Prevention, Health Maintenance, and Care Across Settings
Prevention is individualized
Immunizations: influenza annually, COVID-19 per current schedule, pneumococcal vaccination, Tdap, shingles, and RSV for eligible older adults. Cancer screening should reflect life expectancy, goals, and risk: mammography, colorectal cancer screening, cervical screening, lung cancer screening for eligible smokers, and osteoporosis screening with DXA. Discuss benefits and harms rather than applying a single age cutoff.
Across settings, transitions are dangerous. Hospitalization causes immobility, delirium, pressure injury, catheter-associated infection, and deconditioning. Prevent with early mobility, delirium prevention, catheter avoidance, medication reconciliation, and discharge planning. In long-term care, focus on function, advance care planning, infection stewardship, and avoiding unnecessary transfers. Home care requires safety assessment, caregiver support, and medication management.
Traps: screening patients with limited life expectancy; missing medication reconciliation at discharge; using indwelling catheters for convenience; and ignoring caregiver burden.
Worked example: a 92-year-old with advanced dementia and a life expectancy of less than 5 years presents for a routine visit. Colonoscopy screening is not indicated; instead, update immunizations, review goals of care, assess function and falls, and support the caregiver.
Rule of thumb: use life expectancy and patient goals-not chronologic age alone-to decide screening and prevention.