Preventive Interventions for the Second Half of Life: A Systematic Review

Abstract

Objective:

Recent improvements in life expectancy globally require intensified focus on noncommunicable diseases and age-related conditions. The purpose of this article is to inform the development of age-specific prevention guidelines for adults aged 50 and above, which are currently lacking.

Data Source:

PubMed, Cochrane database, and Google Scholar and explicit outreach to experts in the field.

Study Inclusion and Exclusion Criteria:

Meta-analyses, intervention-based, and prospective cohort studies that reported all-cause mortality, disease-specific mortality, or morbidity in adults were included.

Data Extraction:

A systematic review was undertaken in 2015 using search terms of a combination of <risk factor> and “intervention,” “mortality,” “reduction,” “improvement,” “death,” and “morbidity.”

Data Synthesis:

Interventions were categorized according to the Center for Evidence-Based Medicine Level of Evidence framework.

Results:

A summary table reports for each intervention the impact, strength of evidence, initiation, duration, and details of the intervention. Age-decade-specific preventive recommendations have been proposed relating to physical activity, diet, tobacco and alcohol use, medication adherence, screening and vaccination, and mental and cognitive health.

Conclusion:

Clear recommendations have been made according to the existing evidence base, but further research investment is needed to fill the many gaps. Further, personalized approaches to healthy aging complemented by population-wide approaches and broader cross-sector partnerships will help to ensure greater longevity is an opportunity, rather than a burden, for society.

Keywords

longevity prevention age-specific morbidity mortality lifestyle aging

Objective

Social and economic progress in recent history has resulted in vast improvements in life expectancy and a global aging population. By 2050, the number of people aged 60 and above globally will increase from 841 million to over 2 billion; for the first time in history, the population of older people will be larger than that of children younger than 14 years.¹ The European Union (EU) population is expected to increase by almost 5% from 507 million in 2013 to 526 million in 2050, with the greatest growth in those older than 80.² The Global Burden of Disease Study has demonstrated that rates of years lived with disability (YLDs) are declining much more slowly than mortality rates, with a transition to nonfatal outcomes as the dominant source of burden of disease as a consequence of aging populations. The proportion of disability-adjusted life years due to YLDs increased globally from 21.1% in 1990 to 31.2% in 2013. The main drivers of increases were due to musculoskeletal disorders, mental disorders, substance use disorders, neurological disorders, and chronic respiratory diseases, but countries such as Japan and Singapore with their greater proportion of aging population also see Alzheimer disease, hearing problems, and osteoarthritis in the top 10 conditions.³ Currently, more than 35 million people worldwide are living with dementia, and this is expected to nearly double by 2030 and triple by 2050.⁴

Increased longevity without improvements in health increases demand for services and health-care costs and will result in unprecedented strains on aging-related resources. In addition, as non-communicable diseases (NCDs) require lifelong management, the high costs associated with them threaten individual health security and the ability of governments to provide universal health coverage, with severe implications on productivity and economic growth.⁵ Among EU nations, it is estimated that by 2050 increased spending on health care and long-term care is expected to rise by approximately 2 percentage points of gross domestic product. At the same time, the demographic old-age dependency ratio, that is the number of people aged 65 or above relative to those aged between 15 and 64, is expected to almost double such that EU nations would shift from having 4 working age people for every person aged over 65 to 2 working age people.²

Illness and poor health are not inevitable outcomes of aging; however, many lifestyle and age-related conditions can be mitigated through risk reduction strategies throughout life that address underlying risks including physical inactivity, poor dietary patterns, tobacco use, excess alcohol use, nonadherence to chronic disease medications, screening and vaccination status, and cognitive impairment. Quality of life with advancing age and the extent of financial and social burden will depend largely on morbidity and how to minimize YLDs. Compression of morbidity, that is, the delay of disease onset and therefore a shortened duration of disease, is an effect that has been shown to varying magnitudes on a population level.⁶ If longevity is accompanied by healthy life years, the burden of an aging population need not be as dire as predicted. Moreover, a healthy aging population can confer great benefits to the workforce, economy, and society. Major global corporations including Bank of America, Merrill Lynch, Nestlé Skin Health, BlackRock, BMW, Intel, GE, Novartis, Aegon, Discovery, and Pfizer have embedded “aging” as a key strategic driver of their commercial goals, and others such as Aeon and Home Instead Senior Care are realizing tremendous growth through the same strategy.⁷

In order to promote both health and longevity and achieve the maximal possible compression of morbidity, health-promoting and disease prevention interventions are best considered in age-specific contexts across the lifespan, particularly for age groups 50 and above who face the greatest burden of NCDs and age-related conditions. The World Health Organization (WHO) and national health institutions provide guidance on optimal prevention interventions across the lifespan. However, these guidelines are usually of a general nature, rarely take into account underlying cumulative risks, and rarely provide guidance for age-specific and functional-level groups from age 50. Where some do exist, they have not been combined into coherent, focused packages of value for people as they age. Therefore, the aim of this article is to provide a summary of available scientific evidence to address these needs and outline specific interventions that favorably influence morbidity and mortality from age 50 and beyond.

Methods

Data Sources

The scientific literature was reviewed in 2015 using the online sources of PubMed, Cochrane database, and Google Scholar, which combined contain approximately 124 000 000 publications, including those from major academic journals relevant to this field of research. Explicit outreach to experts in the field was simultaneously undertaken.

Inclusion and Exclusion Criteria

Articles in the English language relating to NCD risk factors, NCD prevention, and behavioral interventions published between January 1, 2000, and December 31, 2015, were sourced. Search terms included a combination of <risk factor> and “intervention,” “mortality,” “reduction,” “improvement,” “death,” and “morbidity.” Meta-analyses, intervention-based, and prospective cohort studies that reported all-cause mortality, disease-specific mortality, or morbidity in the adult population aged 50 or above were included. Expert opinion and updates to consensus statements were accepted until October 26, 2016.

Data Extraction and Data Synthesis

The data gathered were synthesized in 2015 into interventions and recommendations and were assigned categories of levels of evidence as per the Center for Evidence-Based Medicine (CEBM) Level of Evidence framework for therapy, prevention, etiology, or harm (Web Appendix 1).⁸ Interventions that promote healthy aging were reviewed and subsequently categorized into:

Those that impact longevity, that is, where a clear mortality benefit was observed. These interventions relate to the level of physical activity, dietary patterns, tobacco use, excess alcohol intake, medication adherence, cancer screening, and immunization status.

Those that predominantly impact morbidity or quality of life. These interventions relate to immunization status, mental and cognitive health, and frailty and musculoskeletal disorders.

A summary table reports for each intervention the impact, strength of evidence, initiation, duration, and specific intervention. Where different levels of outcome and strength of evidence were available, the highest level of evidence and all outcomes (mortality and morbidity) were presented. The results were then organized into decade-specific recommendations for the ages of 50 and above and assigned CEBM grades (Web Appendix 1).⁸

Specific preventive recommendations have been proposed relating to physical activity, diet, tobacco and alcohol use, medication adherence, screening and vaccination, and mental and cognitive health.

Results

Tables 1 and 2 summarize preventive interventions that favorably impact mortality and morbidity among individuals aged 50 years and older. Based on the available literature on interventions for those aged 50 and above that improve morbidity and mortality, Table 3 outlines preventive recommendations to promote longevity for those aged between 50 and 60 years, 60 and 70 years, 70 and 80 years, and older than 80 years.

Table 1.

Preventive Interventions That Impact Mortality.

Intervention/Evidence for Mortality Benefit	Intervention Impact	Level of Evidence	Optimal Parameters
Intervention/Evidence for Mortality Benefit	Intervention Impact	Level of Evidence	Initiation	Duration	Intervention
Physical activity
Mild physical activity (<3 metabolic equivalents [METs], eg, laundry, home repairs) 1 to 3 times per month reduces all-cause mortality in men and women >50⁹	HR 0.76 (95% CI 0.69-0.83)	2b	No evidence on optimal age to start exercise, though likely the earlier the better	Over 5-15 years to see mortality benefit	Moderate and vigorous physical activity performed frequently (≥300 min/wk) is most effective
Moderate physical activity that ranges in intensity from 3 to 6 METs and expends approximately 1000 (kilo) calories per week of energy (the equivalent of walking about 30 minutes per day reduces mortality¹⁰	20%-40% reduction in mortality	2a
Vigorous physical activity (>6 METs; eg, running, cycling, swimming) more than once per week reduces all-cause mortality in men and women >50⁹	HR: 0.44 (95% CI 0.4-0.48)	2b
There is a dose–response, inverse relationship between the number of minutes per week of moderate or vigorous activity and all-cause mortality¹⁰	HR 0.66 (10-149 minutes); 95% CI 0.61-0.71; HR 0.53 (150-299 minutes); 95% CI 0.48-0.57; HR 0.46 (300+ minutes) (95% CI 0.43-0.49)	2b
Running on average 76 minutes per week and 287-minute vigorous exercise per week extends life in those aged 50 and above¹¹	3.3 years	2b
Aerobic physical activity to achieve weight loss for obese individuals reduces mortality (but not among average-weight or overweight individuals)¹²	RR 0.84 (95% CI 0.73-0.97)	2a
Dietary patterns
Adherence to DASH (Dietary Approaches to Stop Hypertension) diet by women aged 34-59 years reduces risk of fatal coronary heart disease (CHD) and stroke over 24-year follow-up¹³	RR 0.76 (CHD, 95% CI 0.67-0.85); RR 0.82 (stroke, 95% CI 0.71-0.94)	2b	No evidence of optimal age. Likely earlier the better, particularly important at time of hypertension diagnosis	No evidence for optimal duration, studies captured usual intake through validated dietary assessment methods; though likely the longer the better	Regular diet that resembles Mediterranean or DASH diet (high intake of vegetables, fruit, nuts, legumes; moderate intake of whole grains, fish, monounsaturated fats, dairy; low intake of meat, alcohol; sodium intake 3-6 g/d). No evidence on different dietary patterns for different age-groups
High adherence to Mediterranean diet reduces all-cause mortality among adults aged 51-70 years over a 10-year period¹⁴	20%-21%; HR 0.79 (95% CI, 0.76-0.83)	2b
Higher adherence to Mediterranean diet reduces mortality among adults 20-86 years of age with CHD over a 3.78-year period¹⁵	Adjusted mortality ratio: 0.73 (95% CI 0.58-0.93)	2b
Mediterranean diet reduces all-cause mortality among those aged 70-90 years, with higher reduction among those who also were nonsmokers and consumed a moderate amount of alcohol¹⁶	HR 0.77 Med. Diet adherence (95% CI 0.68-0.88)	2b
Average salt intake (6.7-12.6 g/d) decreases mortality and risk of cardiovascular events compared with lower and higher intakes¹⁷	HR 1.16 high versus average intake (95% CI 1.03-1.30); HR 0.91 average versus low intake (95% CI 0.82-0.99)	2a
3-6 g/d sodium intake reduces mortality and risk of cardiovascular events in those aged 35-70 years; strong association among those with existing hypertension¹⁸	OR: 1.15 intake <7 g/d (95% CI 1.02 -1.30)	2b
Tobacco use
Quitting tobacco use before age 50 can completely eliminate excess risk of mortality due to smoking. Quitting after age 50 or 60 reduces risk of all-cause mortality among former smokers¹⁹	HR 0.54 after age 50 (95% CI 0.48-0.61); HR 0.61 after age 60 (95% CI 0.54-0.70)	2b	As early as possible	Excess mortality risk is completely eliminated after about 10 years for light smokers and 20 years for heavy smokers	No evidence for or against specific interventions for quitting smoking for particular age groups
Quitting smoking by individuals with CHD reduces all-cause mortality²⁰	RR 0.64 (95% CI 0.58-0.71)	2a
Quitting at age 30, 40, or 50 incrementally extends life²¹	10 years (quit at 30); 9 years (quit at 40); 6 years (quit at 50)	2b
Among former smokers aged 60 and above, excess mortality decreases with time since quitting as measured by mortality rate advancement periods (RAPs), that is, the age difference by which a risk factor advances mortality²²	3.9 years—quit <10 years ago (95% CI 3.0-4.7); 2.7 years—quit 10-19 years ago (95% CI 1.8-3.6)	2a
Excess alcohol use
Reducing or abstaining from drinking alcohol lowers odds of death compared with continued heavy drinking²³	OR: 0.61—reduce drinking (95% CI 0.39-0.94); OR: 0.35—abstain from drinking (95% CI 0.2-0.6)	2a	No evidence on ideal time to initiate intervention, though likely the earlier the better (and before diseases such as cirrhosis of the liver and malnutrition become evident)	At least 1.5 years of abstinence is required after developing alcoholic cirrhosis before a statistically significant mortality benefit is uncovered	No evidence for or against optimal alcohol abstinence interventions; no evidence for or against programs tailored to different ages. Likely benefit comes from partial or total abstinence, not the manner in which it is achieved
Medication adherence
Nonadherence to antihypertensive medication carries higher odds of death from stroke at 2 years²⁴	OR 3.81 (95% CI 2.85-5.10)	2b	No evidence on ideal time to initiate intervention, though it should always be relevant	No evidence for ideal duration of medication adherence interventions to see a mortality benefit. Ideal duration likely depends on the natural history underlying disease for which the medication is prescribed	No evidence on ideal method; for individuals ≥70 years old, emphasis should be on reducing polypharmacy
Cancer screening
Colorectal cancer: stool-based testing
Guaiac fecal occult blood test (gFOBT)^25 –27	Reduction of CRC-specific mortality by 9%-22%	1b	50 years of age, annually until age 85. No benefit after age 86 as benefit of screening is not seen in trials until at least 7 years later		Annually
FIT^26,27	–	No high-quality studies available			Annually
FIT-DNA^26,27	–	No-high quality studies available			Every 1-3 years
Colorectal cancer: direct visualization tests
Colonoscopy reduces mortality from colorectal cancer.² ^{8 –31}	Mortality reduction to 60%-70% Adjusted HR 0.32	2b 2b	50 years of age (as per US guidelines); 50-75 years grade A 76-85 years grade C 86+ no benefit	Until age 75 unless there is a history of abnormal results	For people at average risk, virtual colonoscopy every 5 years, colonoscopy every 10 years in the United States¹⁹
CT colonography^28,31	No studies available
Flexible sigmoidoscopy^28,31	Decreased CRC-specific mortality, IRR 0.73	1b
Mammography reduces mortality from breast cancer among women who are screened for ≥10 years.^32 –34	15%-20%	1b	From age 50 (as per US guidelines)²²	Until age 75 (as per US guidelines); mortality benefit seen after 10 years’ screening	Mammography screening as indicated in national guidelines, biennially in the United States
Regular Pap smears to screen for cervical cancer reduces mortality among women.^35 –37	80%	2c	Age 21 (as per US guidelines)²⁵	Until age 65 (US guidelines)	Pap smear at regular intervals as indicated by national guidelines (every 3-5 years, depending on results as per US guidelines)
Immunization status
Routine primary prevention with influenza vaccine results in a mortality benefit for patients more than 65 years³⁸	OR 0.69 (95% CI 0.52-0.92)	2c	Age 65 onward	Yearly, indefinitely	Seasonal vaccination per national guidelines
Regular yearly vaccination shows reduced mortality benefit compared with first-time vaccination during influenza epidemics³⁹	41% (95% Cl 13-60)	3b	Age 65 onward	Yearly, indefinitely	Seasonal vaccination per national guidelines

Abbreviation: CHD, coronary heart disease; CI, confidence interval; CRC, colorectal cancer; CT, computerized tomography; DASH, Dietary Approaches to Stop Hypertension; FIT, Fecal Immunochemical Test; FIT-DNA, Fecal Immonochemical Test with DNA Testing; HR, hazard ratio; IRR, incidence rate ratio; OR, odds ratio; RR, relative risk.

Table 2.

Preventive Interventions That Impact on Morbidity.

Intervention/Evidence for Benefit	Intervention Impact	Level of Evidence	Optimal Parameters
Intervention/Evidence for Benefit	Intervention Impact	Level of Evidence	Initiation	Duration	Intervention
Immunization status
Administration of zoster vaccine (for those who did not have the disease in childhood) and shingles vaccine to individuals aged 50+ reduces morbidity risk⁴⁰	N/A	1b	No optimal age	Single administration	Vaccination per national guidelines
Administration of pneumococcal vaccine to adults aged 65 and older reduces risk of developing pneumonia and associated complications⁴¹	N/A	1b	Age 65	Single administration	Vaccination per national guidelines
Mental and cognitive health
Management of major depression (through medication and/or psychotherapy) among 60- to 94-year-old by primary care providers reduces suicidal ideation, depressive symptoms, and all-cause mortality^42,43	12.9% reduction in suicidal ideation; HR 0.55; all-cause mortality (95% CI 0.36-0.84)	2b	No optimal age of initiation but should begin as early as possible	Subject to individual care needs	No evidence for optimal intervention by age-group
Multidomain intervention for adults 60 to 77 years of age at risk of dementia results in improved cognition as measured through neuropsychological test battery. Intervention includes modifying diet to meet Finnish national guidelines (including 5%-10% weight loss if appropriate), physical activity training (strength training 1-3 times per week, aerobic exercise 2-5 times per week), cognitive training (focus on executive processes, working memory, episodic memory, mental speed), and vascular risk monitoring (blood pressure, BMI)⁴⁴	25%	2b	No evidence for optimal time of initiation, though earlier is likely better	No evidence for optimal duration; benefit evident from 2-year multidomain intervention	Multidomain to address multiple risk factors
Frailty and musculoskeletal disorders
30 min/d of moderate-intensity walking, 10 minutes’ strength training (focused on lower extremities), and 10 minutes’ balance and flexibility training for 70- to 89-year-old at risk of disability improves major and persistent mobility disability⁴⁵	HR 0.82—major (95% CI 0.69-0.98); HR 0.72—persistent (95% CI 0.57-0.91)	2b	No evidence for or against optimal starting age, but earlier is likely better than later	At least 5 months	Multicomponent exercise program (30-45 minutes at least 3 times/week) to improve strength, balance, flexibility, aerobic capacity
15 minutes of Tai Chi twice daily over a 15-week period for those aged 70 and above reduces risks of falls⁴⁶	47.5%	2b
Group exercise program involving 1 hour of class 2 times/week (including stretching, moderate-paced walking, conditioning, muscle relaxation, controlled breathing, and guided imagery) over 12 months reduces incidence of fall⁴⁷	22% (incident rate ratio 0.78, 95% CI 0.62-0.99); 31% among those who had fallen in the past year (incident rate ratio 0.69, 95% CI 0.48-0.99)	1b
One-hour exercise class weekly (individually tailored and focused on balance, strength, bone, endurance, flexibility, gait, functional skills, fall avoidance, backward-chaining, functional floor exercises) and 30 minutes of home exercises twice weekly (focus on lower limb strength) over 36 weeks reduced falls, and fall-related injuries⁴⁸	31% fewer falls versus control group (incident rate ratio 0.66, 95% CI 0.49-0.90)	2b
Group exercise program (30 minutes, 3 times/week) that involved strengthening exercises, balance and stability exercises, and active range of motion exercises and encouraged walking outside the home at least twice per week reduced incidence of falls and 12-month mortality⁴⁹	Incident rate ratio 0.68—falls (95% CI 0.56-0.79); RR 0.45—mortality (95% CI 0.25-0.80)	1a
Home safety visits by occupational therapists to provide fall prevention advice and equipment reduces fall incidence and injuries from falls over a 12-month period⁵⁰	41%—falls (incident rate ratio 0.59, 95% CI 0.42-0.83)	1b
Supplementation of calcium and vitamin D (at least 1200 mg calcium and 800 IU vitamin D daily) assists in preventing musculoskeletal disorders such as osteoporosis and fractures⁵¹	12% reduction in all fracture types (RR 0.88, 95% CI 0·83-0·95)	1a	After age 50 (or around menopause for women) and priority for those aged 65 and above (when incidence increases)	No evidence for or against optimal duration, although optimizing diet should always be relevant	Adequate protein to prevent malnutrition and maintain muscle mass and calcium and vitamin D supplements to prevent bone loss and fractures
Average daily intake of protein 1-1.2 g/kg body weight/day for healthy adults aged 65 and above maintains lean body mass and muscle function⁵²	N/A	1b

Abbreviations: BMI, body mass index; CI, confidence interval; HR, hazard ratio; N/A, not appropriate; RR, relative risk.

Table 3.

Age-Specific Preventive Recommendations for Each Decade Over 50.

Age Category	Recommendations
50-60	Physical activity:^a Regular moderate-intensity physical activity (at least 150 minutes per week; grade B) Regular vigorous physical activity (at least once per week, ideally for more than 300 minutes per week; grade B) For those with health conditions impacting the ability to meet recommendations, as much physical activity as their conditions allow (grade B) Diet: Adherence to Mediterranean or DASH-type diet (grade B) Optimal caloric intake for healthy weight (grade B) Salt intake less than 3 to 6 g/d (grade B) Tobacco use: Cease tobacco use by any appropriate means, particularly important for those with CHD grade B Alcohol use: Light to moderate intake (less than 1 standard drink/day for women, 1 to 2 standard drinks for men) or abstain from drinking alcohol grade B Medication adherence: Adhere to NCD medications, particularly antihypertensive medication grade B Cancer screening^b: Regular screening for colon, breast (grade A), and cervical cancer (grade B) Mental health: Screen for and seek treatment for depression as needed (grade B)
60-70	Physical activity: Regular moderate-intensity physical activity (at least 150 minutes per week; grade B) Regular vigorous physical activity (at least once per week, ideally for more than 300 minutes per week; grade B) For those with health conditions impacting the ability to meet recommendations, as much physical activity as their conditions allow (grade B) Diet: Adherence to Mediterranean or DASH-type diet (grade B) Optimal caloric intake for healthy weight (grade B) Salt intake 3-6 g/day (grade B) Adequate calcium and vitamin D for bone health (grade A) Emphasis on protein and micronutrient intake to prevent malnutrition (grade A) Tobacco use: Cease tobacco use by any appropriate means, particularly important for those with CHD (grade B) Alcohol use: Light to moderate intake (less than 1 standard drink/day for women, 1 to 2 standard drinks for men; 1 standard drink from age 65) or abstain from drinking alcohol (grade B) Medication adherence: Adhere to NCD medications, particularly antihypertensive medication (grade B) Cancer screening: Regular screening for colon, breast (grade A), and cervical (until age 65; grade B) cancer Vaccines: Influenza yearly from age 65+ (grade C) Pneumococcal, chickenpox, and shingles once (grade A) Mental and cognitive health: Screen for and seek treatment for depression as needed (grade B) Preventive measures for cognitive decline: following a healthful diet, physical activity that incorporates strength training (1-2 times/week) and aerobic activity (2-5 times/week), brain training exercises, and management of risk factors for CVD (grade A)
70-80	Physical activity: Regular moderate-intensity physical activity (at least 150 minutes per week; grade B) Vigorous physical activity at least once per week (grade B) Multicomponent exercises at least 3 times per week for 30 to 45 minutes per session includes aerobic activity, strength training (at least 10 minutes daily), and balance and flexibility training (at least 10 minutes daily; grade B) For those with health conditions impacting the ability to meet recommendations, as much physical activity as their conditions allow Diet: Adherence to Mediterranean or DASH-type diet grade B Salt intake 3-6 g/day grade B Emphasis on calcium and vitamin D intake for bone health (grade A) Emphasis on protein and micronutrient intake to prevent malnutrition (grade A) Tobacco use: Cease tobacco use by any appropriate means, particularly important for those with CHD (grade B) Alcohol use: Light to moderate intake (less than 1 standard drink/day for women and men) or abstain from drinking alcohol (grade B) Medication adherence: Adhere to NCD medications as prescribed, particularly antihypertensive medication (grade B) Cancer screening: Regular screening for colon and breast cancer^b, both until age 75, or as per national guidelines (grade A) Vaccines: Influenza yearly from age 65+ (grade C) Mental and cognitive health: Screen for and seek treatment for depression as needed (grade B) Preventive measures for cognitive decline: following a healthful diet, physical activity that incorporates strength training (1-2 times/week) and aerobic activity (2-5 times/week), brain training exercises, and management of risk factors for CVD (grade A)
80+	Physical activity^a: Regular moderate-intensity physical activity (at least 150 minutes per week; grade B) Multicomponent exercises at least 3 times per week for 30 to 45 minutes per session; includes aerobic activity, strength training (at least 10 minutes daily), and balance and flexibility training (at least 10 minutes daily; grade B) For those with health conditions impacting the ability to meet recommendations, as much physical activity as their conditions allow Diet: Adherence to Mediterranean or DASH-type diet (grade B) Emphasis on calcium and vitamin D intake for bone health (grade A) Emphasis on protein and micronutrient intake to prevent malnutrition (grade A) Medication adherence: Adherence to NCD medications as prescribed, particularly antihypertensive medication (grade B) Vaccines: Influenza yearly from age 65+ (grade C) Mental and cognitive health: Screen for and seek treatment for depression as needed (grade B) Preventive measures for cognitive decline following a healthful diet, physical activity that incorporates strength training (1-2 times/week) and aerobic activity (2-5 times/week), brain training exercises, and management of risk factors for CVD (grade A)

Abbreviations: CHD, coronary heart disease; CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; NCD, non-communicable disease.

^aModerate physical activity defined as activity that ranges in intensity from 3 to 6 metabolic equivalents (METs); vigorous activity defined as >6 METs, as per World Health Organization (WHO) guidelines.⁵³

^bAt present, screening is recommended in clinical guidelines. The American Cancer Society’s latest recommendations on breast cancer screening for woman at average risk suggest annual screening between ages 45 and 54 and biennial screening from age 55 onwards.⁵⁴ Further research is necessary to determine the mortality benefits of mammography.

For younger age-groups, benefits of physical activity relate to maintaining a healthy weight, controlling blood pressure and cholesterol, reducing insulin resistance, and preventing NCDs. For adults of advanced age, the benefits extend to preventing frailty⁵⁵ and cognitive decline.⁵⁶ Interventions to prevent frailty are essential for maintaining mobility and functional status as people age. Positive effects of physical activity, particularly muscle strengthening and balance training, have been observed even among those already experiencing a decline in mobility.⁴⁵

Dietary patterns that resemble the Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets are among the best for promoting health. The Mediterranean diet emphasizes vegetables, fruits, nuts, legumes, whole grains, fish, and monounsaturated fats, with a lower intake of dairy foods, meat, and alcohol.¹⁵ The DASH diet has a similar profile and emphasizes fruits and vegetables, a moderate intake of dairy products and animal proteins, and a higher intake of plant proteins.¹³ Further, moderation of salt intake throughout adulthood has been shown to reduce the risk of mortality and cardiovascular disease (CVD).^16,17 In addition, there are numerous diets that have been found to be effective for specific target groups based on disease, such as the low glycemic index diet for diabetes mellitus,⁵⁷ or that are goal based, such as the Atkins, Weight Watchers, and other commercial diets for weight loss.⁵⁸ More recently, certain diets have been linked to environment in addition to health gains, for example, vegan or plant-based diets.⁵⁹ These specific diets fall outside the scope of this article.

Mortality is 2 to 3 times higher among middle-aged smokers (aged 30-69 years) than among nonsmokers and causes an average loss of 10 years of life in this age-group.⁶⁰ Although smoking cessation should be emphasized at all times throughout the lifespan, to optimize the mortality benefit, it should be encouraged as early as possible. For those struggling to quit smoking, emphasis should be placed on reducing tobacco use in the interim. Research shows that the risk of heart failure and death for former smokers aged 65 and above becomes similar to that for never-smokers after 15 years of cessation, although this was not observed among heavy smokers (>32 pack-year history), who had a 45% higher risk of heart disease and a 38% higher risk of all-cause mortality than did never-smokers in this age-group.⁶¹

A light to moderate intake of alcohol is associated with a reduced risk of coronary heart disease, stroke, and diabetes, whereas greater consumption is associated with increased cardiovascular risks.⁶² A moderate intake is considered 1 standard drink per day for women and 1 to 2 for men according to age (equivalent to 1.75 to 3.5 units of alcohol).^63,64 Alcohol overuse and abuse are closely linked with liver cirrhosis, ischemic heart disease, stroke, falls, cancers (such as liver, mouth, and esophagus), and cognitive decline.⁶⁵ Excess alcohol intake can predispose an individual to malnutrition and certain vitamin deficiencies.⁶⁶ In addition, excess alcohol use and mental health conditions are highly comorbid (more than one third of alcohol abusers also have psychiatric conditions), and alcohol itself has been shown to be a causal factor in depression.⁶⁷ Although research on this issue is limited, evidence shows that such moderate alcohol consumption has a protective effect against heart disease among those older than 65,^63,68 similar to that seen in the general population. However, the elderly people achieve a higher blood alcohol concentration than younger people after consuming an equal amount of alcohol due to a reduced ability to metabolize and eliminate alcohol as efficiently as younger persons.^63,69 Because of these age-related body changes in both men and women, National Institute on Alcohol Abuse and Alcoholism recommends that persons older than 65 consume no more than 1 drink per day.⁶³

Screening has become an invaluable tool for identifying certain cancers at an early stage before malignancies develop and when treatment can be more effective. In the adult population older than 50 years, major cancers for which screenings are recommended are colon, breast, and cervical cancer. Immunization is important for all ages, for both the primary recipient and those nearby. The effects of certain infectious diseases (such as influenza and pneumococcal disease) can be most devastating to the elderly people, but these diseases are also preventable through vaccination.

Although lifestyle changes to manage risk factors such as hypertension, high cholesterol, and insulin resistance that underlie NCDs should always be emphasized, a large body of evidence supports the use of medication in managing these conditions.⁷⁰ Encouraging adherence to prescribed regimens is essential for their effectiveness. In the case of hypertension, only 50% to 70% of patients are adherent to their treatment regimens and less than two thirds achieve the blood pressure control needed to prevent complications such as stroke.^71,72 Further evidence suggests that the effects of hypertension most impacting cognitive decline in late life may occur in midlife, between 48 and 67 years of,⁷³ strengthening the need for optimal blood pressure control in midlife.

As medication regimens increase in complexity, adherence rates decrease.⁷⁴ Polypharmacy increases the risk of nonadherence and negative side effects, and it is also a recognized contributor to the development of frailty in old age.⁵⁵ Therefore, for people of advancing age and especially those with multiple NCDs, the emphasis should be on reducing polypharmacy, both in terms of the number of medications prescribed and the dosing frequency. This requires the cooperation of the prescribing physician and support from caretakers, family members, and pharmacists.

Mental well-being is essential for healthy aging. Research into subjective well-being and health indicates that greater eudemonic well-being, that is, a sense of purpose and meaning in life, is associated with increased longevity.⁷⁵ The causes of depression among the elderly people are likely a combination of genetic factors, age-related neurobiological changes, and stressful life events (such as the loss of a spouse). Further, financial strain, limitations in daily activities, social isolation, and sleep disturbances can also increase the risk of depression in the elderly people.⁷⁶ Depression in late life is associated with an increased risk of suicide, greater self-neglect, and physical and cognitive decline.⁷⁷ Apart from direct suffering, mental health conditions can also increase dependence on tobacco and alcohol and decrease adherence to medications. In 1 Finnish study of patients with hypertension, depression led to a 1.52 times higher number of “days not treated.”⁷⁸ Depression increases mortality among patients with CVD⁷⁹ and increases health-care spending, symptom burden, and poor self-management among people with type 2 diabetes.⁸⁰

Lifestyle, genetic, and environmental factors across the lifespan influence cognitive aging and risk of dementia.⁵⁶ Changes in cognitive function with age can compromise individuals’ ability to care for themselves properly, adhere to disease treatment, or carry out activities of daily living, impairing their sense of independence and purpose.⁸¹ The risk of developing dementia is strongly associated with modifiable vascular and lifestyle-related factors.⁸² Roughly one-third of the cases of Alzheimer disease, the most common cause of dementia, can be attributed to 7 modifiable risk factors: low education level, midlife hypertension, midlife obesity, diabetes, physical inactivity, smoking, and depression.⁸³

Interventions to improve cognitive function with age are likely to have a greater impact when multiple risk factors are addressed, particularly for individuals with existing dementia who are among those with the highest levels of multimorbidity.⁸⁴ Oxidative stress and vascular impairment play a role in age-related cognitive decline. Antioxidant-rich diets, such as the Mediterranean diet, may therefore confer benefits on cognitive function with age. Improved cognition with age has been demonstrated among men aged 55 to 80 years and women aged 60 to 80 years following a Mediterranean diet with additional supplements of olive oil (1 L/wk) or nuts (30 g/d).⁸⁵ Further, bilingualism and acquisition of a second language in adulthood have been associated with improved late-life cognition.⁸⁶

The aging process compromises nutritional status. Inherent physiological, social, and economic changes impact nutritional requirements and access to nutritious foods. This increases the risk of inadequate caloric and protein intake, contributing to age-related problems of osteoporosis, weakened immunity, and sarcopenia (the gradual and progressive loss of muscle mass, strength, and physical endurance).^87,88 Further, impaired absorption of some vitamins and minerals, such as vitamin B₁₂, zinc, and iron, can lead to micronutrient deficiencies.⁸⁹ Thus, with advancing age, greater focus must be placed on ensuring adequate consumption of protein and micronutrient-dense foods to prevent malnutrition. Adequate protein and calorie consumption along with exercise is considered optimal for preserving muscle mass with age.^89,90

Frailty is a recognized medical syndrome characterized by “diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.”⁵⁵ Interventions to prevent frailty are essential for maintaining mobility and functional status and reducing morbidity as people age. Positive effects of physical activity, particularly muscle strengthening and balance training, on mobility have been observed even among those already experiencing a decline in functional ability.⁴⁵

Frailty greatly increases the risk of falls and related complications. Ninety-five percent of hip fractures, which often result in long-term functional impairment, nursing home admission, and increased mortality, are caused by falls in people aged 65 and above.⁹¹ Key causes of falls among the elderly people include gait problems, muscle weakness, dizziness, medication side effects, confusion, visual impairment, postural hypotension, environmental hazards (such as slippery walkways and poor lighting), ill-fitted clothing and footwear, and inappropriate walking aids.^92,93

The interventions in Tables 1 and 2 fell mostly into CEBM levels 2a and 2b, which equate to good quality cohort studies, systematic reviews (SRs) of cohort studies, or poor quality randomized controlled trials (RCTs). Higher quality studies such as good quality RCTs or SRs of RCTs were available for many interventions impacting morbidity, and for those impacting mortality, breast cancer screening, colorectal cancer screening, and immunizations. Lower quality studies only, such as ecological and case–control studies, were available for cervical cancer screening and some immunizations.

The recommendations in Table 3 are mostly grade B implying that consistent level 2 and 3 studies were available. Some recommendations have been assigned grade A due to consistent level 1 studies, including for breast and colorectal cancer screening, some vaccinations, calcium and Vitamin D supplementation, and preventive measures for cognitive decline. The only recommendation at level C or below is that of influenza vaccination.

Discussion

The recommendations summarized in Table 3 serve as a starting point for the development of age-specific guidelines to improve health throughout adulthood and into old age. There are substantial gaps in the scientific evidence with respect to effective age-specific interventions from age 50 and beyond, limiting the development of such guidelines.

This article aims to present the strongest level of evidence for each screening and preventive intervention. The evidence and recommendations for these interventions are generally well accepted and agreed upon, such that we did not encounter significant differences in recommendations. The authors did not find any situation arising where there was a conflict of recommendations or interventions that posed any significant risks. However, some interventions had a wide range of strength of findings or remain poorly evidence based (eg, colonoscopy in 85+). In such situations, the highest available level of evidence, consensus statements, and expert opinion were used to determine which studies took priority. Others pose problems with access in resource-poor settings such as the recommendation of colonoscopy for colorectal cancer screening.

Several other cancers are considerations for screening, but the evidence base is not supportive to date, with overdiagnosis a real concern. Prostate cancer screening using prostatic-specific antigen remains controversial and cannot be recommended at the present time.⁹⁴ There is insufficient evidence to justify screening for cancers of the lung, bladder, ovaries, stomach, testicular, or skin and melanomas, although some countries do have local recommendations for skin cancer screening.⁹⁵

There remains lack of clarity for the benefit of screening for CVD in terms of the optimal combination of risk factors for the assessment of CVD risk, initial age at screening, frequency of screening, order of tests, and even whether it is better to focus on single risk factor at a time or combine them into a combined risk score. Similarly, for type II diabetes, there is a lack of evidence of the benefit from either targeted or universal screening.⁹⁶ Furthermore, interventions for screen-detected or early Type 2 diabetes, impaired fasting glucose, or impaired glucose tolerance reduce the risk of all-cause mortality, cardiovascular mortality, or stroke.⁹⁶

To refine the recommendations proposed here, these gaps will need to be filled through further research from well-designed, population cohort studies. Nonetheless, if the preventive measures outlined herein are adopted, there are substantial gains to be had in longevity and quality of life. The earlier they are implemented, the better the long-term outcomes. It should be stressed that these recommendations must be considered in a patient-centric manner, accounting for specific comorbidities and changing functional status as individuals age. Cognitive impairment, frailty, and poor mobility affect health behaviors and an individual’s ability to manage conditions.

Readiness for, and acceptance of, lifestyle changes among older people pose different challenges than among younger people. Older individuals may be less likely to adopt new behaviors because of heavily ingrained habits or lack of motivation to engage in behaviors that take years to show benefits. Those of more advanced age may experience functional or cognitive impairments that make it difficult to change habits. Thus, it is important to consider methods to help the older population adopt change. Activities that encourage social connectivity and community engagement (such as group exercise classes) as well as technologies (such as wearable fitness devices and smartphone apps) and insights from behavioral economics can encourage adoption of behaviors that promote longevity. The Experience Corps approach is a novel strategy to drive engagement of the older population.⁹⁷ This social model promotes health through an appeal to older adults to participate in national and community services. Older adults volunteer in public schools to boost students’ academic performance; at the same time, they increase their own physical, cognitive, and social activity. Such interventions have the potential to engage older adults who might not respond to traditional advice on adopting behaviors to improve their health.

Strategies to promote functioning in old age need to be embraced across all sectors of society. Fall prevention programs; sensors, personal alarms, and other emerging technologies (such as robotic walkers); meal delivery services for those unable to cook; and medication management systems (such as text message reminder systems, smartphone applications, pill packs, and “smart” pill bottles) will become increasingly important, particularly with the increasing prevalence of dementia.

The need for healthy aging is not restricted to just high-income countries as globally aging has an impact on health trajectories and multiple comorbidities in later life. Although there is considerable variation in multiple comorbidity prevalence globally, the prevalence is high even in low- and middle-income countries (LMICs) at 8%.⁹⁸ Although the relationship between multiple comorbidity and income is complex and varies between countries, there is a clear association with age, gender, and maternal education.⁹⁸

Another obstacle to healthy aging, particularly in LMICs and resource-poor settings, is that of access to health care for older people. This can be seen in findings from the WHO Study on Global AGEing and adult health (SAGE), which draws on nationally representative samples of older people from China, Ghana, India, Mexico, the Russian Federation, and South Africa.⁹⁹ Across the countries included in SAGE, effective health-care coverage is estimated to range from 21% of patients in Mexico to 48% in South Africa.⁹⁹ As a result, while around 53% of older adults included in SAGE have been found to have high blood pressure, only 4% to 14% of them were receiving effective treatment.¹⁰⁰ Such gaps in health care in LMICs result in high rates of older people who have limitations in functioning and long-term care is passed on to families without the training or support to provide the care needed, with personal financial implications as this may require another family member, usually a woman, to forgo work.⁹⁹

The current metrics and methods used in the field of aging are limited, preventing a complete understanding of the health issues experienced by older people and the usefulness of interventions to address them. Research studies specifically designed around aging are required in order to better understand and act on healthy aging.

The concept of compression of morbidity refers to the postponement of morbidity, which by itself improves health, while postponement of mortality by itself increases ill-health.¹⁰¹ The interventions and recommendations have been reported separately for morbidity and mortality, whereas in reality, interventions can affect either or both types of outcome. For example, breast cancer screening can lead to earlier identification of the tumor and less invasive treatment, impacting on both quality of life and mortality. This dynamic interaction of morbidity and mortality trends is critical for accurate prediction of future health. If mortality was delayed the most, cumulative lifetime morbidity would grow; if morbidity was postponed more than mortality, cumulative lifetime morbidity would be likely to decrease.¹⁰¹

Research study designs used to study compression of morbidity include the longitudinal study of morbidity in populations with differing risk factors, population studies establishing decreases in population disability over long time periods, and RCTs of health risk reduction in senior populations.¹⁰¹

The aging paradigm still used by most research study designs relies on the assumption that interventions for morbidity and mortality have the same impact on morbidity and later mortality regardless of the age at the initiation of the intervention. Aging research study designs, for example, cohort studies, should use a life course approach and look to use staggered age at initiation, from birth to age 80 and above, in order to ascertain the impact on the morbidity and mortality slopes. For example, supercentenarians over the age of 105 have lower lifetime cumulative morbidity than those dying at age 85 or 100.¹⁰² Many common conditions have nonlinear trajectories with age. For example, coronary artery disease has a trajectory of sudden midlife death as the first symptom, a trajectory of sudden death with first symptom at an advanced age, a trajectory of multiple acute coronary events, and a trajectory of slow progression of chronic congestive heart failure.¹⁰¹ The study of the effects of coronary artery disease therefore requires the descriptive information on the several trajectories, the incidence of each, and the sum of these trajectories to be accounted for, in order to determine the impact of this condition on the population morbidity and mortality.¹⁰¹

The importance of this life course approach to the prevention of chronic disease is increasingly recognized. Birth cohorts, such as the Medical Research Council National Survey of Health and Development, a British Birth Cohort Study, have demonstrated differential intervention impact by age of initiation for direct health markers such as body mass index but also for social determinants of health such as socioeconomic position throughout the life course.^103,104 The realization that more complicated models were needed where the dynamic relationship between morbidity and mortality rates could be understood has previously been highlighted,¹⁰¹ but aging research on the whole is slow to adapt.

Ongoing research into genetic determinants of illness and longevity has the potential to yield individualized recommendations for healthy aging. Promising data from the New England Centenarian Study¹⁰⁵ and the Okinawa Centenarian Study¹⁰⁶ demonstrate a number of genetic modifiers that, combined, can extend survival to more than 100 years of age.

Personalized approaches to health promotion must be complemented with population-wide approaches. At the community level, opportunities for social engagement and lifelong learning can foster a sense of purpose and mental well-being. Changes to the physical environment through urban design focused on healthy aging—designing for longevity—can aid mobility and increase community engagement among older adults, particularly those with a degree of physical or cognitive impairment. Key areas to address include access to transport, outdoor recreation, and safe street design. Partnerships are needed across public and private sectors to promote NCD prevention and healthy aging. Organizations must work together to address the challenges of an aging population, including how to keep people engaged in the workforce, how to restructure pension systems and retirement plans, and how to ensure financial security with advancing age (particularly for those having cognitive impairment). Technology and software companies, as well as pharmaceuticals and medical device manufacturers, are uniquely positioned to invest in research to drive healthy aging. Health and life insurers, by promoting health within their insured population, have the mutual benefit of cost savings for both business and policyholders.

Strengths and Limitations of the Study

The purpose of the study was to summarize the evidence base and assign levels of evidence according to the CEBM⁸ and not a critical appraisal of the included studies. Its remit did not include investigation of individual study details such as risk bias and study participant characteristics and these are not included in this article, although such details can be found in the consensus statements and guidelines of consensus bodies that are also cited in this article. The output is a single resource of the latest evidence-based preventive interventions and recommendations for the over 50 age-group. As discussed above, the split into impact from interventions on morbidity and mortality is not always absolute. This study brings together the evidence base for prevention in summarized, usable tables and provides clear recommendations by age decade. Further, while the databases selected to conduct the scientific review provided extensive coverage of the available research, the possibility of missing relevant research not contained within these databases in addition to future changes and in addition to the literature should be acknowledged.

Conclusion

The environmental conditions and individual health behaviors that result in NCDs operate throughout a person’s lifespan, from gestation through childhood, adolescence, adulthood, and old age. The cumulative effect of healthier choices across the lifespan will therefore improve the quality and length of the aging process. This fact must remain central to the planning and implementation of health policies and interventions. Although aging is inevitable, the diseases that afflict old age do not need to be. This article summarizes the evidence base for interventions that reduce morbidity and mortality in those aged 50 and above and provides specific recommendations by 10-year age bands.

Projections of the future costs of an aging population fail to take into account the impact of disease prevention measures being widely in place. Advances in the science of prevention, personalized health technologies, behavioral economics, and genomic predictions are changing the way we approach disease prevention throughout each decade of adulthood. Building partnerships across sectors to drive these advances and promote longevity can realize the opportunities, rather than the burden, of an aging population. Based on the results, the authors concluded that clear recommendations have been made according to the existing evidence base, but further research investment is needed to fill many existing gaps. Further, personalized approaches to healthy aging complemented by population-wide approaches and broader cross-sector partnerships will help to ensure greater longevity is an opportunity, rather than a burden, for society.

SO WHAT?

Diseases and conditions afflicting the elderly people impact longevity, functional independence, and quality of life including obesity, cardiovascular disease, diabetes, certain cancers, dementia, untreated mental health conditions, and musculoskeletal disorders. Approximately, 80% of older adults in the United States currently have at least 1 noncommunicable disease and 50% have at least 2. Currently, more than 35 million people worldwide are living with dementia, and this is expected to nearly double by 2030 and triple by 2050. Quality of life with advancing age and the extent of financial and social burden will depend largely on morbidity and how to minimize years lived with disability. If longevity is accompanied by healthy life years, the burden of an aging population need not be as dire as predicted. Moreover, a healthy aging population can confer great benefits to the workforce, economy, and society. Health-promoting and disease prevention interventions are best considered in age-specific contexts across the lifespan, particularly for age-groups 50 and above who face the greatest burden of noncommunicable disease and age-related conditions.

The World Health Organization and national health institutions provide guidance on optimal prevention interventions across the lifespan. However, these guidelines are usually of a general nature, rarely take into account underlying cumulative risks and rarely provide guidance for age-specific and functional-level groups from age 50.

This article provides a synthesized summary of available scientific evidence to address these needs and outline specific interventions that favorably influence morbidity and mortality from age 50 and beyond including:

Those that predominantly impact morbidity or quality of life. These interventions relate to immunization status, mental and cognitive health, and frailty and musculoskeletal disorders.

Supplemental Material

Supplemental Material, 712355PRISMA_2009_checklist_age_specific_interventions - Preventive Interventions for the Second Half of Life: A Systematic Review

Supplemental Material, 712355PRISMA_2009_checklist_age_specific_interventions for Preventive Interventions for the Second Half of Life: A Systematic Review by Cother Hajat, Adriana Selwyn, Mark Harris, and Derek Yach in American Journal of Health Promotion

Footnotes

Authors’ Note

C.H., A.S., M.H., and D.H. designed the study. A.S. and M.H. were responsible for the data search and literature review. C.H. and A.S. wrote the manuscript. and M.H. and D.H. reviewed the manuscript. In this systematic review, the authors searched PubMed, Cochrane database, and Google Scholar and explicit outreach to experts in the field to inform the development of age-specific prevention guidelines for adults aged 50 and above. They included meta-analyses, intervention-based, and prospective cohort studies that reported all-cause mortality, disease-specific mortality, or morbidity in adults. Data extraction was undertaken in 2015 using search terms of a combination of risk factor and “intervention,” “mortality,” “reduction,” “improvement,” “death,” and “morbidity.” Interventions were categorized according to the Center for Evidence Based Medicine Level of Evidence framework.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C.H., A.S., and D.H. were employed by The Vitality Group which provides lifestyle interventions.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplementary material for this article is available online.

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