American Journal of Health Promotion

The 1993 National Cholesterol Education Program guidelines recommend cholesterol screening for elderly patients with and without known coronary heart disease. This review summarizes clinical trial evidence from the medical literature that addresses cholesterol treatment in the elderly.

References were obtained from a MEDLINE search, bibliographies, metaanalyses, and review articles.

Randomized, controlled clinical trials, including all lipid intervention trials with elderly participants or subgroup analyses of the elderly designed to measure major cardiovascular disease endpoints, were selected.

A MEDLINE search of all clinical trials using key search terms yielded 1360 references. Journal titles and abstracts were reviewed for all references by one of us (K.M.H.). A full journal review was undertaken for 41 references to clinical trials. Five clinical trials fulfilled all criteria and represented unique data.

A MEDLINE search (from 1966 to January 2000) and bibliography reviews yielded five important clinical trials with analyses of elderly participants. Data are presented in text form and a summary table.

Clinical trial evidence supports treating hyperlipidemia in elderly persons for secondary prevention of coronary heart disease. Evidence from four secondary prevention trials demonstrated that major coronary heart disease risk decreased by 25% to 30% in elderly subjects treated for 5 years. Unanswered questions include cholesterol treatment for primary prevention in the elderly, gender effect, and benefit of treatment in persons older than 70.

The disease consequence of smoking occurs disproportionately among the elderly because of the long duration of cumulative injury or change that underlies the bulk of tobacco-caused disease. Older smokers are less likely than younger smokers to attempt quitting, but they are more likely to be successful in the attempts that they do make to quit. Excess absolute rates of disease incidence and mortality due to smoking increase steadily with increasing age and duration of smoking, and there is little evidence to suggest that the disease consequences of smoking diminish among the elderly. Although cardiovascular disease is the most common cause of excess mortality among younger smokers, lung cancer is the largest cause of excess smoking-related mortality over the age of 60 years; and at older ages the excess death rate from chronic obstructive lung disease equals that for cardiovascular disease. Because of the dramatic increases in smoking-related excess mortality with advancing age, approximately 70% of the 400,000 or more deaths occur among those over age 60 years. The benefits of cessation are proportionately somewhat less among the elderly and may manifest more slowly than among younger smokers, but cessation remains the most effective way of altering smoking-induced disease risks at all ages, including those over the age of 60 years.

To highlight the significant impact of social relationships on health and illness and suggest implications of these effects for health promotion efforts among older adults.

Published studies on social relationships and health (or health behaviors) for the period 1970–1998 were identified through MEDLINE by using the key words social relationships, social support, and health, as well as review of health-related journals such as the American Journal of Epidemiology, Annals of Epidemiology, American Journal of Public Health, Journal of Health and Social Behavior, Social Science and Medicine, and the Journals of Gerontology.

Major published original research was considered. Where published research was too extensive for full discussion of all studies, preference was given to studies focusing on older adults and those using stronger methodology (i.e., representative samples, longitudinal data, or multivariate analyses controlling for potential confounders).

Reported findings were organized in terms of three major categories: (1) results related to major health outcomes such as mortality, CHD, and depression; (2) findings related to health behaviors; and (3) findings related to potential biological pathways for observed health effects of social relationships.

Protective effects of social integration with respect to mortality risk among older adults are the most thoroughly documented, although protective effects have also been documented with respect to risks for mental and physical health outcomes and for better recovery after disease onset. There is also now a growing awareness of the potential for negative health effects from social relationships that are characterized by more negative patterns of critical and/or demanding interactions, including increased risks for depression and angina. Biological pathways are suggested by evidence that more negative social interactions are associated with physiological profiles characterized by elevated stress hormones, increased cardiovascular activity, and depressed immune function, whereas more positive, supportive social interactions are associated with the opposite profile.

Available data clearly indicate that social relationships have the potential for both health promoting and health damaging effects in older adults, and that there are biologically plausible pathways for these effects. Such evidence suggests that aspects of the social environment could play an important role in future health promotion efforts for older adults, although careful consideration of both potentially positive as well as negative social influences is needed.

To provide a broad overview of the role of the individual, the physical environment, and the social environment on health and functioning in older adults (65 and older), and to highlight interventions and recommendations for action on each of these levels.

Published studies and government reports on health and functioning in older Americans and on the individual, social, and physical environmental contributors to health were identified through journal and government documents review and computer library searches of medical and social science data bases for 1980–1999.

Preference was given to published studies and government reports that focused specifically on behavioral and environmental contributors and barriers to health promotion in Americans 65 and older and/or that highlighted creative interventions with relevance to this population. Both review articles and presentations of original research were included, with the latter selected based on soundness of design and execution and/or creativity of intervention described.

Studies were examined and their findings organized under three major headings: (1) behavioral risk factors and risk reduction, including current government standards for prevention and screening; (2) the role of the physical environment; and (3) the role of the social environment in relation to health promotion of older adults.

Although most attention has been paid to the role of behavioral factors in health promotion for older adults, a substantial body of evidence suggests that physical and social environmental factors also play a key role. Similarly, interventions that promote individual behavioral risk reduction and interventions targeting the broader social or physical environment all may contribute to health in the later years.

With the rapid aging of America's population, increased attention must be focused on health promotion for those who are or will soon be older adults. Promising intervention strategies addressing the individual, the physical environment, and the social environment should be identified and tested, and their potential for replication explored, as we work toward a more comprehensive approach to improving the health of older Americans in the 21st century.