San Francisco Veterans Affairs Medical Center, University of California, San Francisco.
Division of Geriatrics, University of California, San Francisco.
J Am Geriatr Soc. 2018 Feb;66(2):229-234. doi: 10.1111/jgs.15216. Epub 2017 Nov 20.
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.
预防可以通过在症状出现之前识别和处理疾病来帮助老年人避免疾病，但如果识别和治疗不太可能在个体一生中引起症状的疾病，预防也可能对老年人造成伤害。为了确定预防干预最有可能使（最有可能伤害）的老年人，我们提出了一个框架，该框架将个体的预期寿命（LE）与干预的获益时间（TTB）进行比较。如果 LE 小于 TTB，个体不太可能受益，但会面临干预的风险，一般不建议进行干预。如果 LE 长于 TTB，个体可能受益，一般建议进行干预。如果 LE 与 TTB 相似，个体的价值观和偏好应该是决定的主要因素。为了促进该框架在常规临床护理中的应用，我们探索了估计 LE 的方法，确定了常见预防干预的 TTB，并制定了与个体沟通的策略。我们综合了这些策略，并展示了如何在 Medicare 年度健康访视的背景下将其用于个体化预防。最后，我们将预防置于治疗和以症状为导向的护理背景下，并概述了预防应如何侧重于更健康的老年人，而以症状为导向的护理应在病情更严重的老年人中占主导地位。
