Nurses are seeing an increasing number of individuals who are living longer and receiving therapies that have decreased mortality, and thus are in need of interventions to preserve cardiovascular [ health. Lifestyle change and medications have improved outcomes only moderately. Death, disability, and costs are higher for heart disease in the United States than any other disease (American Heart Association, 1999). Increasingly research points to prevention of cardiovascular disease as the approach that must be the focus of future health care. This needs to occur at all three levels: primary, secondary, and tertiary.
Primary prevention pertains to the promotion of health and specific protection of a healthy or asymptomatic population; the focus is on * prevention of disease and minimizing risk factors. Secondary prevention, which comes into play when pathology is present, pertains to early diagnosis and treatment and limiting development of disability. Tertiary prevention pertains to rehabilitation and prevention of recurrence. This month's issue provides guidance for all three levels of prevention in promoting cardiovascular health for older adults.
It has long been recognized that prevention is more cost effective than treatment. More recently, evidence has suggested that health care providers, including nurses, have an extremely important role in identifying risks and convincing patients to make lifestyle changes. Exploration of this area has important implications for nurses. First, assessment must be clear and concise, identification of the problems or needs must be complete and timely, motivation must be a key part of implementation to change risks, and evaluation must be ongoing. Effective prevention at all levels has the potential to impact significantly on the maintenance of cardiovascular health for older adults.
Exploratory and experimental studies have provided precedence for the hypothesis that prevention can be cost effective and can preserve quality of life. The levels of prevention are not mutually exclusive. Focusing on changing a single risk factor is unlikely to succeed, but changing one behavior or decreasing the risk in one area at a time can be the best approach in older adults who may be overwhelmed by a need to change the way they have lived for decades. Studies related to preserving cardiovascular health in older adults must be carefully examined to find the evidence supporting this. Recent work produced by centers such as The University of Iowa's Gerontological Nursing Interventions Research Center and Case Western Reserve University, Bolton School of Nursing's Sarah Cole Hirsch Institute for Best Nursing Practice are helping to provide nurses with the body of evidence and clear strategies for implementation needed to affect practice. This month's issue provides evidence to support all levels of prevention in the promotion of cardiovascular health for older adults.
Primary prevention is the approach examined by Fleury and Keller. Their focus is the risk factors that can be assessed and modified in elderly individuals. They discuss the importance of accurately evaluating and adjusting medications to obtain optimal effectiveness with minimal dosing. Age, male gender, and family history of coronary heart disease (CHD) are considered nonmodifiable risk factors but are indicators of a need for further assessment of risk. Smoking cessation, managing weight, maintaining physical activity, controlling diabetes mellitus, and dietary management are risk modifiers that can have a key impact in preserving cardiovascular health in elderly individuals. Additionally the authors suggest that Type A behavior, low socioeconomic status, and low social support are modifiable risk factors. Nurses need to take advantage of narrow windows of opportunity, such as calling to renew medications, performing necessary assessments, and implementing strategies to prevent the onset of cardiovascular disease.
Artinian and colleagues emphasize secondary prevention in the need to change lifestyle related to dietary behaviors following a cardiac event. As the population ages, an increase in the prevalence of CHD necessitates lifestyle changes in many older adults. The ability to problem-solve questions related to dietary management and situational problems encountered in dining is important in this difficult behavior change. Yet, the ability to generate high-quality solutions can decrease after age 50. Multiple teaching methods can enhance problemsolving ability. Nurses are in a unique position to teach dietary problem-solving as they intervene to assist older adults to live with cardiac disease.
Robinson and Sloan focus on both primary and secondary prevention, addressing CHD in women. The poor prognosis of older women with CHD relates to multiple factors, including smaller anatomical size, delay in seeking treatment, misinterpretation of standard tests, hormonal changes, and multiple comorbid conditions that impact the heart. Risk factors of smoking, diabetes mellitus, high lipids and high blood pressure, along with obesity and stress reactions increase as women age and thus increase their risk. Primary and secondary prevention to alter the risk factors is essential. Social support for healthy living is suggested as one necessary solution. Nurses are seen as the front line in changing the perception that heart disease is a man's disease and in providing primary and secondary prevention strategies for change at every opportunity.
Celia examines secondary prevention relative to pain management in older adults who have undergone coronary artery bypass surgery (CABS), finding that little of the pain control medication prescribed in both men and women was actualIy administered. In addition, assessment of pain was not frequent. There were differences in the management of pain following CABS, with men and those with complications receiving significantly more pain medication. Celia 's discussion addresses the need for frequent, accurate, and uncomplicated assessment of pain. Older adults especialIy can have delayed surgical recovery without adequate pain control. Without adequate pain control, it is feasible older adults will have a longer than average length of stay (LOS) in the hospital. Tertiary prevention, the rehabilitation phase, may be delayed.
The LOS following hospitalization with a dual diagnosis of congestive heart failure and chronic obstructive pulmonary disease is one of the key components of the model identified by Narsavage and Naylor that may be used to predict the need for home care referrals in elders. This work also supports others who found that not all patients in need of home care are identified to receive pre-discharge referral. Using this and other research on discharge planning, nurses may have an algorithm that can be used to target those who should be referred for home care immediately after hospital discharge. A key component of prevention to preserve cardiovascular health is timely referral for additional post-discharge care to support tertiary prevention.
The high prevalence of cardiovascular disease in older adults warrants incorporating assessment of risk factors and prevention-focused interventions when interacting with older adults for any reason. It is unfortunate that even though the primary payer of health care for older adults has provided funding for preventive therapy, only about 1 in 10 Medicare beneficiaries received preventive testing. The need to support health promotion among older adults through prevention cannot be overemphasized.
While moving into a new era and focusing on the healthimprovement targets of Healthy People 2010, nurses can help improve the cardiovascular health of older adults and have an impact on their quality of life. The health care system must continue to move from financial support and reimbursement for curative therapy into a focus on prevention. Older adults need to understand the value of prevention. The Journal of Gerontological Nursing is a key resource in providing this information. The nurse as a provider and the client as a consumer of health care services can be empowered to form a relationship to advocate and effect change in health policies and services.
- American Heart Association. (1999). Heart and stroke facts statistics. Dallas, TX: Author.