Our findings indicate that older women are not receiving the preventive health measures most likely to be effective based on their age and health status. Cancer screening was not targeted to women aged 80 and older in above average health even though many of these women have more than 5 years of life expectancy.3
Meanwhile, many women (49%) aged 80 and older in below average health were screened with mammography. We also found that many older women did not receive recommended immunizations. Notably, women aged 85 and older in below average health were less likely to get influenza vaccinations than women aged 85 and older in better health even though the oldest women in poor health are at the greatest risk of mortality from influenza.17
In addition, despite a growing and robust literature demonstrating that exercise can delay disability and help maintain independence, we found that older women, especially those in good health, infrequently reported receiving exercise counseling.7
Higher exercise counseling among older women in poor health may reflect disease specific guidelines, however, exercise recommendations are also important for those in good health. Finally, very few older women simultaneously receive all preventive health measures appropriately. Interventions are necessary to improve the delivery and targeting of preventive health measures to older women.
Targeting of preventive health services to elderly women by health status may be poor for several reasons. Clinicians may use age rather than health status when deciding whether or not to screen women in their 80s and 90s for cancer. Also, elderly women, regardless of their health status, may perceive limited life expectancy for themselves and be reluctant to accept preventive health measures. Although increasing age significantly impacts life expectancy, older women’s health can also strongly affect life expectancy.3
Cancer screening in older women in poor health is concerning because it places women at risk for complications and anxiety related to diagnosis and treatment even though the cancer would be unlikely to become clinically significant in their lifetime.3
Denying or forgoing a screening test to elderly women in good health is equally inappropriate since these women may live long enough to benefit.
We wondered if greater number of clinic visits among the oldest women in poor health accounted for some of the poor targeting of preventive health services since additional clinic visits could be associated with more opportunities for physicians to recommend preventive services. However, in post hoc analyses we found that those in poor health status did not have significantly more clinic visits than those in good health status. Furthermore, physicians may need to use more clinic time to address active issues among older women in poor health.
We also found that many women aged 65–79 in good health did not report receiving breast (19%) or colon cancer screening (45%). Other studies that have examined receipt of colon cancer screening among US older adults have also found low rates.18
Interventions are necessary to increase breast and colon cancer screening among older women in good health. Ideally these interventions would focus on older women with life expectancies greater than 10 years. Interventions may also be necessary to reduce breast cancer screening among elderly women in poor health, especially since we found that 49% of women aged 80 and older in below average health were screened and these women likely have life expectancies of less than 5 years.
Interventions discussed in the medical literature designed to increase cancer screening among older women include physician education seminars,19
preventive health check lists,20
and support from non-physician staff. 22
We are unaware of interventions to reduce cancer screening among elderly women in poor health but such an intervention would likely require clinician counseling. Although discussing stopping screening may be uncomfortable, we recommend that clinicians discuss potential risks of screening and that there is little data showing any benefit of cancer screening among women aged 80 and older with multiple comorbidities.23;24
We also recommend that clinicians focus discussions on preventive measures whose benefits may be achieved in a short time (e.g., exercise or immunizations) so that elderly women do not feel like they are being “given-up on.”25
This may be particularly important since we found that many older women do not receive exercise counseling or immunizations. Finally, interventions designed to improve preventive health care delivery to older women may need to be comprehensive rather than focused on a specific service, since we found that so few older women receive all preventive health measures appropriately.
There are several limitations to this study. First, we relied on self-report, which can lead to recall bias and misclassification. Second, our measure of health status has not been validated and the survey only asks about a limited number of diseases and lacks information on severity and duration of disease. Third, the NHIS only releases an overall response rate to the survey, however sample weights are adjusted for non-response. Finally, the health of older women in our study may have changed since they underwent colonoscopy; however, 92% reported being screened for colon cancer in the past five years. Despite these limitations, this study represents a significant contribution to the literature by examining receipt of a wide range of preventive health measures simultaneously among a nationally representative sample of older US women stratified by health status.
In summary, we found evidence of poor targeting and inappropriate use of screening and preventive health measures among older women. Many older women in above average health were not screened for breast and/or colon cancer while many of the oldest women in below average health were screened. Regardless of health status, many older women did not receive immunizations from which they may benefit and many received PAP smears from which they are unlikely to benefit. Exercise counseling was uncommon and was least common among the oldest women in good health. Interventions are necessary to improve the quality and targeting of preventive health care delivered to older women.