon cancer and depression). Table 3 summarizes the recommendations for preventive activities cited widely by the most recent expert panels. Several common denominators cut across the strategies in all guidelines. Most of these activities can be broadly grouped under primary and secondary preventive techniques. The most widespread primary preventive techniques include avoiding cardiovascular risk factors, such as smoking, hypertension, and hyperlipidemia. The most common secondary prevention methods include screening for early cancer and reducing risk factors for people with established conditions, such as heart disease and stroke. Several primary and secondary strategies are effective for multiple conditions. For example, avoiding cigarette smoking is an effective primary preventive of heart disease, '~ ~ cancer, stroke, lung disease, and a number of other conditions. Lowdose aspirin prophylaxis (i.e., one-half to one aspirin tablet daily or even every other day) has considerable evidence documenting its effectiveness in preventing myocardial infarction, stroke, and possibly colon cancer. Estrogen therapy for postmenopausal women provides effective primary prevention of both heart disease and osteoporosis; recent studies indicate possible beneficial effects for preventing Alzheimer's diseasel Exercising regularly and eating a prudent diet are good preventive strategies for a growing list of the major causes of death and morbidity. Probably the best way to ensure that these preventive activities will be accomplished is to organize them into a systematic program of education, screening, examination, and follow-up in the primary care context. This program can be accomplished in a variety of ways, including performing the whole set of interventions in connection with the "annual physical," spreading out the pieces over several visits throughout the year, or having the screening and education functions performed by a nurse practitioner either in the office or home. ~ Each method has its advantages and disadvantages. For example, the home visit allows patient observation in his or her natural environment and permits an actual look for physical hazards, nutritional adequacy, and appropriateness of the home pharmacy. This method has been tested in small controlled trials and has had beneficial outcomes. 1~'~ The Geriatric Nursing Volume 19, Number 1 15

TABLE 3. PREVENTIVE STRATEGIES RECOMMENDED BY EXPERT panels FOR INCORPORATION INTO PERIODIC HEALTH CARE PROVIDER VISITS History (items to inquire about during the patient history) Tobacco use Nutrition Exercise Medications Falls and accidents Social activities and isolation Incontinence Functional status and mobility Tobacco use is the single largest cause of preventable disease and death. About 15% of the elderly population is malnourished. Regular exercise is an important concomitant of healthy aging. Polypharmacy, drug side effects, and interactions are common. Falls and accidents are common and many are preventable. Regular.social interaction is associated with healthy aging and helps ensure assistance when needed. Incontinence is common, disabling, and usually treatable. Functional deterioration is a common denominator of failing health, predicts need for institutionalization or medical attention, and often is undiagnosed and treatable. Memory and depression Memory problems and depression are common and devastating problems that must be recognized and treated. Physical examination (items to focus on) Height and weight Blood pressure Vision and nearing Skin Oral examination Breasts Feet Gait aria balance Malnutrition and weight loss are common and important to detect. ~ypertension is common, asymetomatlc, and crucial to detect and treat. Problems with vision and hearing are common, often undetected, disabling, and usually treatable. Skin cancer and other curable lesions are common and often undetected. Dental oroblems and oral cancer are common and important to detect and treat. Breast cancer is common and is more likely cured by early detection, which regular examination can facilitate. Foot utoers vascular lesions, and other abnormalities can impair function and lead to infection and even amputation. Impairments of balance and gait are common causes of falls and reoucea mobility, often are unappreciated, and have many treatable causes. Cognitive function screening Cognitive impairment should be screened for because it affects a substantial portion of older oersons, begins insidiously, ana often is not appreciated until many opportunities to -- plan effective short- and ~ong-term care have ~rrevocably passed. Depression screening Prostate examination Depression affects almost one third of the elderly population and causes preventable suffering and even suicide. If diagnosea, aepression can be effectively treated, out it is often unnoticed and should be screened for. Prostate cancer is the most common cancer ~n men and can be detected while asymutomatic in a large proportion of patients, a strategy likely to enhance survtval, although not conclusively documented to do so. office context is cheaper and more likely to be reimbursed by third-party payers, especially if the visit is accomplished when the patient is being evaluated for an identifiable clinical problem. Whatever method is chosen, keeping careful records and flowcharts is essential to ensure that the appropriate set of activities is being done at appropriate intervals, follow-up is being performed, and the patient is complying with the recommendations. Each of the items in Table 3 ideally should be incorporated into the program, together with other patient-specific items of prevention that would be relevant to a person's individual needs or set of medical conditions or physical needs (e.g., a person with a stroke or one who lives alone with a disability would have a special set of prevention needs). In summary, we are in a challenging time in terms of preventive medicine. Not only has the average length of high-quality life been extended to a dramatic degree compared with past centuries (or even past decades), but each year brings proof of new and effective techniques to further prevent disease and morbidity. Many effective strategies that can be carried out immediately-and many more on the horizon will continueto extend life at increasingly high quality. REFERENCES 1. U.S. Department of Health and Human Services. Health, United States, 1992. Hyattsville (MD): The Department; 1993. 2. Fiatarone M, Rubenstein LZ. Assessment and prevention in the older woman. In: Breen JL, editor. The gynecologist and the older patient. Rockville (MD): Aspen; 1988. p. 358-97. 3. Kennie DC. Preventive care for elderly people. Cambridge: Cambridge University Press; 1993. 4. Scheitel SM, Fleming KC, Chutka DS, Evans JM. Geriatric health maintenance. Mayo Clin Proc 1996;71:289-302. 16 Geriatric Nursing Volume 19, Number 1

Laboratory tests (items to obtain routinely) Mammography Fecal occult blood Cholesterol Pap smear Thyroid screen Urinalysis Complete blood count Other routine interventions Immunization Estrogen and calcium Aspirin Exercise counseling Environmental hazards Advance directives Programs of regular mammography have been proven to enhance survival and are a rational preventive strategy when a person otherwise can be expected to survive at least 6 years. Recent studies have documented improved survival from regular programs of fecal occult blood testing and follow-up. Cholesterol screening and treatment have been shown to improve survival for patients with atherosclerotic heart disease (secondary prevention) and may be likewise beneficial for primary prevention in persons without heart disease. Although the incidence of new cervical cancer is not common in elderly women, women older than 65 who have not had documented negative Pap smear results should be screened yearly at least twice to document the absence of cancer. Asymptomatic thyroid disease (both hypothyroidism and hyperthyroidism) is common enough that many experts advocate regular screening (checking serum levels of thyroid-stimulating hormone), although conclusive data are lacking. Asymptomatic urinary tract infections, hematuria, and proteinuria are common, usually treatable, and probably worth screening for, although conclusive data are lacking. Asymptomatic anemia and other blood abnormalities are common, usually treatable, and probably worth screening for, although conclusive data are lacking. Anr'ual influenza vaccination, at least one vaccination against oneumococcal disease, an(] tetanus immunjzation every 10 years have been ShOWn to De beneficial ~n reducing morbidity and enhancing survival. In women both estrogen replacement therapy and calcium supplementation can reduce risk of osteoporosis; estrogens also significantly reduce risk of atherosclerotic heart disease and possibly Alzheimer's disease, SeveraJ good studies have shown that low-dose aspirin administered once daily significantly reduces the risk of heart disease, as well as stroke and possibly colon cancer. Exercise clearly is associated with successful aging and generally should De advocated (unless contraindicated) in an individualized program, with regular walking being an easy-toorescribe minimum. Several helpful environmental assessment pamphlets and checklists are available that can be useful in improving safety, reducing falls, and enhancing environmental accessibility. Discussion of aavance directives for end-of-life decisions should be part of any preventive care program. 5. Rubenstein LZ, Josephson KR. Falls in the elderly: causes and preventive approaches. In: Vellas B, Toupet M, Rubenstein LZ, Albarede JL, editors. Falls, balance, and gait disorders in the elderly. Amsterdam: Elsevier; 1992. p. 21-38. 6. Morley JE, Glick Z, Rubenstein LZ, editors. Geriatric nutrition. 2nd ed. New York: Raven Press; 1995. 7. Damrosch S. General strategies for motivating people to change their behavior. Nurs Clin North Am 1991;26:833-43. 8. Pender NJ. Health promotion in nursing practice. Norwalk (CT): Appleton & Lange; 1987. 9. Bohny BJ. A time for self-care: role of the home health care nurse. Home Healthcare Nurse 1997;15:281-6. 10. Rnbenstein LZ, Wieland D, Bernabei R. Geriatric assessment technology: the state of the art. Milan: Kurtis Publishers; 1995. 11. Fabacher D, Josephson KR, Pietruszka E Linderborn K, Morley JE, Rubenstein LZ. An in-home preventive assessment program for independent older adults: a randomized controlled trial. J Am Geriatr Soc 1994;42:444-50. 12. Stuck AE, Aronow H, SteIner A, Alessi CA, Bula C, Gold M, et al. A trial of annual in-home comprehensive geriatric assessments and other Interventions In elderly people living in the community. N Engl J Med 1995;333:1184-9. 13. Stuck AE, Siu AL, Wieland D, Adams J, Rubenstein LZ. Effects of comprehensive geriatric assessment on survival, residence, and function: a meta-analysis of controlled trials. Lancet 1993;342:1032-6. LAURENCE Z. RUBENSTEIN, MD, MPH, is a professor of geriatric medicine at the UCLA School of Medicine and the director of Geriatric Research Education & Clinical Center. RUTH NAHAS, RN- C, GNP, MPH, is director of the Home-Based Primary Care Program at the VA Medical Center in Sepulveda, Calif. Copyright 1998 by Mosby, Inc. 0197-4572/98/$5,00 + 0 3411184287 Geriatric Nursing Volume 19, Number I 17

gill est I.D. No.: G84287 Credit hours: 1.0 ~1~ i Processing fee: $9 Passing score: 7 correct answers (70%) 1. What is the primary cause of death among older people? A. Cardiovascular problems B. Stroke C. Cancer D. Accidents 2. Controlling the risk factor of smoking is preventive for the following diseases EXCEPT: A. Cardiovascular B. Stroke C. Cancer D. Diabetes 3. Controlling the risk factor of hypertension is preventive for the following diseases EXCEPT: A. Cardiovascular B. Cancer C. Stroke D. Kidney 4. Taking aspirin is controlling a risk factor for the following diseases EXCEPT: A. Cardiovascular B. Stroke C. Liver 5. The most common cancers in both elderly men and women are: A. Skin and breast B. Colon and lung C. Oral and skin D. Breast and bone 6. A prudent diet for elderly people includes minimizing: A. Protein B. Calcium C. Fats D. Vitamin C 7. Behavioral changes will occur with a combination of all the following EXCEPT: A. Creating a supportive learning environment B. Identifying bad behavior conditions C. Attaining short-term objectives D. Using positive reinforcement 8. The most common primary preventive teaching strategies include all the following EXCEPT: A. Smoking cessation B. Hyperlipidemia control C. Hypertension management 9. Self-care activities can be initiated only when individuals possess the requisite skills and abilities to carry out the activity and: A. Funding is available to support the activities B. They perceive the outcome will be desirable C. Their health is good enough to participate D. They are educated why these activities should happen 10. Besides the role of assessor, educator, and motivator, the nurse also functions as a: A. Healer B. Caregiver C. Reminder 18 Geriatric Nursing Volume 19, Number I