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The Health Maintenance Clinical Glidepath answers the first two questions above and addresses the limitations of two types of clinical decision‐making tools: practice guidelines and evidence‐based medicine (EBM). Although practice guidelines and EBM have been important in raising the standards of healthcare in the past decade, their use in preventive geriatrics is limited. Many guidelines do not include older age groups or, if they do, are no more specific than ‘over 65 years of age’. EBM emphasizes outcomes of populations, whereas clinical practice emphasizes the outcome of the individual. One of the limitations of EBM is the discrepancy between patients in the EBM studies and clinical practice. For example, many randomized controlled trials of medication interventions for common diseases such as congestive heart failure and osteoporosis exclude patients who are frail, demented, or at the end of life.

The older we get, the more unique we become. Chronological age does not equate with physiological or functional age. Guidelines for preventive geriatrics need to take this into account. One approach is to use life expectancy and functional status to help delineate categories of older people that are more useful than those based on chronological age. Overall health status is a good predictor of life expectancy compared with age alone, and functional capacity among older people has been found to be a predictor of mortality. Four categories can be used to help guide decisions about preventive measures. Although overlap exists and functional status may fluctuate, Gillick proposed the following: Robust (life expectancy of >5 years and functionally independent), Frail (life expectancy of <5 years and significant functional impairment), Moderately Demented (life expectancy 2–10 years and may or may not be functionally impaired), and End of Life (usually a life expectancy of <2 years).¹

Preventive geriatrics requires making decisions. Healthcare decisions are complex, involving society, healthcare workers, and patients. Guidelines for preventive geriatrics need to take into account the following practice principles: (i) patients’ expectations and needs, including quality of life, satisfaction, and reassurance; (ii) physicians’ need for diagnostic certainty; (iii) physicians’ comfort with risk‐taking and concerns about malpractice; (iv) the need for cost‐effective medical care; (v) variations in practice patterns, particularly with regard to subspecialty care; and (vi) the practical realities of running a practice.²

Healthcare decisions are not black and white. Thus, four levels of recommendation were developed to allow for decisions to be made on a ‘graded’ rather than an ‘all or nothing’ basis and to allow for better patient involvement in decision‐making. The four levels are also based, when available, on the strength or weakness of EBM that exists or does not exist. The four levels are ‘Do’, ‘Discuss’, ‘Consider’ and ‘* * * *’. ‘Do’ reflects the strongest recommendation. ‘Discuss’ reflects a recommendation that the physician discusses the risk‐benefit of the decision with the patient. ‘Consider’ reflects a recommendation that the physician gives consideration but does not necessarily need to discuss the decision with the patient. ‘* * * *’ reflects that a particular evaluation or management measure is not recommended based on these principles.

Table 9.1 is a shortened version of the original Health Maintenance Clinical Glidepath that details the recommendations for each area of prevention and each category of Robust, Frail, Moderately Demented, and End of Life. It will be noted in the following sections whether recommendations are based on organizational guidelines, EBM, or expert consensus. All areas of the Glidepath underwent a Delphi process.³