DR. DAVID B. HOGAN
Head, Division of Geriatric Medicine
University of Calgary
Calgary, Alberta

NOVEMBER, 1999

INTRODUCTION: Probably the most important thing to say at the start is that our practices should be guided by what research has shown to work. (1-6) There is a large difference between what we might hope is true and what is actually true. One of the challenges in the effort to make sound recommendations for health promotion is the distressingly small number of high quality studies available on which to base these suggestions. In many situations we have inadequate information on which to decide with confidence whether we should or should not do something. Notwithstanding this we should only go as far as the data allows us. Unanswered questions provide fertile soil for future research.

We have to start with some definitions. Primary prevention addresses factors which lead to the onset of a condition. It is an intervention implemented BEFORE there is evidence of a disease, injury, condition, and/or problem. This strategy aims to reduce or eliminate causative risk factors. With secondary prevention we attempt to detect latent conditions with the hope that we can eliminate them, reduce their severity, and/or halt their progression. It is implemented after a disease, condition, and/or problem has begun but BEFORE it is symptomatic. Screening is a form of secondary prevention. Early detection by screening is not always a good thing in itself. We must ask - if we find something, can we do anything which will lead to improved outcomes? If not, all we may be doing by early detection is adding to the burden of suffering by labeling, increasing anxiety, or causing some other adverse consequence (e.g., increasing health care costs). This is contrary to the common perception that early diagnosis always leads to some type of benefit. Tertiary prevention occurs after a disease, injury, condition, and/or problem has become established and is symptomatic. It aims to minimize sequelae and focuses on the prevention of disability.

How can we promote health? Health promotion is any combination of health education and related organizational, economic, and environmental supports for behaviours conducive to health. To promote health, clinicians can do certain things like screening for problems and immunizing people. We can try to alter behaviour by educating and counseling people to, for example, stop smoking, eat better, and/or exercise more. The government can spend more money on services like roads to improve highway safety. It can raise taxes on cigarettes to decrease their consumption. Legislation can be passed to enforce the wearing of safety belts to decrease motor vehicle accident injuries. We can try to improve the quality of the environment by, for example, ensuring a safe water supply. With health promotion we attempt to enable people to increase control over, and to improve, their health.

DETERMINANTS OF HEALTH: The World Health Organization gives an arguably overly sweeping definition for health - "a state of complete physical, mental, and social well-being not possible without peace, shelter, education, food, income, a healthy and sustainable physical environment, social justice, and equity." To determine the "health" of a population we can look at mortality and morbidity rates. While these measures are crude and not adequate in themselves, they are a starting point.

The determinants of a person’s health are the social environment (personal/family income, education, social contact and support, employment opportunities), physical environment (the environment at work and home; access to recreational facilities/areas), biological endowment (genetic inheritance), lifestyle choices (diet, habits like smoking/drinking, driving patterns, exercise/physical activity), coping strategies (when to bend or adapt/when to fight), and the quality of the health care services he/she can access (preventive, primary care, secondary care, tertiary care, emergency services, community-based services, institution-based services). (2,7)

PROMOTING HEALTH: As can be deduced from the above, some of the factors promoting health are within the person himself or herself, and some are external.

           INTRA-INDIVIDUAL FACTORS - It is not a simple, straightforward task to convince another person to change his or her behaviour. You usually cannot do it solely by providing information. It requires a personalized education effort. First you have to establish rapport and credibility. The person’s goals and values must be considered. Picking the appropriate time to educate and involve the person can be critical. A concrete plan with clear goals should be agreed upon. On-going review and reinforcement will be required. Surveys show that behaviour change is influenced by knowledge, role models, support from family and friends, and advice from health professionals. (1)

          EXTRA-INDIVIDUAL FACTORS - A challenge is trying to determine where to provide health promotion services, how to organize and finance them, and choosing who will be the "change-agent." The primary medical care setting does offer opportunities for an individualized approach. An estimated 80% of Canadians see a physician at least once every year. They are often "reachable" and "teachable" when they are seen because they are there about their health. Physicians are usually viewed by the general public as credible. Unfortunately studies have shown the provision of these services leaves much room for improvement. Reasons for this include time constraints, practice organization issues, non-adherence by the patient/client, poor counseling skills, deficient practitioner knowledge, and confusing, contradictory recommendations being made in the literature by "experts." On the other hand, physicians do fear missing a diagnosis and this can lead to over-testing. There is the need to combine this one-on-one approach with large-scale public health efforts. (1)

SELECT CONDITIONS/PROBLEMS: The commonest causes of death for seniors are cardiovascular diseases (including strokes), cancer, respiratory diseases (including pneumonia and influenza), digestive diseases (including chronic liver disease and GI hemorrhage), endocrine diseases (including diabetes), mental disorders (including dementia), and accidents. (8) The commonest causes of disability are arthritis, stroke, visual impairment, heart disease, dementia, peripheral vascular disease, lung disease, depression, diabetes, hearing impairment, and hypertension. (9) In this section we will talk principally about what should be routinely done for all seniors. Recommendations for seniors at higher risk for select conditions might well be quite different. We will highlight the recommendations of the Canadian Task Force on the Periodic Health Examination (CTFPHE). (1,2,3) (Note: The CTFPHE is now called the Canadian Task Force on Preventive Health Care.) We will note when additional suggestions have been made by the U.S. Preventive Services Task Force. (5,6)

          TOBACCO USE – Twelve point three per cent of Canadians 65+ (15.1% of males, 10.2 % of women) smoked daily in 1996-7 (Statistics Canada). All smokers should be counseled on smoking cessation and offered nicotine replacement therapy (CTFPHE recommendation). Referral to a validated smoking cessation program after giving general cessation advice is also indicated (CTFPHE recommendation).

          ALCOHOL USE - Routine active case-finding followed by advice or counseling should be offered (CTFPHE).

          POLYPHARMACY - Over 80% of the senior population receive at least one prescribed medication over a one-year period. Non-prescribed medications and herbal preparations are also heavily used. Appropriate prescribing is a complex task. Drugs should only be prescribed for an acceptable indication at a correct dose and frequency and for an acceptable duration. Care must be taken to avoid inappropriate duplication of drugs, potentially adverse drug-disease interaction, and potentially adverse drug-drug interactions. Even when used appropriately, adverse outcomes can occur with the use of medications. For example, a "prescribing cascade" can develop in which the use of one drug leads to the use of another to deal with the side effects of the first. Polypharmacy can be defined as any drug regimen with at least one unnecessary medication. Excess use of medications is a serious, preventable public health problem. It increases the risk of iatrogenic illness, the likelihood of noncompliance, and both direct and indirect (to deal with drug-related illness) health care costs. Interventions to deal with polypharmacy include the following: ensuring that patients have a single primary care physician and a single dispensing pharmacy; drug use review programs; and, one-on-one education of practising physicians by trained pharmacists ("academic detailing"). General strategies to reduce polypharmacy have been published. (10) The CTFPHE has not reviewed this topic.

          CARDIOVASCULAR DISEASES - Blood pressure should be routinely measured, at least every two years, in seniors 65 to 84 (CTFPHE suggestion). There is good evidence to routinely treat hypertension up to the age of 84 (CTFPHE recommendation). Men 30 to 69 should be advised to decrease their intake of total fat, saturated fat, and cholesterol (CTFPHE). Stepped care with a fat-modified diet followed by a cholesterol-lowering drug is recommended for men 30 to 59 with elevated lipids (CTFPHE). The U.S. Preventative Services Task Force recommends the determination of a serum cholesterol in adults every 5 years up to the age of 64.

          MALIGNANT DISEASES - A large number of manoeuvres have been suggested for routine cancer screening in the elderly by respected agencies like the American Cancer Society - e.g., breast self-examination/physical examination/mammography, Pap test (for cervical cancer), skin inspection (for skin cancer), mouth inspection/palpation (for oral malignancies), digital rectal examination/stool for occult blood/sigmoidoscopy or colonoscopy (for colon cancer), digital rectal examination/PSA determination (for prostate cancer), and chest radiograph/sputum cytology for lung cancer. The CTFPHE recommends the following routine screening tests and/or preventive manoeuvres - counselling about smoking and alcohol consumption; mammography and clinical breast examination for women 50 to 69; routine Pap smears (if sexually active) up to the age 65-69; counselling about avoiding sunlight exposure and wearing protective clothing; and annual oral/dental (for gum/dental disease as well as cancer detection). The U.S. Preventive Services Task Force also suggests doing stool for occult blood and/or sigmoidoscopy.

          INFECTIONS - Annual immunization for influenza is recommended for those 65+ years of age (CTFPHE suggestion). Nurse/physician reminders and letter or phone contact to encourage influenza vaccination is recommended (CTFPHE). Amantadine chemoprophylaxis of unvaccinated seniors exposed to a case of influenza is recommended (CTFPHE). While the CTFPHE does not recommend universal pneumococcal vaccination of seniors, other authorities (including the U.S. Preventive Services Task Force and certain provinces) do. Primary immunization and booster vaccinations every 10 years is recommended for tetanus-diphtheria (CTFPHE suggestion).

           DIABETES - The 1998 Clinical Practice Guidelines for Management of Diabetes in Canada recommended screening for diabetes by obtaining a fasting plasma glucose every three years in those over 45 years of age. (11) They would recommend more frequent or earlier testing (or both) in those with additional risk factors for diabetes such as having a first-degree relative with diabetes, being a member of a high-risk population, suffering from obesity, having lipid abnormalities, personal history of impaired glucose tolerance or impaired fasting glucose, presence of complications typically associated with diabetes, personal history of gestational diabetes, having a baby with a birth weight of over 4 kilos (for women), presence of hypertension, and/or presence of coronary artery disease. For prevention, they recommend a program of weight control through diet and regular exercise for those individuals at an increased risk for diabetes as it is felt that this may prevent diabetes. If an individual is diabetic, a program of screening for the complications of diabetes (retinopathy, nephropathy, neuropathy, foot problems, cardiovascular disease, hypertension) is suggested. The CTFPHE does not recommend screening the general population for diabetes.

           MUSCULOSKELETAL CONDITIONS (INCLUDING FRACTURES) - Prevention/treatment of osteoporosis and effective interventions to decrease the likelihood of falling (see next section) should decrease the number of fall-associated injuries endured by seniors. Osteoporotic prevention/therapy would include some combinations of screening (e.g., determination of bone mineral density), calcium/vitamin D supplementation, ovarian replacement therapy (including SERM’s), calcitonin, and/or biphosphonates. In very high risk groups (e.g., residents of continuing care facilities) use of hip protectors might also offer benefit. The CTFPHE suggests counselling peri-menopausal women about hormone replacement therapy.

Osteoarthritis is a major cause of disability in the elderly. Osteoarthritis has a multifactorial etiology. To lower the risk of knee and/or hip osteoarthritis currently recognized risk factors which are modifiable are obesity, occurrence of knee injuries, and jobs requiring bending and carrying. (12) Other factors which hold promise (but are as yet unproven) for prevention of osteoarthritis would include muscle strengthening, estrogen use, and nutritional factors. The CTFPHE makes no recommendations about osteoarthritis.

          ACCIDENTS (INCLUDING FALLS) - Counselling on wearing a seat belt is recommended (CTFPHE suggestion). The U.S. Preventive Services Task Force also recommends counselling on avoiding alcohol/drug use while driving (and swimming or boating), wearing motorcycle and/or bicycle helmets, safely storing/removing of firearms, installing smoke detectors, setting the hot water heater to <120-130°F, and CPR training for household members. For seniors who have fallen, there is data to support a careful multidimensional assessment for personal and environmental risk factors for falls coupled with a plan for risk factor modification (CTFPHE recommendation).

          DEMENTIA - Dementia can be defined as acquired cognitive deficits of sufficient severity to interfere with social or occupational functioning in a person without depression or a delirium (acute confusional state). (13) This condition can arise from a number of diseases such as Alzheimer’s disease. It is usually progressive when due to a primary neurodegenerative process such as Alzheimer’s disease. The Canadian Consensus Conference on Dementia stated that there is insufficient evidence to recommend for or against screening for dementia but practitioners should maintain a high index of suspicion for dementia and follow-up any concerns about, and observations of, functional decline and/or memory loss. When clinical conditions that can lead to cognitive impairment are uncovered by clinical and/or laboratory assessment, appropriate corrective therapy should be instituted. Treating vascular risk factors such as hypertension, hypercholesterolemia, diabetes, smoking, and atrial fibrillation, may reduce the risk of dementia. Treating transient ischemic attacks and/or strokes with secondary preventive measures like anticoagulants (for example, in the setting of atrial fibrillation), anti-thrombotic agents, and carotid endarterectomy (as appropriate) may likewise lower the risk of vascular dementia. There is evidence suggesting that sub-standard education (i.e., less than 6 years of formal education) or head trauma may increase the risk of Alzheimer’s disease. This would lend support to advocacy for minimum standards of education and for head injury avoidance (banning boxing) or protection (such as the use of seat belts while driving and helmets while cycling). At the present time, non-steroidal anti-inflammatories, estrogen, and/or anti-oxidants cannot be recommended for the primary prevention of Alzheimer’s disease and/or other types of dementia. A recent study showed an association between social disengagement and cognitive impairment. More study is required before any recommendations can be made. (14) In a small number of families there is autosomal-dominant transmission of Alzheimer’s disease which generally manifests itself in middle age. Asymptomatic individuals presenting with concerns regarding inheritance of Alzheimer’s disease can be referred to a genetic clinic if the family history is suggestive of an autosomal-dominant inheritance. Almost all individuals with Down syndrome over the age of 40 have neuropathological changes typical of Alzheimer’s disease. Attention should be paid to changes in functional abilities in middle-aged people with Down syndrome because they are at high risk for the development of Alzheimer’s disease. The CTFPHE found insufficient evidence on which to make a recommendation on screening for dementia.

          DEPRESSIVE SYMPTOMS/DEPRESSION - Depressive syndromes and depressive symptoms are common among the elderly. Risk factors for the development of depression after age 65 include being female, unmarried, poor, socially isolated, having a prior history of depression at a younger age, loss and grief, caretaking responsibilities, and medical illness in the individual or spouse. Effective forms of non-pharmacologic and pharmacological therapy are available for depression. Many seniors with depression are not diagnosed and/or offered effective treatment. While screening for depression is not recommended by the CTFPHE, clinicians are advised to have a high index of suspicion for this condition. They should be trained to look carefully for all symptoms of the depressive syndrome. Screening instruments such as the Geriatric Depression Scale can be used to improve detection. Studies to improve the recognition of depression by primary care practitioners have been done. Unfortunately, while detection is improved, patient outcomes have not shown significant improvements in these studies. (15) A recent Canadian study did show modest benefits of an educational program for physicians based on clinical practice guidelines for depression. (16)

          HEARING/VISUAL IMPAIRMENTS - As a society we should control noise levels and encourage the use of hearing protection (CTFPHE recommendation). Opportunistic enquiry about and testing for hearing and vision loss is recommended (CTFPHE).

          DISABILITY - In 1979 the CTFPHE recommended the routine enquiry (possibly every two years) about physical, psychological, and social abilities during a home visit.

In this manuscript we use the following definitions - impairments are dysfunctions and structural abnormalities in specific body systems; functional limitations are restrictions in basic physical and mental actions such as the ability to ambulate, reach, stoop, talk, and see standard print; and, disability is difficulty in doing activities of daily living such as holding a job, performing personal care, and looking after your own home. (9) Figure 1 outlines the "Disablement Process" (i.e., how people develop disabilities). While pathology leading to impairments, functional limitations, and disability is the "main pathway", there is growing acceptance of the importance of social, psychological, environmental, and other contributing factors in mediating the development of both functional limitations and disabilities. In 1986 there were 3.3 million disabled Canadians (13% of the population). (17) Seniors are the most likely age-group to be disabled. The strongest risk factors for declines in functional abilities would be the following: the presence of depressive symptoms, abstinence from drinking alcohol or heavy alcohol consumption, cognitive impairment, increase in levels of co-morbidity (for example, the number of chronic conditions) , falls, functional limitations at baseline, use of multiple medications, high body mass index or low body mass index, weight loss, low levels of physical activity, poor self-rated health, smoking, low levels of social activity or low frequencies of social contacts, visual impairments, specific conditions (for example, arthritis, hypertension, cerebrovascular disease, diabetes), increasing age, lower socio-economic status, and few years of formal schooling. (9)

As a general measure to prevent disability, physical activity/exercise has attracted the most interest. One could recommend moderate physical activity in an effort to prevent future disability. As well one could advocate for mild to moderate alcohol consumption only, avoidance of the excessive use of medications, maintenance of an appropriate weight, not smoking, being socially active, and preventing/effectively treating medical conditions which can lead to disability. A number of studies have evaluated the utility of a thorough assessment with targeting of identified risk factors in preventing future disabilities. Taken collectively, these studies support the approach of risk factor modification in an effort to prevent disability. (9)

          ELDER ABUSE - The CTFPHE did not feel there was sufficient information to recommend inclusion or exclusion of routine questioning about elder abuse. This is because of concerns about the accuracy of the results of routine questioning and the variable, often disappointing, results of interventions. A different approach may be required. (18)

          CARE-GIVER STRESS - Over the last two decades there have been a gradual shift in the provision of care from facilities to the community. (19) A good deal of the community care of seniors is "informal", provided mainly by family members. Many caregivers find this a rewarding experience. But, on the other hand, many caregivers face physical, emotional, social, and financial problems which arise from their caregiving duties. (20) Caregivers require recognition, information, and support. (19) When a senior requires personal care, it is important for the clinician to identify the primary caregiver (if present). This person and other family members should be evaluated to assess their caregiving functioning and its impact on their health. If appropriate, interventions should be suggested. These interventions would include education, support services, support groups, respite care, family therapy, and/or individual treatment (for caregivers with overt distress and/or psychopathology). (21) One study found that a comprehensive, on-going support and counselling service for spouse-caregivers of patients with Alzheimer’s disease did substantially increase the time spouse-caregivers were able to care for the patient with Alzheimer’s at home. (22)

          MISCELLANEOUS - To prevent dental caries, fluoride (toothpaste or supplement), brushing, and flossing are recommended (CTFPHE recommendation). All Canadians are encouraged to participate in moderate physical activity (to accumulate 30 minutes or more) most days of the week (CTFPHE recommendation). In 1996-7, 49.6% of seniors (52.7% for males, 47.2% for females) reported that they exercised (defined as vigorous activities such a brisk walking for at least 15 minutes) three or more times weekly (Statistics Canada). On the other hand, 31.9% (26.7% males, 35.8% females) stated they exercised less than once weekly or never. Over time Canadian seniors have become more physically active (Canadian Fitness and Lifestyle Research Institute). General dietary advice should be routinely offered (CTFPHE). The World Health Organization (WHO) recommends the consumption of a diet high in fibre and low in animal fat and salt. The WHO also recommends weight reduction if overweight and the maintenance of normal body weight. The U.S. Preventive Services Task Force also recommended routinely measuring weight and height, regular visits to a dental care provider, and counselling seniors about Sexually Transmitted Diseases (STD) prevention.

          RECENT TRENDS IN MEASURES OF HEALTH STATUS - For a number of diseases associated with mortality and morbidity in the elderly, incidence and prevalence figures have declined. In Canada, age-adjusted mortality from stroke has declined by 50% over the last 20 years. (23) This may be in part due to improvements in the early detection and treatment of hypertension. Cervical cancer mortality has also fallen by 50% since Pap testing by women became widely available. (24)

American data has shown that the age-adjusted chronic disability prevalence rate has declined 1.3% per year between 1982 and 1994. (9) The reasons for this decline are not known. It can be speculated that it is at least partially related to the introduction and dissemination of effective forms of prevention and treatment for some of the chronic conditions that lead to disability. This optimistic news must be tempered by the realization that in the future the absolute number of seniors will increase markedly. The hope is that the percentage of chronically disabled in the elderly population will continue to drop and this will help balance out the increase in absolute numbers of seniors.

What will happen in the future is an area of fierce debate. The elimination of select chronic conditions in our aging population could either increase or decrease the societal burden of disability. Eliminating chronic, nonfatal diseases which cause disability would lead to an increase in disability-free life expectancy with total life expectancy remaining essentially constant. This means that on average an individual will spend less time disabled and there truly will be a "compression of morbidity." The situation might be quite different for fatal illnesses such as cancer. The elimination of cancer, for example, could result not only in an increase in disability-free life expectancy but possibly an even greater increase in total life expectancy. During the extra years of survival, disability may arise from other causes. The elimination of a highly lethal disease could lead to a relative expansion of disability in a senior population.

There are changes in the determinants of health which might have an impact on the overall health of seniors. More years of formal education appears to be predictive of good health. The future cohorts of seniors will be better educated. (25) Whether education will still predict health status in the future is unknown. In Canada we have seen rising incomes among seniors. (26) Between 1981 and 1997 the average income of seniors rose 17% (adjusted for inflation), compared with a 2% decline for the population under 65. The proportion of seniors living below Statistics Canada’s Low Income Cut-off declined from 34% in 1980 to 21% in 1986. It should be pointed out that seniors are still more likely than younger adults to have low incomes and this overall decline masks the fact that older women living alone often face very significant financial hardship. As noted earlier, physical activity levels appear to be increasing among seniors. Mammography and monthly breast self-examination rates have gone up in Canadian women 50 to 69 years of age. (27)

          A TASK FOR EVERYONE: There is no gain in "passing the buck." All of us - seniors, families, practitioners, public health specialists, government, and researchers - have to embrace the challenge of health promotion for seniors. (4) Mutual respect and a clear description of our various roles must form the foundation of our efforts.

          SENIORS - Health promotion for seniors will only work with the willing, active participation of seniors themselves. It is important for them not to rest on their laurels. In our senior years, there is the opportunity to continue our self-development. It is important for seniors to adopt a healthy lifestyle. This will likely require education and persuasion. There are significant gaps in knowledge. For example, the awareness of the major causes of cardiovascular disease is low among older Canadians, particularly in men and those 65-74 years of age. (28) One thing we will likely have more of in our senior years is free time. (29) How we spend this time is up to us. Health promotion for our senior years is a life-long process. It even extends to the time before we are born. Research is showing a link between intrauterine exposures and long term diseases. (30) Habits developed earlier in life like smoking can have a major impact on health later in life.

          FAMILIES/INFORMAL CARE-GIVERS - As a society it is important that we continue to provide support to our older relatives (when this is needed). This must be coupled with respect for the older person’s independence and autonomy. This may lead to discord when the older individual wishes to maintain a particular lifestyle which a family may not view as being in the person’s "best interest." Overprotection must be avoided. Overprotection can lead to a decline in the older person’s health.

          HEALTH CARE PROVIDERS - Providers must "walk the talk." We should base our actions on what has been shown to work. If something is useless, we should not suggest its continued use. Practitioners have to re-appraise traditional approaches. For example, the "annual physical examination" does not appear to be an effective or, in particular, a cost-effective approach to health promotion. Many physicians use the "annual physical examination", though, as an organizational strategy. (31) We will have to look at how we structure our practices so as to facilitate health promotion. Preventive strategies should be personalized. We are not all alike. Practitioners must keep in mind the dictum, "do no harm." Finally, practitioners must recognize and support family caregivers.

          PUBLIC HEALTH AGENCIES - Public health experts must provide leadership and guidance to organizations and practitioners. They must advise on appropriate preventive strategies that will have the maximum impact on the health of older populations. This may require lobbying for the appropriate re-allocation of funding. They can be important in supporting local community initiatives.

          GOVERNMENT - The government must ensure consistency in its approach to health promotion. It is important that as a society we have sustainable economic development so we can improve the determinants of health and afford health promotion and care. Careful use of financial incentives and disincentives can help promote the adoption of healthy lifestyles. Legislation can be used to restrict unhealthy behaviour and empower older individuals to lead a full, healthy life.

          RESEARCH COMMUNITY/EDUCATORS - Health promotion is important. It requires an important place in the education of the general population and, more specifically, in the education of health care workers. We have much to learn about health promotion. An appropriate balance should be struck between basic and applied research. History has shown that diseases can be prevented/treated long before they are fully understood. (27) In 1753 a preventive measure for scurvy was discovered. Vitamin C (ascorbic acid) was only discovered in 1928 - 175 years later. We need to be much better in disseminating research data, delivering health promotion services, and persuading people to adopt healthy lifestyles.

          COLLECTIVE TASKS - Seniors make important contributions to society. Many of them are care-givers and serve as a resource to their family. (33) Most seniors are healthy, independent, and active in society. Like everyone else they must feel they are in control of their lives and making a positive contribution. Ageism, the prejudice against individuals based solely on their being old, must be combated. The various sectors of society must come together to promote the health of seniors. We cannot work in isolation from each other. We have to ensure that we are "on the same page." There is a wonderful opportunity for all of us to come together to promote the health of seniors. The alternatives are not worthy of contemplation by a civilized society.

          PROGRAMS TO SUPPORT HEALTHY AGING: "Healthy Cities" is a community-based problem-solving process for health promotion. (34) These sustainable communities make health, environment and quality of life issues part of their community planning process and development. Ensuring consideration of these issues will hopefully improve the "environmental" determinants of health and consistency in public policy.

Health promotion services can be integrated within senior centres, clubs, work-sites, schools, and recreational facilities – wherever people gather and meet. These should incorporate joint consumer-provider planning and implementation with an emphasis on education. Sustainability of these initiatives can be a concern. (35) This is influenced by factors such as whether paid staff is used, program flexibility, and whether a local champion was present. Free-standing interventions have been designed and implemented. While these may take the guise of a physical centre, some have been mail-based (36) and one can easily imagine programs using interactive telecommunication.

Specific community-based programs targeted at seniors have been implemented. Some have developed "ground-up". For example, peer-led senior health education programs to promote participation in society and sense of well-being have been studied and do appear to have some benefits. (37) Numerous nurse-led programs that provide education, screening manoeuvres, and referrals have been implemented. A number of integrated, multi-strategy fall prevention programs have been developed. (38, 39) One from Norway incorporated public health nurse home visits and education, public education, exercise programs, environmental alterations/modifications, and safety equipment. (38) This led to fewer fall-associated fractures and hospital admissions. Similar approaches have been implemented or at least considered for other prevalent problems like cardiovascular diseases and osteoporosis.

Attending family physicians hold a unique position within the health care system with regard to individualized health promotion. Their presumed knowledge of the person’s values/goals, lifestyle, and medical history coupled with a position of respect and trust makes them important potential agents for health promotion. It does appear that questioning about lifestyle health risks is not being routinely done. (40) Another important issue, though, is how to integrate health promotion within the framework of an office practice. Enhanced training on preventive services of the physician and changes to the organization of their practice will be necessary.

Computer-based clinical decision support systems do appear able to improve preventive care but it remains unknown whether this will lead to improved outcomes. (41) Another approach is the systematic assessment of risk and assignment of responsibility for health promotion to a health care professional allied with a practice. (42-4) Interventions are often advocated as if there is only one health care concern. The reality is often more complex than that. For example, an aging woman may be at particular risk for falls, osteoporosis, heart disease, cancer, social isolation, depression, and other health concerns. Devising a practical, acceptable, preventive strategy for that person will be a challenging task.

          IMPACT OF TECHNOLOGY: Technology will likely be a two-edged sword. The same health care approaches that effectively (and thankfully) dealt with acute illnesses in our early years made it more likely that we would survive to be troubled by chronic diseases and their complications. (45) Unfortunately, chronic illnesses will not yield easily to research, prevention, and health care. Treatment itself can lead to potentially preventable health problems. Iatrogenesis is commonly encountered in our hospitals. In 1971 Abdel R. Omran stated that we are now in the Age of Degenerative and Man-Made Diseases. We are even seeing a resurgence of infections partially related to our overuse of antibiotics.

On the other hand advances have clearly occurred. We are developing a better understanding of what causes chronic health problems, how these concerns can be prevented, and if they do occur how we can treat them. Screening for latent problems will likely expand, possibly in unexpected directions. The Human Genome Project may lead to the identification of disease-promoting genes for many of the chronic conditions that afflict us. At puberty or even earlier we may be given a "genetic report card" outlining what conditions we may be prone to. This would hopefully be coupled with what steps we should take to minimize our risk. Opening this Pandora’s Box will likely raise difficult legal and ethical issues for our society. (46)

          CONCLUDING COMMENTS: The approaches we have outlined in this paper are "effective." We do not wish to imply that other interventions are not - they may be but just have not been proven to be. We also do not state that these interventions are necessarily cost-effective. That is an entirely different issue. Determining cost-effectiveness is a complex question. (6,47) JM McGinnis and WL Foege wrote in 1993 that the actual major non-genetic causes of death in the United States are tobacco, diet, physical activity patterns, and alcohol. (48) There are clear opportunities for us to modify these and other risks to the continued good health of seniors.

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